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BY: FRED ROTTNEK, MD, M.A.H.C.M. AND BRIAN YANOFCHICK, M.A., M.B.A.

Implementation of the Affordable Care Act has many in health care working overtime to prepare for significant shifts in how patient care is delivered and how providers are paid for what they do. In all discussions, one concern persists that predates this law: In the U.S., we do not have enough physicians who are providing direct patient care. The shortage affects all of us in Catholic health care — we cannot carry out our mission if our systems are lacking physicians. And we cannot provide patient-centered, effective, safe, cost-effective care without dedicated and fulfilled physicians.

We continue to have a steady stream of applicants to the healing professions, and we are training more physicians than ever before. But training more students is not correcting our society's shortages and disparities. Even if we are able to admit the right student, we are not guaranteed the graduation of a physician with values and competence we prize. Likewise, a practicing physician may not have developed the personal strengths and resilience that supports a lifeline practice of patient care.

Our society's (and Catholic health care's) challenges include recruiting a diverse workforce that reflects the populations we serve, training physicians in areas of societal need and retaining physicians in patient care for the full course of their careers. This is our goal, our Point B. To get from Point A — students matriculating into medical school — to Point B, we must re-envision medical education. Catholic health systems can support this change. We must, because we need the workforce. We cannot continue the same traditional training process, increase the volume and expect different results.

Saint Louis University is one school that is adapting in order to address these needs. Known as SLU, it is a Jesuit, Catholic university which fosters the intellectual and spiritual growth of over 13,000 students through a broad array of undergraduate, graduate and professional degree programs. The Jesuit ideal of academic excellence is based upon the conception of the person as a free and responsible agent capable of making a difference for good or ill in the world. Hence, SLU directs its educational efforts to help students develop as critically reflective and socially responsible persons capable of exercising leadership in advancing the cause of human good.

STARTING AT POINT A
Born between 1980 and 1999, Millennial students (Gen Y), ages 32 years and younger, are our medical students today. They are an idealistic, generally optimistic lot. They have high expectations of self and others. Cherished as children, they are accustomed to praise and external validation. They expect support from people and services as well as very explicit guidelines, instruction and feedback. They are interested in, and often even expect, mentoring.

In their applications to SLU, the majority of these students are idealistic and state that they wish to operationalize this idealism (albeit often idealistically) in the course of their medical education. They crave community engagement and service, and they speak of the social mission of medicine. They seek lessons in advocacy, education skills and leadership. They want a balanced life and time for a family and individual pursuits.

Unfortunately, there are not yet many of them in academics. So while we are busy responding to their learning styles by adapting our didactics, we must also respond to their idealism in a manner that fans, rather than snuffs out, the flame of humanistic medicine.

So, although our students may start off with the best of intentions toward achieving their idealized careers, they can soon fall off this path after encountering the realities of medical studies. In the application to the medical school's Rodney M. Coe Distinction in Community Service program, students state why they wish to be part of a four-year, longitudinal, faculty-mentored community service program. Here are excerpts from three individual first-year medical student applications:

"Upon entering medical school, a goal of mine was to keep the human side of medicine in perspective throughout all four years of study. It has been only three and a half months, and I can already feel that human interaction slipping away. There is always more material to read and lectures to watch, and as hard as we try, building leadership and communication skills takes a back seat."

"It was one week before the first human anatomy exam when I found myself on the phone with my mom assuring her that classes were great and I had made new friends; the truth was I felt down and not myself. Having been in medical school for only a few short weeks, I had already recognized the ease with which I fell into a class-focused mindset and found myself anxious about how I measured up to my peers …."

"I do not want to lose the sense of humanity that originally attracted me to medicine. More specifically, I am not interested in the big, dramatic moments of medicine; I find solace in the small moments, the simple pleasures of making connections with others, engaging in conversation, and learning more about myself and the surrounding world."

Clearly, these students have identified some of the barriers they face. Our challenges as faculty are responding to these students' needs and promoting the flourishing they require for successful professional formation.

PROFESSIONAL FORMATION PROGRAMS
We in Catholic health care often find ourselves looking for ways to help our physicians maintain and recover some of their initial idealism. We want to be a unique workplace where physicians are encouraged to practice both the science and the art of medicine. We hear our physicians describe the loss of a sense of collegiality among themselves, leaving them to cope with the stress of their work on their own. Many, having only a diminished sense of meaning in their work, grasp at personal gain as a weak substitute for true personal satisfaction.

At SLU we have cultivated collaboration among the School of Medicine, community agencies and the SLU Area Health Education Center program office to create programs and provide faculty leadership and mentoring to students for community-based, primary-care-focused course work and experience that promote student wellness and education towards understanding community need.

The programs have these things in common:

• Explicit links to school mission and program objectives
• Explicit links to vocation and sense of self, the development of professionalism, which include
  – Commitment to lifelong learning (including a reflective mindset)
  – Resilience (ability to weather challenges, changes, barriers)
  – Perseverance (ability to continue practice and prevent burnout)
  – Self-knowledge (in terms of assets/strengths)
  – Maintenance of an internal locus of control and self-regulation
  – Response to the need of the community/those whom the profession serves
• Critical reflections, with a regular format encompassing:
  – What? The recall of a specific event
  – So What? What personal attitudes or emotions came up about this event? What cultural, personal, or system factors contributed to this event?
  – Now What? How does the personal experience relate to project/course themes or objectives? How may this event and reflection inform a developing clinician's knowledge, attitudes and behaviors?
• Explicit links to a professional practicing within a community
• Explicit structure, opportunities and expectations for success
• Faculty mentoring and support of aspirations and objectives

Programs such as these help to encourage medical students who will understand the commitments we hold to be core to who we are as Catholic health care:

• Promoting and defending human dignity
• Attending to the whole person
• Caring for the poor and vulnerable
• Promoting the common good
• Acting on behalf of justice

It is interesting to note that in SLU's experience, many of the students who choose the school indicate a personal congruence with many of the principles of Catholic social teaching, regardless of their faith background.

MENTORED COMMUNITY SERVICE
The Rodney M. Coe Distinction has been awarded to medical students upon their commencement from SLU since the class of 1995. This distinction program recognizes students who commit to a minimum of 180 hours of mentored service with a community agency. It requires annual individual and group meetings, reflection summaries of service and a mentored fourth-year project. The distinction is limited to a maximum of 25 students, and mentors are faculty from within the Department of Family and Community Medicine. The program's intention is formation of physicians with an understanding of community need and successful engagement with community agencies, and 60 percent of Coe graduates have entered primary care. Current research in the department includes measuring outcomes of the program, including residency and first practice site locations and ongoing engagement of graduates in community service and practice.

EXPOSURE TO THE UNDERSERVED
SLU made several curricular changes beginning in 2009 to promote student wellness, class cohesion and education outside the walls of the classroom. One such change involved the development of five learning communities: student wellness, research, global health, academic medicine, and service and advocacy. To allow protected time for these interests, students received scheduled elective time in their first and second years of training — traditionally classroom-heavy years for instruction.

For the service and advocacy learning community, faculty from the Department of Family and Community Medicine are the students' advisers. Building upon long-standing relationships with community partners, faculty members have been able to guide students to agencies and projects of mutual benefit to the students, the agencies and their clients. In these electives, students are expected to develop two objectives: a program objective — what will be done, delivered or provided while working with the agency?— and a personal learning objective — what does the student expect to learn as a result of this activity and interaction? Many of the students engaged in the service and advocacy electives also are Coe students, and all students in these electives benefit from a structured, advised program of community engagement.

Both the Coe Distinction program and the service and advocacy learning community electives are built upon data regarding physician formation. The data indicate these factors may help to increase the recruitment and retention of social-justice-minded trainees:

• Specifically including aspects of mission and social justice in the admissions and interview process
• Understanding that none of the physicians who train during residency in non-underserved areas decide on a job in an underserved area, so training must occur in communities of need
• Providing support mechanisms, including positive mentors, to help students along the way once they get into medical school.¹

We know that students must have early and repeated exposure across their medical school training to structured clinical and service experiences in order to develop the necessary skills and awareness that influence their decision to practice in an underserved area. Early exposure to medically underserved communities, populations and individuals, combined with medical training experiences in underserved settings, have a positive effect on later practice site choice.²

Random exposure to service in medically underserved areas does not, by itself, increase a medical student's skills or confidence level in being able to address the need of underserved populations. There is evidence to the contrary that commitment to caring for the medically underserved decreases with current medical school education.³

Students can develop and enhance their ability to address unmet community needs while they progress through their medical school training. They do so in structured, faculty-mentored, longitudinal service programs that focus on the development of leadership skills and self-efficacy at engaging in community-based service learning.^{4, 5}

Experiences that provide early exposure to positive primary care role models coupled with service learning, introduction to community-oriented primary care skills and critical reflection, have very positive impacts on students towards the goal of caring for the poor and medically underserved.^6,7 Students who encounter faculty role models with humanistic habits early in their training will try to emulate them as they advance. The mentoring relationships formed early in medical school through service learning and clinical shadowing enable students to form relationships that help guide them through clerkship training and professional discipline selection in the third and fourth year of medical school.⁸

Increasing the number and duration of these experiences can successfully influence students' residency choice and practice location decisions. Over the 11 years of the SLU Area Health Education Center program, 183 medical school graduates have selected family medicine residency programs, and 59 of those graduates entered family medicine residency programs in Missouri. By providing structured experiences, program will increase the number of primary care health care providers in underserved areas.⁹

COMMUNITY-BASED CLINICAL TRAINING
The Department of Family and Community and the SLU Area Health Education Program office provide over 75 percent of all the community-based ambulatory care clinical experiences for medical students at SLU. Moreover, greater than 40 percent of the family medicine training sites are in medically underserved areas of St. Louis.

In 2009, The Robert Graham Center for Policy Studies in Family Practice and Primary Care¹⁰ published a report that incorporates nearly 20 years' worth of survey data from graduating medical students about their experiences, their debt, their beliefs and their intentions. The report documents measurable student characteristics, intentions and training experiences that are significant predictors of what influences student and resident choices of practice location and specialty. Rural birth, interest in serving underserved or minority populations, exposure to Title VII-funded health professions workforce programs in medical school, and rural or inner-city training experiences all significantly increased the likelihood students will choose primary care, rural and underserved careers. By providing community-based training, SLU is providing needed exposure to clinical settings to promote diversity in practice sites.

INTERPROFESSIONAL EDUCATION
It was about a decade ago that an Institute of Medicine report, Crossing the Quality Chasm, described the condition of the health care system as failing to provide the health care needed by all the people of our country. It concluded that the system needed a complete redesign.¹¹ Among the recommendations, the report said care should be patient-centered, coordinated, evidence-based, documented by electronic health records and provided by interprofessional teams of health care providers. These themes now are included as components of the nationally proposed initiatives for reforming health care.

SLU integrated and embedded its Interprofessional Education (IPE) curriculum in the baccalaureate level health sciences programs in 2006. Since 2009, the SLU Area Health Education Center program has been leading efforts to integrate interprofessional education into the School of Medicine and collaborations across post-baccalaureate health professions programs.

CATHOLIC HEALTH CARE AND STUDENT DEVELOPMENT
Catholic health systems could benefit from closer collaboration with Catholic medical schools to nurture the careers of future physicians who see medicine as we do. This collaboration could include:

• Providing clinical training experiences, including "away rotations" at rural hospitals and clinics
• Becoming engaged in the curricula of Catholic medical schools to broaden students' understanding of the mission of Catholic health beyond prohibited services
• Developing mentoring programs sponsored by Catholic health systems to create relationships and guide students toward a deeper commitment to community health
• Sponsoring educational programs and faculty time to support professional formation for students and residents
• Taking advantage of available programs to recruit physicians to underserved areas and creating new recruitment programs to bring physicians to areas of greatest need

Much has been written about "hiring for mission fit" with regard to our recruitment of executive leaders in Catholic health care. Medical schools such as SLU's are adapting to the needs of our society and our ministries by educating physicians to meet our current and future health care challenges. Collaboration with Catholic medical schools offers an opportunity to nurture leadership long before the hiring point. Such efforts will contribute mightily to the future of a more compassionate, responsive and effective American health system.

FRED ROTTNEK is associate professor and medical director, Area Health Education Center program office, Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis.

BRIAN YANOFCHICK is senior director, mission and leadership development, Catholic Health Association, St. Louis.

NOTES

1. Health Workforce Information Center, Health Workforce News, (Nov. 2010) www.hwic.org/news/nov10 Accessed January 2012.
2. Laura A. Tavernier et al., "Does Exposure to Medically Underserved Areas during Training Influence Eventual Choice of Practice Location?" Medical Education 37, no.4 (2003): 299-304.
3. Sonia J. S. Crandall et al., "Medical Students' Attitudes toward Underserved Patients: A Longitudinal Comparison of Problem-Based and Traditional Medical Curricula," Advances in Health Sciences Education 12, no. 1 (2007): 71-86.
4. Adam O. Goldstein et al., "Teaching Advanced Leadership Skills in Community Service (ALSCS) to Medical Students," Academic Medicine 84, no.3 (2009): 754-809.
5. Cynthia L. Haq, Michelle Grosch and Donald Carufel-Wert, "Leadership Opportunities with Communities, the Medically Underserved, and Special Populations (LOCUS)," Academic Medicine 77, no. 7 (2002): 740.
6. Delese Wear and Mark Kuczewski, "Perspective: Medical Students' Perceptions of the Poor: What Impact Can Medical Education Have?" Academic Medicine 83, no. 7 (2008): 639-45.
7. E. Tippets and K. Westpheling, "The Health Promotion-Disease Prevention Project: Effect on Medical Students' Attitudes toward Practice in Medically Underserved Areas," Family Medicine 28, no. 7 (1996): 508-10.
8. Larrie Greenberg and Benjamin Blatt, "Perspective: Successfully Negotiating the Clerkship Years of Medical School: A Guide for Medical Students, Implications for Residents and Faculty," Academic Medicine 85, no. 4 (2010): 706-9.
9. Kathleen Quinn et al., "Influencing Residency Choice and Practice Location through a Longitudinal Rural Pipeline Program," Academic Medicine 89, no. 11 (2011): 1397-1406.
10. Robert Graham Center for Policy Studies in Family Practice and Primary Care, "Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student and Resident Choices?" 2009; www.graham-center.org/online/graham/home/publications/monographs-books/2009/rgcmo-specialty-geographic.html. Accessed January 2012.
11. Institute of Medicine, Crossing the Quality Chasm (Washington, D.C.: National Academy of Sciences, 2001): 48-51.

DOCTORS WORRY ABOUT MEETING DEMAND

A recent survey by The Doctors Company, a national doctor-owned malpractice insurance company, reveals significant concerns among its members. These include worries about their ability to meet the demands for care by 32 million newly insured Americans who will have access to coverage by 2014, especially given the current shortage of primary care doctors and nurses. These worries go beyond questions about capacity to concerns about their ability to spend enough time with patients to assure the right quality of care. This affects the patient, but it also affects career satisfaction for physicians. Among the 5,000 physicians who responded to the survey, an astounding 90 percent said they would not recommend medicine to others as a career. Over 40 percent stated they are considering retiring in the next five years because of changes they anticipate in the American health system.

MISSION STATEMENT OF THE SCHOOL OF MEDICINE

The mission of Saint Louis University School of Medicine is to educate future professionals from diverse backgrounds to practice and advance knowledge in medicine and the sciences relevant to medicine. The educational approach embraces integrated activities in basic and clinical research, in provision of patient-centered, compassionate, culturally competent health care, and involvement with the community through public service. These diverse educational experiences prepare individuals for careers and leadership roles in medicine and the medical sciences through training grounded in an understanding of the scientific method and an appreciation for personal commitment and service to others.