Pipeline Issues: How to
Get the Right People
Into the Practices that
Make a Difference
Scholarship in Medicine Series
Maine Dartmouth Family Medicine Residency
Harold Alfond Center for Cancer Care
July 26, 2011
Donald Kollisch, MD
Deputy Dean for Academic Affairs
Sophie Davis School of Biomedical Education at The City
College of New York
Which Practices “Make a
Difference” ?
Are located in the right place
geographically
Have systems in place to respond to
community needs
Have financial incentives well-aligned
with best-practices
Fit into broader systems of care
(regional, state, national)
Theoretical Models for Practices
that Make a Difference
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Community Oriented Primary Care
Patient-Centered Medical Home
Examples of Practices that
Make a Difference
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FQHC’s
RHC’s
Hospital/State sponsored CHC’s
Who are the “Right People”

Personal characteristics
Attitudes well-aligned to practices
that care for underserved
communities
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Dedicated
Compassionate
Patient
Flexible
Who are the “Right People”

Training characteristics
• Knowledge
• Skills

Social attributes
• Rural/Urban
• Ethnicity
• Gender
Rural Health Pipeline
Admissions
Medical school
Decision
to be a
Doctor
•Family
•Middle School
•High School
•College
Choosing a practice
Residency
Residency selection
Practice
Retention
Rural Doctor
•Primary care
-Family Med
-Internal Med
-Pediatrics
•Surgery
•Ob-Gyn
•Psychiatry
•….others..
Recommendations from Executive
Summary
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Create more opportunities for students and
young physicians to trade debt for service,
through effective programs such as the
National Health Service Corps.
Reduce or resolve disparities in physician
income.
Admit a greater proportion of students to
medical school who are more likely to
choose primary care, rural practice, and
care of the underserved.
Study the degree to which educational debt
prevents middle class and poor students
from applying to medical school and
potential policies to reduce such barriers.
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Shift substantially more training of
medical students and residents to
community, rural and underserved
settings.
Support primary care departments and
residency programs and their roles in
teaching and mentoring trainees.
Reauthorize and revitalize funding
through Title VII, Section 747 of the
Public Health Service Act.
Study how to make rural areas more
likely practice options, especially for
women physicians.
New medical schools should be public
with preference for rural locations.
What is missing?
The earlier portion of the pipe.
Who are the people who go to medical
school?
How do the right people get to BE
the right people?
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Genes
Up-bringing (family, community)
School
• K-12
• College
• Medical

Residency
Pipeline
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What are the pathways – for it is not
a single pathway - by which (young)
people end up as Primary Care
doctors for the Rural and Urban
Underserved?
Which level(s) of the pipeline are
crucial?
How can we keep the big picture in
mind?
Pipeline
Pipeline 2
Mission of Sophie Davis School
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Provide access to medical education
for youth from under-represented
minorities and economicallydisadvantaged families
Promote careers in Primary Care
Promote careers in Underserved
Communities
Provide an excellent educational
program to prepare learners to enter
clinical training
Special Features of Sophie
Davis
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Students admitted straight out of
high school – recruiting and pipeline
programs
Students agree to provide 2 years’
primary care service in a physician
shortage area of New York State
after completing residency –
primarily urban
Approximately 20% attrition
(voluntary or dismissed)
Unique Structure and
Curriculum: 7 year combined
BS-MD
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First 5 years at City College on our
Harlem campus, with components of
Baccalaureate PLUS the “basic
sciences” which usually comprise the
first 2 years of Medical School
Final 2 years at one of 6 “cooperating”
schools: Albany, Dartmouth,
Downstate, New York Medical, NYU,
Stony Brook
Sophie Davis Curriculum
Physical Diagnosis
Introduction to Medicine
Systemic Pathology
Neuropsychiatry
Host Defense, Infection and Pathogenesis
Pharmacology
Step
11
Behavioral Medicine
Systemic Functions
Step 9
Step 8
Neuroscience
Step 7
Structure
Step 5
Molecules to Cells
College
courses,
including premed
requirements
Step
3
Step 6
Step 4
Step 2
Step
1
Community Health
COPC
Patient-Doctor (interviewing)
Step 10
Step
12
Diversity

Why is diversity an issue?
• Social equity and fairness
• Historically, middle and upper class white doctors tend to
practice in the social communities from which they came
• And, historically, doctors from minority communities tend
to practice in the social communities from which THEY
came
• A diverse class in school and residency can be an
important component of social education
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AAMC: “Underrepresented in medicine means
those racial and ethnic populations that are
underrepresented in the medical professions
relative to their numbers in the general
population.” (2004)
How fine is the definition cut?
Does “Low-income” count? YES!
Diversity at Sophie Davis
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Ethnicity:
• 1/3 African-American
• 1/3 Asian-American (South and South-East)
• 1/6 Latino-American (Dominican, Puerto Rican, South
America)
• 1/6 Caucasian
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Gender:
• 60-65% female
• 35-40% male
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Low-income:
• 32% from families below 100% of the FPL
• 75-80% are eligible for Financial Aid at City College
(where tuition/fees are $5,000/year)
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Immigrant 25%
First-generation 57%
Challenges and Lessons Learned
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Of the 20% who leave Sophie Davis, ¾ are URM
Students who come from at-risk communities
have extraordinary social as well as academic
challenges
Each Cooperating School wants >1/2 of “their”
transfers to be URM and from the upper half of
the class
Students from “humble origins” are perceived by
Cooperating Schools as beneficial to their
schools, even if not URM
One of the ways to get away from the poor
predictive value of MCATs and college GPAs is to
get away from MCATs and GPAs
Dissemination of this model is limited by
availability of Clerkship slots, especially facing
competition from Caribbean schools
Sophie Davis in the Pipeline
Can we generalize from Sophie
Davis to the needs of Rural Maine?
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What are the pipeline programs of Maine?
• AHEC
• FAME - Financial
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Maine Health Professions Loan Program
Doctors for Maine’s Future Scholarships – Tufts/MMC or
UNECOM
• Exposure – the “Cambridge” model in smaller rural
hospitals via Tufts/MMC
• Service Obligation?
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“Binary” program – BS/DO (UoM/UNECOM)
Who else is working on the pipeline earlier than
college?
Who is working on the Pipeline in
Maine?