What we know from many studies is that most medical students enter medical school with a stated altruism, many wanting to work for social justice, to serve the underserved, and in primary care careers. And then the attrition starts, moment by moment, and it is down hill from there.
By graduation, the students going into rural and underserved careers drop the majority of those initially interested.
Think of it as a pipeline. It has a diameter to hold all of the students going who, at entry, want these careers. At graduation there is a much smaller trickle of those going into primary care and of those, a few drops choose rural or urban underserved practices. I won’t bore you with all that we don’t know about how to impact this; suffice it to say that it matters to some of us medical educators and health policy nuts and so we keep trying. There are of course the extrinsic factors (like “specialty bashing” or remuneration differentials that select procedures over time spent with a patient in life style conversations) and we don’t control those. And we keep trying to impact what we can.
Tonight, maybe seventy-five people were in the room, ranging from deans to first year medical students with faculty, staff, and second, third, and fourth year students in between. Two thirds were students. The states of Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) were represented with both deans, students, and staff. A few “out of states” students were there as well, at least one from California.
Some of us have spent a good portion of our work lives developing and feeding that pipeline I mentioned above and then nurturing the students in it to continue their commitment to careers caring for rural and urban underserved communities. The WWAMI states have 28% of the US land mass and only 3.5% of the population, of which 35% are rural residents. And what we might call rural in Washington is considered urban in Montana, Wyoming, Alaska.
The University of Washington Medical School serves those five states, through the WWAMI Program. Two recent initiatives to nurture that pipeline are the Underserved Pathway (UP) and the TRUST Program. The UP is a program any student can join, providing structure to students for planning their curriculum, mentorship, and on-line educational modules. The TRUST program admits a cohort of students to be scholars (now 10 a year in Montana, 5 in Eastern Washington, 5 in Western Washington, 5 in Idaho, and soon some from Alaska and Wyoming) from an applicant pool who have both the credentials for admission to the school of medicine and those that support a stated desire to have a career in rural or underserved health care. TRUST scholars have a longitudinal relationship with one rural community for the entire four years of medical school. They spend two weeks in their community before first year classes even begin, visit during the years one and two, a month in the summer after first year, and 4-7 months in third year, returning for elective work in fourth year. All complete the UP.
The regional deans from Alaska, Wyoming, Montana, Idaho, Eastern Washington and Western Washington are in town this week for a variety of meetings purposely packed into one week. As part of this visit, they like to spend time with the students from their state and we (TRUST and UP) want to pull them all together for an educational session. That was tonight’s gathering.
After a Kaiser Foundation video on the ACA and a clicker response quiz, small groups formed to discuss hopes, fears, impacts, and real stories these students have already witnessed. Each state dean gave an overview and update of what is happening in their state. While Washington is the only of the five with medicaid expansion, several are on board with exchanges and several are having ongoing medicaid expansion discussions with strong support from groups like physicians, hospitals, business, labor, and others.
In the wrap up it was clear that these medical students see their lives as having a social context and contract to improve health and access.
They worry about their capacity and acknowledge we need new models of care.
They know that whether they are activists or not, they are being political, which opens a discussion of how to be active effectively.
Many believe that universal single payer insurance will be the only thing that will work.
They are realistic that change is hard and will be incremental.
I worried that this would feel like a downer. From the energy in the room and the comments after, I think it was energizing. Lesson for me: hard topics with no easy solutions are less so with the support of others.
And me: I am deeply touched by the realism, passion, energy, and clarity of these students. They seem up for the task. And there are more of them than were in my generation. If our programs keep their fire kindled, I will feel success. If one of each of us elders fosters two or more who take on the mission, I will feel success. Tonight I am grateful to be part of the effort and to our students who keep me with some modicum of focus and youth.