Free Medical School?

UC Riverside Medical Research Building RS

One of the most compelling medical stories in the country is unfolding within the sprawling landscape of inland Southern California. The story centers on the University of California, Riverside School of Medicine where G. Richard Olds, MD, the school’s dean, is taking on one of the uber challenges in health care today: How to get doctors into areas significantly underserved by health care professionals.

The UC-Riverside School of Medicine is in its infancy having welcomed its first class of 50 students just last year. But it has embarked on an innovative program fueled by a passion not only to get doctors into geographic areas where they are most urgently needed, but also to make sure these physicians practice specialties most in demand. “There are 18 new medical schools in the United States and the vast majority are just like existing medical schools,” says Dean Olds. “We are substantially different than most other new schools. We are designed around a unique mission – to try and address the health workforce needs of inland Southern California. We need to train health care professionals who come from backgrounds and communities they will be taking care of.”

Serving One’s Hometown The dean notes that research indicates that about “40 percent of the decision of where doctors practice is determined by where you come from. Therefore we would not be successful in our mission if we did not give priority to those students from our geographic region.” Applicants from throughout the vast inland Southern California area are given a recruitment advantage over students from more populous areas. In the first class of 2013, only about 10 percent of applicants were from the geographic region but 50 percent of those admitted are from the area. “When you are giving geographic preference, you have to work at it to also get an academically well-prepared class,” he says. But the dean is clear that this does not mean compromising on the quality of students. Dean G. Olds, University of California, Riverside School of Medicine
Dean G. Richard Olds, UC Riverside School of Medicine

The first two classes include students with test scores comparable to the average of all U.S. medical schools. When the school opened two years ago, there was an avalanche of applicants – 2,600 in all. From that pool, the school offered admission to only 83 students and filled a class of 50. The geographic challenge is immense. Riverside and San Bernardino counties — commonly known as the Inland Empire — combined are geographically larger than nine states, with Riverside County remaining among California’s fastest-growing counties. In addition to finding students from areas most in need, Dean Olds and his team are encouraging students to pursue the specialties in greatest demand by patients throughout inland Southern California. Within primary care, the need is for physicians specializing in general internal medicine, primary care pediatrics, and family medicine. In addition, there is a great need for doctors specializing in psychiatry, obstetrics and gynecology, and general surgery. This presents a double challenge: Attracting students from the areas that need physicians most and having those students go into fields where the need is greatest. A couple of forces steer many students away from primary care, says the dean. “Most medical school faculties are biased against primary care,” he says. But at UC-Riverside, “the vast majority of our faculty come from the six disciplines we are encouraging, and as a result they create very positive role models for our students.” Providing ‘Mission-based Scholarships’ The other barrier, of course, is money. “Often people do not go into primary care because high indebtedness from tuition discourages students to go into a field they see as having lower compensation,” says Dean Olds. “Attempts to address that – loan forgiveness, for example – have not been terribly effective because they occur after the students have decided on their specialties.” Thus, a program at UC-Riverside has been started where students going into one of the six most needed disciplines receive a “mission-based scholarship” to attend medical school for free. Subsidizing tuition serves students who are in need of financial support while at the same time attracting the students UC-Riverside needs to the specialties most in demand. “We blatantly stole this idea from the military. If you go into one of the six fields and practice in inland Southern California for a minimum of five years then medical school is free.”

“Often people do not go into primary care because high indebtedness from tuition discourages students to go into a field they see as having lower compensation.” — G. Richard Olds, dean of UC-Riverside School of Medicine

These “mission-based scholarships” are funded by a mix of medical school funds and private donors. The first class included just two such scholarships, but in the current class there are 10 students and the dean anticipates there will be as many as a dozen next year. While California law prohibits affirmative action based on race, Dean Olds and his team have developed a definition of diversity that serves the medical school’s goals. “We define diversity as first in the family to go to college, English as a second language, and educationally and/or economically disadvantaged status. In our initial class, 44 percent of our students come from a disadvantaged background,” he says. “This is in sharp contrast with most medical schools where the vast majority of students come from affluent families. We have many students who come from the social background and fabric we are serving.” Research shows such students are more likely to practice in underserved communities like the communities they come from. Pell Grants go to undergraduate students who are economically disadvantaged. Remarkably, UC-Riverside has more Pell grant recipients than all but one of the other UC campuses — and more than all of the Ivy League schools combined. Outpatient Training in the Community Serving communities in need animates the whole UC-Riverside program. Another element of this is having students train in outpatient clinics. “A big problem in existing medical schools is that they use primarily inpatient university hospital experience as the principle teaching platform,” says the dean. “Because of that most students don’t see much ambulatory-based medicine and they certainly don’t get experience with primary care. “We’ve changed that to largely outpatient-based experience. All of our students spend three years adopting a clinic, working with teams in the clinic. Our students also adopt the community in which that clinic exists. They not only learn to take care of patients but they also learn about population health management, practice-based improvements, and the social determinants of health.” One of the big questions in health care today is this: How big is our ambition? The UC-Riverside program is massively ambitious and rightly so. The multiple challenges in health care will not be solved unless we identify the mega challenges with which we are faced and find solutions. Attracting the right students from the right places into the most needed areas of medical specialization? Now that is a mega ambition. See this article from the Atlantic: “Why Are There So Few Doctors in Rural America?” Getting this medical school up and running has taken years and an ability to maneuver skillfully through a state budget minefield. But the school is in full swing with a powerful sense of hope and optimism surrounding it. It is a grand experiment holding risk, of course, but great promise, as well. We are rooting hard for its success. Is this a scalable concept? Do you know of other models or pilots that jointly address student and community needs?

3 replies »

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  2. The above may be one step in filling rural physician positions, though it still leaves the very big hole of filling all the ongoing infrastructure costs (EMR, regulatory, insurance, lab, transportation), pharmacy needs, and personnel for the clinic. Given that most rural areas are only served by one commercial insurance product (if any), along with a large Medicaid/Medicare base, and you have the recipe for poor reimbursement.

    Here is hoping that they are planning to look that far forward.

  3. This is a great step in the right direction for rural Primary Care. I would look for programs that have it as a priority, perhaps the only thing it does, and join forces. Large University and Medical Center complexes are not serving this effort. The ACGME and its ilk are frankly obstructing the ability to have smaller programs that focus on smaller communities and thrive in rural areas. The workforce is in general, poorly prepared for doing full scope, high quality Primary Care. The current model has done very well at creating a referral machine for subspecialists. I don’t think redemption is possible for it. Starting anew, as suggested, may be the only way out. The payment issue is only part of the equation. There has to be a system that cultivates the right people for the job and deals with the endless discouragement facing those who would really like to go back to their hometown and practice medicine. In the last year, I have personally witnessed community hospitals closed, ambulance service eliminated, and Primary Care clinics abandoned in rural areas. In the background is the empty talk about support for community medicine, need for access, health care disparities, blah, blah, blah. It is critical that the economics behind these disturbing trends be addressed; least good ideas like this suffer a similar fate.