Medical Education in Underserved Communities: Experience From an Urban Area Health Education Center
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Brief communication 109 MEDICAL EDUCATION IN UNDERSERVED COMMUNITIES: EXPERIENCE FROM AN URBAN AREA HEALTH EDUCATION CENTER In 1986, Rieselbach and Jackson proposed that primary care medical education at a graduate level could be financed if linked directly to payment for primary care services to the poor.1 This proposal was based on the fact that a considerable amount of care for the poor was already being provided by training programs, and that the provision of primary care, with ambulatory services delivered by residents and faculty, would reduce the costs of emergency and hospital care. This proposal did not address the problem in financing ambulatory undergraduate education,2,3 nor did it address the problem of how to deliver care where it is most needed—in geographic or economically underserved communities. The conventional view is that students are not efficient providers, and hence it is impossible to finance their educational programs through patient care revenues.3 In spite of the general acknowledgment that medical education provides a considerable amount of care to the poor,4,5 no governmental payer at a federal, state, or local level has funded a project specifically to demonstrate the feasibility and cost-effectiveness of linking primary care; education to service for underserved communities. Recognizing this, the University of Miami's Area Health Education Center (UMAHEC) has been committed to linking health professions education to service for underserved communities since its inception as part of its broader mission to address the maldistribution of health professionals in the state of Florida. UMAHEC now has sufficient experience to allow others grappling with how to maintain or expand services for underserved populations to consider the education-service linkage represented by our AHEC model as a viable approach to providing quality services to the medically needy. The National, Florida, and UMAHEC programs The AHEC concept was conceived by a Carnegie Commission and first authorized by Congress in 1972.6 The commission addressed the problem of geographic maldistribution of health professionals. It proposed that educational programs could serve as an alternative to financial incentives to recruit and retain health professionals in underserved rural communities. In 1975, the Journal of Health Care for the Poor and Underserved · Vol. 9, No. 2 · 1998 110 Medical Education in Underserved Communities________________ authority was expanded to include urban underserved communities. Currently , there are AHEC programs in 33 states. The federal government makes awards to allopathic and osteopathic medical schools for the establishment of AHECs, which are typically situated in areas geographically remote from medical centers. At least 75 percent of funding must be contracted to these centers. These provisions are intended to secure community empowerment by granting control over these funds and the programs they create to independent centers with community governing boards. Medical schools receiving these funds must also provide a minimum of 10 percent of their undergraduate clinical education in community-based sites and must also develop multidisciplinary educational programs. The federal AHEC program, administered within the Health Resources and Services Administration, encourages programs to solicit state and local funding to support the accomplishment of state health professions goals in advance of the withdrawal of federal funds. Typically, programs receive federal funding for 9 to 12 years, with state or local governments progressively picking up the costs during the later years of federal support. The Florida AHEC program began as a regional program, first funded in 1984 with an award to (what was at the time) Southeastern College of Osteopathic Medicine (SECOM). The University of Miami School of Medicine (UMSM) began a combined urban/rural program in 1985. In 1987, these two schools agreed to collaborate for programmatic purposes, forming the Florida AHEC Network. The University of Horida joined the network in 1988, and the University of South Horida joined in 1993. Because of the finite cycle of federal awards, Nova Southeastern University (the former SECOM) and the University of Miami have now completed their core federal funding, and continue completely on state and local funding. Each school has a responsibility to provide community-based health professions training to students who serve underserved communities in defined catchment areas. The schools collaborate for programmatic and financial planning, and for certain statewide recruitment and retention activities. Through...