By A. Hal Strelnick, MD, Professor, Family & Social Medicine, and Assistant Dean for Community Engagement, Montefiore Medical Center, Albert Einstein College of Medicine
“Imitation is not just the sincerest form of flattery – it’s the sincerest form of learning.” ― George Bernard Shaw
The editors at Academic Medicine asked me to comment on the March article “Training in Urban Medicine and Public Health: TRIUMPH,” by Cynthia Haq and her University of Wisconsin (UW) colleagues, because I’d written in 2008 about the Residency Program in Social Medicine (RPSM) at Montefiore Medical Center in the Bronx, New York. Haq and colleagues cited Montefiore’s program as the “curriculum framework and learning objectives” from which they adapted their program.
Little did they know that I had grown up in Milwaukee County, where TRIUMPH is located. Milwaukee’s poverty rate (27%) is only exceeded by the Rust Belt poster cities, Detroit (36%), Cleveland (35%), and Buffalo (29%),1 and its racial segregation is greater than any other metropolitan area in the United States,2 so the demography and epidemiology of the Bronx, the nation’s poorest urban county,3 share much in common with these and other “urban inner cities.” In fact, the RPSM’s founder, David Kindig, left the Bronx to become a Badger and UW’s Vice Chancellor for Health from 1980-85. While there, he helped launch the Population Health Institute and County Health Rankings that led UW to change its name to the School of Medicine and Public Health and expand its mission to match.
Dr. Kindig left us the unspeakable acronym, “RPSM,” while Haq and colleagues chose an aspirational one, “TRIUMPH.” It is a brilliant choice, especially given the difficult task of recruiting medical students for primary care practice in urban underserved communities.
Dr. Haq and her colleagues have done an impressive evaluation of their program’s success, demonstrating TRIUMPH students’ comparable performance on GPAs, professional skills assessments, and standardized subject and Step 1 and 2 exams; the authors followed-up on their students’ residency choice and found most chose primary care residencies that serve underserved urban communities. Like us at Montefiore, they struggle with what serves as a fair comparison and what demonstrates truly making a difference when individuals apply and choose a desired intervention (i.e., specialized training like TRIUMPH) and those offering the intervention select the best candidates, building in a “mutual selection bias.”
Today, the RPSM boasts 684 graduates (andlike TRIUMPH, 60% of our graduates are women). In our 2008 Academic Medicine4 article we compared our graduates’ practices with those who applied to our program through the NRMP match but trained elsewhere. Between RPSM graduates and their “applicant controls,” we found both dramatically different residency training experiences and rates of practice in primary care with the underserved. The RPSM and TRIUMPH share many curriculum elements significantly associated with primary care practice in underserved communities, including continuity practice in an inner city, social medicine projects, and learning about the community of their practices. With more time and graduates I am confident that TRIUMPH will “imitate” these successful outcomes, too.
Why is education in urban underserved practice emphasizing the social determinants of health so important? The authors briefly review the plight of the 60 million Americans (20%) living in Health Professions Shortage Areas, equally divided between urban and rural populations, and the projections for worsening shortages of both primary care and specialty physicians over the next decade. Despite federal programs like Community Health Centers since the 1960s, the National Health Service Corps (NHSC) since 1970, and many state and federal loan repayment programs, that number of underserved Americans has not budged since I entered the NHSC in the South Bronx in 1978, even whilethe national physician-to-population ratio has doubled! Although the 2010 Affordable Care Act established a National Healthcare Workforce Commission to address this dilemma, Congress has not funded it, so its members cannot even speak with each other, let alone meet or act.5 Our diffuse, decentralized public and private health workforce incentives, planning, and implementation are dysfunctional.6,7 Until we empower a future Alexandra to cut through this Gordian knot and align our contradictory workforce policies, we must rely on individual programs like TRIUMPH to recruit and train internally-driven physicians one at a time to care for the urban underserved.
1. U.S. Census Bureau, “Table 708. Household, Family, and Per Capita Income and Individuals, and Families Below Poverty Level by City: 2009.” Statistical Abstract of the United States, 2012
2. Glaeser E, Vigdor J. The End of the Segregated Century: Racial Separation in America’s Neighborhoods, 1890-2010. New York, NY: Manhattan Institute, Civic Report, No. 66, January 2012. [Among the 630 U.S. metropolitan and micropolitan statistical areas analyzed using the most widely used statistical measures of residential segregation, Milwaukee had the highest Dissimilarity Index (0.777) with Cleveland (0.767), Buffalo (0.756), and Detroit close behind (0.735), while on the Isolation Index the four cities were Cleveland (0.640), Detroit (0.610), Milwaukee (0.586), and Buffalo (0.547).]
3. Roberts S. “One in Five New York City Residents Living in Poverty.” New York Times, September 22, 2011.
4. Strelnick AH, Swiderski D, Fornari A, Gorski V, Korin E, Ozuah P, Townsend JM, Selwyn PA. The Residency Program in Social Medicine of Montefiore Medical Center: 37 Years of Mission-Driven, Interdisciplinary Training in Primary Care, Population Health, and Social Medicine. Academic Medicine 2008; 83:378–389.
5. Pear R. “Panel on Health Care Work Force, Lacking a Budget, Is Left Waiting.” New York Times, February 24, 2013.
6. Association of Academic Health Centers. Out of Order, Out of Time: The State of the Nation’s Health Workforce. Washington, DC: Association of Academic Health Centers, 2008.
7. American Colleges of Physicians. The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care: A Report from the American College of Physicians. Philadelphia, PA: American College of Physicians, January 30, 2006.