Department of Family Medicine Medical Student Education Section University of Washington E304 Magnuson Health Sciences Building 206.616.7889

Kimberly Kardonsky, MD Sharon Dobie, MD, MCP Lynn Oliver, MD Genya Shimkin, MPH Audrey Lew

September 19, 2019 Dear Colleagues, The Underserved Pathway (UP) is pleased to share our 2018-2019 Annual Report. This year, the Pathway team continued its work delivering content and experiences that build on and enhance students’ required curriculum. Students strive to gain or expand their understanding of working in underserved communities and we are proud to highlight their accomplishments. We continue to have close ties with the Community-focused Urban Scholars Program (CUSP) and the Targeted Rural/Underserved Track (TRUST). We look forward to continued participation and support from medical students, mentors, and other team members in the WWAMI region. Together, we will make health care more equitable and accessible for all. Please feel free to contact us with any comments or suggestions. Kimberly Kardonsky, MD Underserved Pathway Director Sharon Dobie, MD, MCP Underserved Pathway Faculty Lynn Oliver, MD Underserved Pathway Faculty Genya Shimkin, MPH Underserved Pathway Program Manager Audrey Lew Medical Student Education Section Manager

Students in the Underserved Pathway complete curricular and extra-curricular requirements across all four years of medical school.

UNDERSERVEDPATHWAY

UPATH@UW.EDU

Students enrolled in the UnderservedPathway are more likely than their non-Pathway peers to match in a Primary CareResidency (57% compared to 46%).

PrimaryCare Match

Rate

307StudentsEnrolled

692019

Graduates

UW SCHOOL OF MEDICINEDEPARTMENT OF FAMILY MEDICINE

2018-2019 Annual Report

57%

In May 2019, 69 students graduated with aCertificate from the Underserved Pathway. Thisis a 10% increase over our 2018 graduating class!

72 Pathway Scholars are entering their fourthyear and are eligible for a Pathway Certificateat Graduation 2020!

Students from all six WWAMI sitescomplete the Pathway. Montana has thehighest enrollment rate of any campus.

THREE Underserved Pathway scholars were selected forthe 2019 Husky 100, which highlights the University ofWashington's most dynamic and engaged leaders!

206.616.7889

@UWSOM_UP

Kimberly Kardonsky, MDPathway Director Sharon Dobie, MD, MCPPathway Faculty Lynn Oliver, MD, DTMHPathway Faculty Genya Shimkin, MPHProgram Manager

Overview

The Underserved pathway (UP) launched 12 years ago at the University of Washington School of Medicine (UWSOM) with three aims:

1. Address physician shortages in underserved areas 2. Support students who have an interest in careers working with underserved populations 3. Provide curricula important to this work and not necessarily taught in the general medical

school curriculum.

The UP helps to train medical students to work with underserved and vulnerable populations locally, nationally, and globally; this is a key goal in the mission of the UWSOM.

The UP has several components including curricular and extra-curricular components, which span across all four years of medical school, and all three phases of the curriculum. Students enroll during Foundations Phase and complete components throughout their time in medical school. Figure 1 is a schematic of the phases of the curriculum and the UP components.

Figure 1

Participation 307 students participated in the UP during the 2018-2019 academic year. In May 2019, 69 students graduated with UP certificates. Since its inception, 435 students have graduated from the UP (Figure 2). We continue to see interest from students across our six campuses. Figure 3 shows the percentage of enrolled UP scholars from each Foundations Campus. Figure 4 shows how many students from each Foundations Campus are enrolled in the UP. The campus with the highest percentage of enrolled students is Montana, with 47% of its students enrolled in the Pathway. Alaska and Seattle have a 28% enrollment rate, Idaho has 25% Wyoming 23%, and Spokane 20%. These figures help guide our recruitment strategy for the entering class of 2019.

Figure 2

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2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020*

Number of Pathway Graduates, 2008-2019

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Figure 3

Figure 4

8%

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19%

39%

6%

15%

UNDERSERVED PATHWAY ENROLLMENT, BY FOUNDATIONS CAMPUS, 2018-2019 (N=307)

Alaska (UAA) Idaho (UI) MSU Seattle UWYO Spokane

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Underserved Pathway Students vs Non Underserved Pathways Students by Foundations Campus, N=1061

Underserved Pathways Students (n=307) Non-UP Students (n=754)

Mentorship

We have been fortunate to have 176 active mentors this past year. Many mentors have more than one mentee at a time, with some mentors (especially TRUST preceptors) having several mentees. Mentors and mentees meet once per academic quarter and this can be in person, by email, phone, or skype. Students may seek out a mentor based on their cultural background, specialty, geographic area, or practice with specific underserved populations. Primary care is the most common specialty of mentors but the UP benefits from having a variety of specialists and physicians from the different regions in WWAMI volunteering their time to mentor students (Figures 5 and 6). While most students select their own mentor, pathway staff work with students seeking guidance in finding a mentor. Sharing the joys and challenges of working in an underserved area is a key component of UP mentorship. We already have a few UP graduates that are mentors and hope that we continue to build that cohort.

Figure 5

As you can see, our mentor pool has an overrepresentation of physicians from Western Washington. We are always looking for more mentors throughout the region, and particularly from rural communities, Native American reservations, and military bases and/or Veteran’s Affairs. If you have colleagues that you think would make excellent mentors, please let us know! Our goal is to continue building a community of mentors who represent the diversity of our region and the interests of our students.

16

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Number of UP Mentors by Region, 2018-2019n=176

Figure 6

We were fortunate to have financial support from the King County Academy of Family Physicians to host a “Speed Mentor” event based in Seattle in April 2019 featuring a variety of practices in underserved communities. Another goal of this event was to introduce medical students to possible UP mentors since a majority of the student participants were in their Foundations Phase (the first 16 months of medical school) which is primarily classroom based. The event featured 12 local primary care physicians, and 20 medical students. We received positive feedback and are planning a follow up event on October 8th, 2019 in partnership with the Seattle Family Medicine Interest Group.

Service and Advocacy

Pathway scholars are required to complete 24 hours of service learning throughout medical school. We find that in general, students go above and beyond that requirement. Students are involved in a variety of activities, including volunteering at free clinics, health fairs, mentoring events, or advocacy work. Many UP scholars take on leadership roles in Service Learning,

62%

4%

16%

7%

4%1%

6%

UP MENTORS BY SPECIALTY, 2018-2019N=175

Family Medicine Emergency Internal Medicine Pediatrics Psychiatry Surgery Other

demonstrating their willingness to go beyond the minimum requirements and truly commit themselves to their service.

Three of our pathway students were Husky 100 honorees in 2019! The Husky 100 recognizes 100 students across the entire University of Washington who make connections between classroom learning and practical experience and who apply what they learn to make a difference on campus or in their communities. We are extremely proud of Laurie Bazan, Jess Dawson, and Garrett Strizich, who exemplify commitment to community, equity, and excellence. All UP students are doing work outside of the classroom and clinics to make health care more equitable, and we are delighted that the University recognizes the exceptional work of our Pathway scholars.

Outcomes

In the 2019 residency match, 57% percent of UP graduates matched in primary care (defined as Family Medicine, Pediatrics, Medicine-Primary, Internal Medicine, Medicine-Pediatrics) compared to 46% of the total UWSOM graduating medical students. Figure 7 show the breakdown of students matching in all primary care specialties. Figures 8 and 9 show the breakdown by primary care specialty for UP graduates and the full School of Medicine class.

Figure 7

46%54%

UWSOM GRADUATES MATCHING IN PRIMARY CARE,

2019. N= 264

Primary Care Other Specialties

57%43%

PATHWAY GRADUATES MATCHING IN PRIMARY CARE, 2019. N=69

Primary Care Other Specialties

Figure 8

Figure 9

29%

15%

7%0%6%

43%

PATHWAY GRADUATES MATCHING IN PRIMARY CARE, 2019. N=69

Family Medicine Internal Medicine Medicine-Primary

Med-Peds Pediatrics Non-Primary Care Specialties

17%

16%

5%2%

6%

54%

UWSOM GRADUATES MATCHING IN PRIMARY CARE, 2019. N=264

Family Medicine Internal Medicine Medicine-Primary

Med-Peds Pediatrics Non-Primary Care Specialties

Modules and Evaluations A key component of the UP curriculum is our online modules; all students are required to complete 10 modules from a list of 27 options. Topics range from skills-based content (for example, health literacy), to overviews of specific populations (LGBTQ health, immigrant and refugee health, rural health), to modules that focus on specific medical conditions (substance use disorders, HIV). The module content is publicly available! You can view our modules at the following link: https://canvas.uw.edu/courses/1176574

All participants are required to complete “Who are the Underserved” and TRUST scholars complete “Understanding Population Health Data” as part of a series of assignments to learn about their TRUST community. Aside from those modules, the most visited modules are “Intimate Partner Violence,” “Ethics of Medical Volunteerism,” “Introduction to HIV,” and “Advocacy I: Physicians as Advocates.” Changes to some modules’ structure affected student participation. For example, we separated our Advocacy module into two new modules, and did the same for the former module on “Chronic Poverty and Low-Income,” which is now two separate modules: “Poverty: Definitions, Characteristics, and Trends” and “Poverty and Health.”

Upon completion of a module, students are directed to an online evaluation, which helps us track participation, content quality, and student feedback. Figure 10 shows how many students submitted an evaluation for each module. Of the 496 module evaluations submitted during the 2018-2019 school year, 327 (66%) reported the module content contributed “a great deal” or “a good deal” to their knowledge. Further, 319 (64%) rated the content as “extremely effective” or “very effective” at conveying information. The module that students rated most highly in terms of its contribution to their knowledge was “Oral Health.” We also ask scholars to rate whether the module content is encouraging or discouraging of their interest in care of the underserved. “Oral Health,” “Intimate Partner Violence” (which we overhauled and updated this year), “Health Literacy” and the new “Human Sex Trafficking” ranked as most encouraging (Figure 11). In this figure we included only those modules which had 10 or more evaluations.

Figure 10

Figure 11

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COUNT OF MODULES EVALUATED 2018-2019, BY TITLEN=496

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Percent Reporting Module Content Was Encouraging for their Interest in Care of the Underserved

New Modules

The newest UP modules are “Veterans’ Health” and “Human Sex Trafficking.” We retired “Reflections: Chimamanda Adichie and The Danger of a Single Story” because it has been taken on as required curriculum in the UW School of Medicine. For the development of the Veterans’ Health module, the Pathway team worked with several Veterans in our community, including medical student and faculty veterans, to help frame and add content to the presented information.

During the 2018-2019 school year, we offered three in-person modules (live events featuring a guest speaker, panel discussion, or lecture) that completed a series on Poverty featuring Professor Scott Allard from the UW Evans School of Public Policy and Governance. Dr. Allard was mindful of the questions that students asked and incorporated information from questions for subsequent live modules. These were available via Zoom to all students, every state, all years. Across all three lectures, over 120 students participated in these in-person modules.

Since UWSOM covers a five-state region, one goal is to have one of the WWAMI sites outside of Seattle host or co-host a live module. We are excited to report that we received funding from the Washington Academy of Family Physicians to do a live-module based in Spokane. We are organizing a panel of physicians from different settings who prescribe medications to patients with opioid use disorder. Following the panel, we are hosting a dinner reception for Spokane-area medical students (including students from the new Washington State University program) and local physicians. We hope this event will encourage connection between medical students, and serve as a recruiting space for both students and mentors. The event is scheduled for November 14th, 2019 at the John J. Hemmingson Center – Third Floor Ballroom at Gonzaga University. If you’re interested in joining us, please email upath@uw.edu for more information!

Community-focused Urban Scholars Program and Targeted Rural Underserved Track The Community-focused Urban Scholars Program (CUSP) is now in its third year. All CUSP Scholars will participate in the UP and complete primary care practicum at an urban underserved site in Seattle. There will be four new CUSP scholars welcomed in the fall of 2019. For the incoming class of 2020, CUSP will have separate admissions, similar to the TRUST admissions process. The CUSP team is also in the process of exploring expansion to the Spokane and Anchorage Foundation Sites.

Effective for the class entering Fall 2019, The Targeted Rural Underserved Track (TRUST)

students will continue to have some required UP curriculum and then participate in the full UP experience if they elect to do so. This is a change from requiring all TRUST students complete the full UP, which is still the requirement for students entering before 2019. Since many of the requirements of the UP are met within the TRUST experience, we look forward to working with students, faculty, and staff across WWAMI to encourage enrollment in and completion of the Pathway by TRUST scholars.

Changes and Upcoming Projects

This fall we are excited to host our first in-person module in Spokane! The event will include a panel of primary care physicians who treat patients with opioid use disorders in multiple settings (for example, rural clinic, urban clinic, community health center). We are grateful to the Washington Academy of Family Physicians, which awarded us a grant to fund this event.

A follow up to our “Speed Mentor” event will take place in Seattle on October 8, 2019. Collaborating with the Seattle Family Medicine Interest Group, this event will be part of National Primary Care week, highlighting different family medicine practice sites within underserved communities and promoting mentorship/mentee matches within the UP.

We are also working to ensure that students throughout the WWAMI region are aware of the UP and have a clear picture of the benefits of UP participation. We will introduce the UP at multiple points during first year, and seek opportunities regionally to expose students to the UP and encourage participation. Further, we have extended our deadline to allow students who discover an interest in care of the underserved after starting clerkships to join later.

Tracking Outcomes Beyond Residency

The overall goal of the Pathway is to train future physicians for work in underserved areas and with vulnerable populations. We continue to work to track our graduates’ residency specialties and plan to compare the post residency sites of practice for UP graduates with other UWSOM graduates who did not complete the UP. We have received approval from the UW Human Subjects Division to undertake a research project exploring the practice sites of our graduates, and are working with researchers at the School of Medicine to review the data. We hope to publish a paper summarizing our findings in 2020.

Our Impact on Students

Each spring, we ask graduating Pathway scholars to complete a Graduation Survey, which asks them to reflect on their time in the Pathway, give feedback on program components, and offer suggestions for future directions. Our scholars are candid, thoughtful, and sincere in their feedback, and we are proud to work from their feedback to improve our programming. From their comments, it is clear we are meeting our goals:

“I feel I have gained a feeling of connectedness to other students who are interested in working with underserved patients. I also got some great info

from the modules, especially the Medicaid and Medicare ones.”

“There is a lot if information to cover over the course of medical school, and participating in the Underserved Pathway carved out time to focus on crucial

socio-medical issues that may have otherwise been lost in the shuffle. I gained a deeper understanding and awareness of many key issues that I will

encounter as a physician, and felt challenged and encouraged to consider what my response would be in those scenarios. Through the modules, I

learned some data and information that piqued my curiosity in issues of which I had a surface-level understanding beforehand. The most beneficial aspect

was taking clinical electives in underserved settings; it reinforced my desire to do that kind of work for my career.”

Perhaps our biggest point of pride is the fact that, after graduating 11 classes of physicians, our alumni are now volunteering their time as Pathway mentors. To have this full-circle program reflects the power of this model and the willingness of our alumni to pay it forward and offer support and guidance to the next generation. We are honored that they choose to return to the Pathway as practicing physicians.

We are grateful to have such a dynamic, supportive, and passionate community for our students. Thank you for being part of that community.

PATHWAY MODULES AT-A-GLANCE

modules with80+% positive

rating

496evaluations

UW SCHOOL OF MEDICINEDEPARTMENT OF FAMILY MEDICINE

The Underserved Pathway team moderates studentcomments on 27 online modules, and collects student

feedback on module content and effectiveness.

7

Exploring Disability: Beyond the Medical Model "I thought this was the best module I have doneso far. Very thought provoking!"

Oral Health: "I thought this module did a very good job of bringingoral health/dental care access disparities to light. Ilearned a lot about the impacts of oral health on thehealthcare system and individuals and recognized areasin which I could help to decrease barriers to care."

Who Are the Underserved?:

"I really like the definitions of underserved, vulnerability,inequality, inequity, etc. It's good to have a basicunderstanding of these things."

66%

34%

66%positive

contribution toknowledge

In evaluations, students rate modules' contribution to their knowledge, effectivenessas conveying information, and impact on their interest on care of the underserved.

Veterans' Health (new this year!): "I did not realize the VA did not cover all veterans, solearning about what they have to have to qualify for VAcare was extremely valuable. I really enjoyed the videosabout military culture."

Health Literacy: I love the resource to assess readability of text. This isnow bookmarked on my computer. Thank you!

After an update in 2019,"Intimate Partner Violence"jumped from number 8 tonumber 2 on the list of mostpopular modules!

During 2018-2019, we hosted athree-part lecture series onPoverty and Health, featuringProfessor Scott Allard fromthe UW Evans School!

Student Comments and Feedback