The Journal of Texas Medicine: August 2012

What the Joint Admission Medical Program (JAMP) Can Do for Texas Physicians; What Texas Physicians Can Do for JAMP 

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The Journal – August 2012 


 Tex Med. 2012;108(8):e1.

By Alan Podawiltz, DO, MS; James Richardson, DVM,  PhD; Wallace Gleason, MD; Kathleen Fallon, MD; David Jones, PhD; Elizabeth Kimberli Peck, MD; Jeffrey Rabek, PhD; Manuel Schydlower, MD; William Thomson, PhD; Russell T. Warne, PhD; Budge Mabry; Paul Hermesmeyer, MST; and  Quentin W. Smith, MS.    

Alan Podawiltz, DO, MS, chair, Department of Psychiatry, University of North Texas Health Science Center-Texas College of Osteopathic Medicine; James Richardson, DVM,  PhD, professor of pathology, Molecular Biology & Plastic Surgery, The University of Texas Southwestern Medical School, Dallas, Texas; Wallace Gleason, MD, professor of pediatrics and assistant dean for admissions, The University of Texas Health Science Center at Houston School of Medicine; Kathleen Fallon, MD, senior associate dean for student   affairs, Texas A&M University Health Science Center College of Medicine; David Jones, PhD, senior associate dean for admissions, The University of Texas Health Science Center at San Antonio School of Medicine; Elizabeth Kimberli Peck, MD, associate dean of admissions, Texas Tech Health Sciences Center, Lubbock, Texas; Jeffrey Rabek, PhD, assistant dean, Student Affairs & Admissions, The University of Texas Medical Branch at Galveston; Manuel Schydlower, MD, associate dean of admissions, Paul L. Foster School of Medicine in El Paso, Texas Tech University Health Sciences Center; William Thomson, PhD, assistant dean for continuing medical education, Baylor College of Medicine, Houston, Texas; Russell T. Warne, PhD, assistant professor, Department of Behavioral Science, Utah Valley University; Budge Mabry, director emeritus, Joint Admission Medical Program (JAMP); Paul Hermesmeyer, MST, coordinator, Joint Admission Medical Program (JAMP); and Quentin W. Smith, MS, associate professor, Allied Health Sciences and Family and Community Medicine, Baylor College of Medicine, Houston, Texas. Send correspondence to Quentin W. Smith, Baylor College of Medicine, 1 Baylor Plaza, MS 155, Houston, TX 77030; email: qsmith@bcm.edu.  


Abstract    

 

Texas faces health challenges requiring a physician workforce with understanding of a broad range of issues – including the role of culture, income level, and health beliefs – that affect the health of individuals and communities. Building on previous successful physician workforce "pipeline" efforts, Texas established the Joint Admission Medical Program (JAMP), a first-of-its-kind program to encourage access to medical education by Texans who are economically disadvantaged. The program benefits those from racial and ethnic minority groups and involves all 31 public and 34 private Texas undergraduate colleges and universities offering life science degrees, as well as all 9 medical schools. Available program data indicate that JAMP has broadened enrollment diversity in Texas' medical schools. However, greater progress requires strengthened partnerships with professional colleagues practicing medicine in communities across Texas. This article explores how JAMP can help Texas physicians and how Texas physicians can help JAMP. 


Texas Faces Significant Health Challenges    

 

Like the rest of the country, Texas faces many challenges to the health of its population, including many that will become more acute over the coming decades. Although not exhaustive in terms of coverage, some factors that contribute to the health challenges facing Texas include the following: 

  • Texas has seen and is likely to continue seeing dramatic population growth well into the future, with an increase projected to about 36 million by 2040.1,2 A logical result will be substantially greater demand for health care.3  
  • The population of Texans 60 years and older is projected to increase by 193% during the years 2000 to 2040.4 Demand for physician visits nationally is expected to increase by more than 50% by 2020 as a result of an aging population.5  
  • Racial and ethnic characteristics of the state are changing, with the proportions of Anglo and Hispanic Texans – currently just over one-half and one-third, respectively – expected to flip-flop by 2040.1 Understanding socioeconomic, cultural, and behavioral factors affecting health outcomes will assume growing importance in delivery of care to Texas' growing Hispanic population.6 
  • Epidemic rates of obesity and diabetes in the United States and in Texas are alarming.7,8 The added burden in health costs and morbidity associated with these conditions is staggering.8,9 
  • Decreases in ratios of primary care physicians to population have been documented in 106 Texas counties in the decade beginning in 1998, with 63 of these counties experiencing overall loss in numbers of primary care physicians.10 In 2007, Texas had 27 counties with no physicians at all.10 Inadequate access to health care is a problem for many Texans.
  • Texas is reported to have the highest rate (26% in 2009) of uninsured persons in the country.11 Even for persons with coverage under public programs, such as Medicaid and the Children's Health Insurance Program, finding care may be problematic. The numbers of Texas physicians willing to accept patients with such coverage is reported to be declining.12,13  

The previous summary paints a picture of a state in which preparing and recruiting physicians will remain a high priority over both the near- and long-term. In fact, reports from 2007 and 2008 indicate that although the gap showed signs of lessening, Texas still lagged behind the rest of the country in the ratio of direct care physicians per 100,000 population.10,14   


"Pipeline" Programs as a Strategy in Addressing Medical Workforce Needs      

 

Programs designed to facilitate access to careers in medicine, often referred to as "pipeline" programs, have existed since the early 1970s.15 By the 21st century, numerous pipeline programs were in place, many operating with some form of federal support.16 Although efforts to promote diversity in higher education were slowed following the landmark Hopwood v Texas ruling,17 the Grutter v Bollinger ruling in 2003 reinstated the narrowly tailored use of race in admission decisions to promote educational benefits flowing from a diverse student body.18 

Specific to the physician workforce and issues of diversity apart from race and ethnicity, an Association of American Medical Colleges (AAMC) report in 2008 included the observation that the percentage of students from the highest quintile in terms of household incomes has never been less than 48.1% of entering medical school classes. The report also noted that the percentage of students from the lowest quintile in terms of household incomes has never been higher than 5.5% of entering medical school classes.19  

Studies have also identified strong correlations between where a physician goes to practice and where he or she lived during preadulthood, attended medical school, and completed residency.20,21 A goal of the Joint Admission Medical Program (JAMP), described in the next section of the paper, has been to identify, recruit, and retain students into premedical and undergraduate medical programs who are more likely than their urban counterparts to pursue medical careers in rural areas.22-27 

The 2010 standards for accreditation published by the Liaison Committee on Medical Education (LCME) require that an accredited medical school have "policies and practices to achieve appropriate diversity among its students, faculty, staff . . . and must engage in ongoing, systematic, and focused efforts to attract and retain students, faculty, staff, and others from demographically diverse backgrounds."28(p5) These standards cite "institutionalization of pipeline programs" as one example of a strategy to achieve diversity.28    


Texas Launches a Bold Experiment in Fostering Medical Career Opportunities  

Even before the Grutter v. Bollinger ruling, leaders in Texas were exploring ways in which to address issues of underrepresentation of persons from disadvantaged backgrounds in medical education and medical careers. These efforts, initially focusing on racial and ethnic workforce disparities and the need to increase participation of underrepresented minorities in medicine and other health-related and scientific careers, eventually embraced a broader definition of diversity.  

 . . . a few visionary leaders saw the potential damage that could result from dampening efforts designed to enhance student diversity in medical school classes. These leaders took bold steps to identify . . . means within the law to achieve a more diverse physician workforce. In 2001, with strong and active support from the state's medical schools and bipartisan leadership from Texas state senators Teel Bivins and Royce West, the Texas legislature created JAMP. This program was designed to serve as a pipeline to medical school for economically disadvantaged students from throughout the state of Texas.29(p1374) 

JAMP was the first-of-its-kind program in the country. Beyond simply, "institutionalizing" a pipeline program, JAMP took the approach of creating a statewide program involving multiple undergraduate institutions and all of Texas' medical schools. Now in its 10th year of operation and 9 years after the first students entered in 2003,* JAMP admission is based primarily on socioeconomic status and academic performance indicators. Deliberate efforts are made to promote participation by students from racial and ethnic minority groups, as well as by students from families with little prior experience in accessing college.

In 2008, AAMC published clarifying language pertaining to use of race and ethnicity as factors in promoting enrollment diversity. Such efforts must "articulate the precise benefits associated with a diverse student body, including with respect to race and ethnicity, but not solely with respect to race and ethnicity" [italics included in the AAMC report].30(pV)   

JAMP continues to operate in a manner consistent with principles enunciated subsequently in the AAMC report and captured in standards approved by the LCME and implemented in 2011.         

Application to and Acceptance Into JAMP 

All students in Texas' 31 public and 34 private baccalaureate-granting institutions are eligible to apply for admission to JAMP during the first semester of their sophomore year. The first criterion that JAMP applicants must meet involves documenting economic disadvantage. "The definition of economically disadvantaged is financial eligibility for a Pell grant or an Estimated Family Contribution (EFC) up to $8,000, calculated from the Free Application for Federal Student Aid (FAFSA)."31 Pell grants are available to students who document family economic need by completing and submitting the FAFSA application forms.

Documenting economic disadvantage is part of the comprehensive web-based JAMP application process that includes providing official transcripts of high school and undergraduate grade point averages (GPAs), as well as scores on the Scholastic Aptitude Test (SAT) and/or the American College Testing Program (now known as ACT) examination. Applicants also provide information on family background, family members’ high school and college attendance/graduation, location of hometown, and language spoken at home.

Acceptance into JAMP requires completion of 27 semester hours of coursework by the end of the freshman year, with a GPA of 3.25 on coursework taken, and a science GPA of at least 3.25 on a 4.0 grading scale. Two evaluation letters from college faculty must be submitted with the application. One of the evaluation letters must be from the JAMP Faculty Director (JFD), a faculty member with overall responsibility for coordination of JAMP activities at each undergraduate institution, with the other letter provided by a faculty member chosen by the applicant.

Each application received by the published deadline is rated by two members of the JAMP Council. This council, which serves as the policymaking and operational oversight body for JAMP, comprises one faculty member appointed by the president or dean from each of the 9 Texas medical schools. The ratings are reviewed and discussed by the entire JAMP Council, and qualified students are invited for interviews. JAMP Council ratings, including numerically scored interview results, are used in combination with other factors (eg, GPA and SAT score) to determine who will be invited to participate in JAMP. The council also identifies a group of JAMP alternates. Should one or more selected students decline to participate, or should a student not continue participation over the entire JAMP undergraduate period, an alternate is offered an opportunity to participate.

Participating in JAMP Activities 

Accepted students enter JAMP during the second semester of the undergraduate sophomore year. Once in the program, JAMP undergraduate students participate, with JFD guidance and oversight, in enriched learning offerings and other activities to prepare them for the rigors of medical education. In conformance with the terms of a signed agreement executed on acceptance into JAMP, each JAMP participant must meet regularly with the JFD to review academic progress and performance in JAMP-related learning activities, including summer sessions. Undergraduate JAMP participants receive faculty and staff advising, mentoring, and tutoring services. Limited scholarship support is also available to JAMP undergraduate students.

Beyond participation in undergraduate activities of the home institution, each undergraduate JAMP participant is assigned a mentor at one of Texas' 9 medical schools. This mentor is available to answer questions regarding preparation for medical school, provide information on medical careers, and offer other support and assistance as the student prepares for the challenge of getting into medical school. In internships arranged during the summers, JAMP students engage in learning in clinical settings, interacting with patients and health care professionals.

JAMP students also participate in preparation for the Medical College Admission Test (MCAT) and in other rigorous learning activities. In the first summer session, each student completes a basic science course (eg, anatomy or physiology) and an ethics or current issues course, as well as other internship activities. The second summer internship involves courses in embryology, advanced life science (eg, biochemistry or genetics), and ethics or current issues. Participants are coached on completing an application and on interviewing skills to prepare them for gaining entry to medical school.

JAMP participants must maintain at least a 3.25 (on a 4.0 scale) cumulative GPA and a 3.25 science GPA until graduation from their undergraduate college or university. Students who meet these performance levels and score at least 23 on the MCAT, with no section scores below 7, are guaranteed admission to medical school if no indications of unsuitability for a health professional role are present.

Participants in the medical school phase of JAMP receive support from each institution's student affairs office. These services are the same as those available to all medical students. Each JAMP medical student also meets regularly with the JAMP Council representative during medical school. This representative reports periodically to the JAMP Council on each JAMP student's standing, on any problems encountered by JAMP students, and on steps taken (eg, providing academic tutoring, personal counseling, or financial management counseling) by the medical school to help students perform academically as required to remain enrolled. Limited scholarship support is available to JAMP participants in medical school.

During their medical school years, JAMP participants are also involved in outreach (eg, health career days and other activities) to other undergraduate students who have the potential for selection into JAMP. These activities are used to spread the word about JAMP and to encourage participation by talented students who may or may not have been considering careers in medicine. Comments from students in the medical school portion of JAMP reflect enthusiasm for outreach activities and a sense of responsibility for ensuring that other disadvantaged students have opportunities to pursue medical career goals.  

 


 

JAMP Activities and Outcomes to Date     

 

 

Participant counts and demographic information on JAMP participants to date are provided in Table 1 and Table 2. Available data indicate that, to date, JAMP productivity is comparable to that of other programs nationally in terms of providing opportunities for disadvantaged students to access medical education and enter careers in medicine.32 Other data, not presented here, including the selection of JAMP medical school graduates into highly selective residency programs, indicate that JAMP participants are capable of performing academically at levels that make them competitive in the challenging medical school environment.

From a total of 58 JAMP participants (23 in 2010 and 35 in 2011) who have completed medical school to date, 36 (62%) entered postgraduate residency programs in Texas. This compares with 55% of Texas medical school graduates overall who enter residencies in Texas institutions. Most of those who leave the state to pursue residency programs elsewhere do not return to Texas to practice.33 Table 3 provides demographic data on all JAMP participants who have completed the undergraduate portions of the JAMP program and are currently enrolled in or have completed medical school.

The JAMP population is more diverse in terms of race and ethnicity (ie, 24.3% white, 9.1% black, 26.2% Hispanic, 36.5% Asian/Pacific Islander, and 3.9% other) than is the medical school student population in general, and all JAMP participants are economically disadvantaged. National enrollment data for medical school students in 2011 showed a distribution that was 59.8% white, 7.0% black, 8.4% Hispanic, and 22.4%  Asian/Pacific Islander, and skewing in favor of students from more affluent backgrounds was noted previously.19,34  

Although sound evidence shows that JAMP is succeeding in providing opportunities for disadvantaged students to access careers in medicine, adjustments to the program are made regularly to address specific performance issues (eg, moving entry into JAMP from the first to the second undergraduate year to provide an opportunity for students to acclimate to the college environment). Efforts are currently under way to strengthen evaluation components for purposes of identifying factors that affect performance and refine students' educational experiences across all levels of JAMP.  


What JAMP Can Do for Texas Physicians 

 

JAMP was designed specifically to promote better health for all Texans through creation of a physician workforce that reflects the characteristics of Texas' population better than the current workforce does. Many areas of Texas have little in the way of health care provided by professionals who appreciate the cultural, linguistic, economic, and educational characteristics that shape health care behaviors and influence overall health.

The emergence of chronic disease as the segment of health care demanding the greatest commitment of resources makes it increasingly important that care providers, and especially primary care providers, have the knowledge and skills needed to promote healthy living and to place health care interventions in contexts relevant to patients' lifestyle factors.35,36 In addition to the demographic features of care recipients (eg, gender, age, and educational attainment), these lifestyle factors relate to the environments in which care is delivered (eg, the health of the surrounding community as characterized by the percentage of residents living below the poverty line).35  

Ensuring that JAMP is reaching out to young people in communities that require expanded health care services and that opportunities for interactions with health care providers and patients in these communities are available to JAMP participants requires ongoing collaboration with clinicians and health care organizations that serve these communities.24,37,38 Real progress toward JAMP goals depends on building closer ties to physicians across Texas and especially in underserved areas. We believe such partnerships will benefit physicians who have taken on the challenge of meeting Texas' health care needs. JAMP can benefit Texas physicians by the following:

 Helping to build linkages between health care providers and the communities they serve through strategies that engage young people from underserved communities in health-related activities;

  • Offering incentives for young people from communities across Texas to engage in volunteer activities in clinical practice settings that help them prepare for later careers, while also helping to address health issues in the community;
  • Heightening awareness among and understanding by legislators and policymakers about the challenges physicians face in addressing the growing burden of chronic care, particularly in resource-poor communities;
  • Building the pool of potential care providers likely to return to underserved settings and assist in addressing the challenge of promoting health and well-being in health professional shortage areas that may lack important resources to improve health; and
  • Increasing the number of culturally diverse health care providers who can address the health needs of an increasingly diverse Texas.     

     


     

     What Texas Physicians Can Do for JAMP   

     

Perhaps more importantly, JAMP needs to be actively engaged with physicians from across Texas who can help the program realize its full potential. The involvement of Texas physicians is critical to efforts to reach out to communities where potential JAMP participants live. Texas physicians can help JAMP in the following ways:  

Perhaps more importantly, JAMP needs to be actively engaged with physicians from across Texas who can help the program realize its full potential. The involvement of Texas physicians is critical to efforts to reach out to communities where potential JAMP participants live. Texas physicians can help JAMP in the following ways:   

  • Spreading the word about JAMP and the opportunities that it affords young people who may not think that a career in medicine is within their grasp;
  • Offering opportunities for volunteer and paid work in practice settings where young people have opportunities to learn about health care and the challenges that many people face in obtaining care appropriate to their needs and consistent with their health beliefs;
  • Helping to organize communities to develop support systems (eg, monetary assistance, school arrangements, and family support) for talented, disadvantaged young people who have the capabilities to pursue careers in medicine and who, although willing to return to the community to provide care, may face challenges from economic factors, cultural issues, or other concerns;
  • Promoting economic support for local colleges (public and private) that serve disadvantaged students; and
  • Submitting suggestions to JAMP on strategies for improvement, including ideas for early outreach activities that might help in identifying talented young people still in secondary school and alerting them to the opportunities that JAMP offers.      

     


    Conclusions                  

     

     

As a first-of-its-kind program, JAMP is off to a strong start, but we are learning as we go. An important part of efforts to improve involves enhancing the scope and nature of interactions with our colleagues in medical practice throughout Texas. We encourage all Texas physicians to visit the JAMP website at http://www.texasjamp.org to learn about the program and to contact the JAMP office at (512) 499-4352 or by email at jamp@utsystem.edu to learn more about the JAMP program, its undergraduate and medical school partners, or other aspects of the program.

The future of Texas health care rests on the knowledge, skills, and understanding that we imbue in generations of health care providers who will follow those now in practice. If JAMP achieves the success that we hope to attain, then Texas' physician workforce of tomorrow will reflect a population that is increasingly diverse with respect to race, ethnicity, income strata, geographic origin, and undergraduate institutional affiliation. JAMP can be a catalyst to bring about change that helps meet the health needs of all Texans. However, our success will be constrained if we fail to build strong and effective partnerships with clinicians throughout Texas who are on the front lines in meeting current and emerging health care challenges. 


*For a more complete description of JAMP, its history, and structural components, readers are referred to Dalley B, Podawiltz A, Castro R, et al. The Joint Admission Medical Program: a statewide approach to expanding medical education and career opportunities for disadvantaged students. Acad Med. 2009;84(10):1373-1382.


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