Q&A with Kara Odom Walker, MD, MPH, University of California, San Francisco, Department of Family and Community Medicine, formerly a Robert Wood Johnson Foundation Clinical Scholar

By Laura Trude, HWIC Information Specialist

The American Journal of Public Health recently published study focused on strategies for increasing the number of primary care physicians in urban health professional shortage areas (HPSAs). Dr. Walker, the principal investigator, discusses some of the similarities and differences between recruiting for urban versus rural underserved areas, the study’s findings, and recommendations for how to improve the recruitment and retention of primary care physicians and other health professionals to underserved communities.

Could you provide an overview of the recruitment and retention challenges that urban underserved areas face as opposed to underserved areas in general?

Most of the research that’s out there shows that people from underserved areas, including rural and minority backgrounds, are more likely to go and work and stay in underserved areas. A lot of that research is focused on who stays at community health centers and who works at clinics and these health professional shortage areas.

We were really interested in trying to figure out what community clinics could do to recruit and retain physicians. Many of these clinics get people who are interested but leave or the clinics focus a lot on recruiting out of residency without knowing exactly which residency programs to focus on. Part of our goal was to figure out some practical strategies to help clinics in urban environments determine who is more likely to work at their clinic in the first place and then how to retain those physicians. We didn’t look at issues around rural physicians, but urban underserved areas may have an easier time finding several local residency programs to target recruitment activities. Most medical schools are also located in urban areas and so they can recruit students out of the experiences they have during training in both medical school and residency.

The main challenge for both rural and urban environments is trying to find people who are willing to work in these environments. It’s not just about paying them more; it’s about trying to find people who are committed and mission-driven and interested in serving underserved communities.

One finding that stood out from our research is that those who go into primary care, generally speaking, have made a decision to accept a lower salary. They know they’re not going to make the same amount of money as an orthopedic surgeon or anesthesiologist. The money is important, but it’s not the only deciding factor. We found that it just comes down to finding the right person.

Medical school doesn’t necessarily focus on admitting students who are interested in going into these areas. They are focused on those who have the right scores, are interested in medicine and are going to be academically successful. The challenge is truly trying to find mission-driven people with all of the characteristics for academic success. That’s not necessarily how we decide to recruit students into medical schools.

Along the way, trainees are discouraged from working in these environments. They may have negative experiences in their training or they may be discouraged by their peers or mentors from considering these opportunities. The challenges are two-fold: even if you get motivated people interested, they may say “I’m not going to stay in these kind of areas” or “Never mind, I decided I’m going to work somewhere else” because of peer-influence or debt-concerns.

That’s really interesting, especially given the recent literature on the subject, like “ The Social Mission of Medical Education.” Ideally, how do you see that playing out for medical schools in terms of how they select students or structure the curriculum?

The first step is trying to figure out how to creatively recruit pre-medical students who are mission-driven and motivated by social justice issues. Not all medical schools in the country have that as their mission. Part of the article on social missions talked about the medical schools that focus on recruiting mission-driven students in the first place and put in place experiences along the way that will encourage and support medical students to pursue those goals.

I think we need to move towards finding these mission-driven students through a more holistic application and admission process. It’s more than just saying “Write in your personal statement of why you want to go to medical school.” It’s including questions about why they want to serve certain communities or what experiences they’ve had in their life that have motivated them to provide service to other communities. We need people who are motivated to go into medicine and serve all populations. It’s not to say that this is important for all of our medical student slots, but I do think that every medical school could contribute a certain number of positions to those who are interested in serving underserved communities. Once we get those medical students into school, it really does mean supporting them in those goals. Having rotations and mentorship opportunities that are in underserved areas is really important.

Another finding that stood out and surprised us, even with the small numbers that we looked at in our study, was that none of the physicians who trained during residency in non-underserved areas—none of those physicians—decided on a job in an underserved area. There’s something about working and having an experience in these types of community settings that promotes people thinking about it long-term.

From my own personal experience, it’s very easy to get off-track. There are lots of people who come into medical school saying, “This is what I want to do: I want to give back, I want to work in the community,” but there are lots of opportunities to be derailed from that: negative experiences with mentors, debt load, not having mentors who support you in pursuing that goal. We really need support mechanisms to help students along the way once they get into medical school.

What initiatives have been undertaken in this regard?

There are some good examples. I am very familiar with the strategies of mission-focused medical schools and programs, such as the historically Black medical schools (i.e. Howard, Meharry, Morehouse, and Charles Drew University) and programs such as the Urban Underserved Program at Jefferson Medical School. Studies have shown that their graduates are more likely to work in underserved and minority populations.

Historically Black medical schools are definitely structured around supporting a mission and supporting opportunities to work in minority communities and underserved communities. My alma mater, Jefferson Medical School, has a Physician Shortage Area Program that has been very successful in helping those who are from rural areas go back and train in rural areas during medical school. There are similar rural-focused programs around the country, but there are also programs like the University of California PRIME program that is focused on recruiting people who are interested in serving underserved areas and providing additional training and experiences in medical school to encourage students to think about those things.

There are fewer programs and linkages for people once they get to residency. That’s a key deciding point where trainees might say, “I definitely had good experiences during medical school, but now what do I do?” and they go into a residency program that doesn’t support and encourage training in underserved environments. Residency is so busy and so focused on getting the training needed and you don’t have a lot of flexibility, so the residency programs are responsible for providing opportunities that encourage people along the way.

Do you have any specific suggestions for how residency programs could support underserved areas?

Many residency programs are in community-based and underserved settings such as county hospitals or formerly county hospitals that work with Medicare and Medicaid populations, so there are opportunities for all residency programs to say, “We are going to provide opportunities for training in a community clinic or underserved environment and pair them up with mentors and preceptors who can guide them in a long-term decision around working in these environments.”

This not only goes for primary care residencies, but also specialists. We need more specialists who are willing to think about serving underserved areas even if it’s part-time, and we need to figure out how to structure training experiences to support that. I think it would be wonderful to include an accreditation requirement for providing a certain number of hours in these kinds of environments. That may not be feasible everywhere, but it would be one step to improving the exposure people have to working in these kinds of communities.

Finding physicians for underserved areas goes beyond physician workforce diversity. I think that was the other part of this story that was unique. Much of the research out there says that minority physicians are more likely to serve minorities and work in underserved areas. What we found was that even non-minority physicians identified with a mission and with the communities served. It is about experiences they had in their backgrounds where they grew up or with their family members or some kind of service experience volunteering somewhere that they said, “This is something that is important to me and I want to do it.” All physicians have to have opportunities along the way to train with preceptors in medical school and in residencies to consider underserved areas as a long-term career option.

Do you have any additional recommendations for those trying to recruit more physicians to urban underserved areas?

The main findings emphasized where people had training and what experiences they had along the way. Physicians who chose to work in urban underserved environments also chose to work in settings where they identified with the patient populations. “Identifying” could be along many lines: it could be along language concordance, racial concordance, or that they felt like they were from a similar socio-economic background and could relate to what the patients were going through.

Some of the physicians who stood out most in my mind were those who had some kind of experience early on in their lives and careers—whether they worked in the military, at a neighborhood clinic or some other kind of setting—where they said, “This is something that is really important to me.” Almost all of them had a story: their parents encouraged them, they felt like they were giving back in some way to the patients they served. I think that’s unique in urban environments because often they are large enough that you can find a clinic which serves the unique needs of a community population.

With health care reform and a bigger push to get training opportunities in community clinics, there may be even more opportunities to recruit physicians who stay in community health centers long-term. We need to provide medical students and residents with training opportunities and encourage them to help stay in these kinds of community settings.

Are you referring to the teaching health center provisions in the Affordable Care Act?

Exactly. I know that implementing the provision is going to be challenging. Even my own residency program has tried to figure out how to put residents in community settings. They are often resource poor environments that need to focus on their bottom-line – the physicians working there often don’t have a lot of time set aside to teach. Ensuring the quality of education in establishing residency programs is really important. Once we get over those challenges, I think it will be a wonderful pipeline opportunity to get more physicians to consider working in underserved environments, to set up their own practices, and to have physicians from multiple backgrounds working in underserved areas and recruiting patients from these communities.

I’ve also read that there are some challenges with funding the training health centers.

There are multiple challenges with implementing the training health centers. On the face of it, it’s a great idea, but implementing it in a way that works for accrediting bodies and making sure trainees get a well-rounded experience is going to be very difficult, but it’s a great step in the right direction. It will also help with getting more people from other disciplines involved in community health. We don’t only need doctors there, we need nurses and nurse practitioners and PAs and health workers, everyone.

Is there anything else you would like to highlight or add?

This is an exploratory study and we can’t necessarily generalize our findings to all types of training venues or across the country. Los Angeles is a big place, but it definitely has some unique challenges. I do think that the findings are applicable for moving the conversation forward on how we recruit more physicians who are mission-driven and are interested in serving certain populations, but hopefully not forgetting that we also need to encourage people during their residency training to think about these long-term careers.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.