There has been a sweeping call for increased diversity in the health workforce to improve the delivery of health care and combat widespread racial disparities in outcomes.1–4 Emerging evidence shows that provider-patient concordance is associated with improved health outcomes for patients of color across the lifespan, including improvements in infant mortality, decreases in pain, and higher engagement in preventive care.5–7 Unfortunately, patients of color often do not have access to providers of their own race,5 as evidenced by the fact that while underrepresented minorities (URMs) comprise almost 30% of the US population, they made up only 13% of matriculating medical students in 2018–2019.8
Multiple articles have examined this discrepancy and identified barriers and challenges, and have suggested mechanisms for improvement.9,10 High school pathway programs have been promoted as a method of increasing racial and ethnic diversity in the health professions.10–12 Pathway programs are designed to address barriers to URMs entering the health professions, such as a lack of social support and mentoring.9 Evaluations of such programs have traditionally focused on short-term outcomes and few have examined retrospective perceptions of program alumni.10,13–15 A recent long-term evaluation study of 3 summer diversity pathway programs aimed to fill this literature gap by conducting a survey of past participants. The survey found that these programs helped participants reach their goals of working in health care, played a key role in the formation of their professional identities, and helped address systemic inequities.15 Furthermore, clinical experience, mentorship, exposure to health careers, and opportunities to conduct research were identified as components vital to participants’ experience.
In 2005, Mountain Area Health Education Center (MAHEC), in collaboration with Mission Hospital, Western Carolina Medical Society (then Buncombe County Medical Society), and the Asheville Buncombe Institute of Parity Achievement (ABIPA), established a high school pathway program, the Minority Medical Mentoring Program (MMMP). MMMP is based in Buncombe County, North Carolina, where approximately 4% of physicians and registered nurses are African American/Black, American Indian or Alaskan Native, and/or Hispanic/Latino, compared to a population comprised of 6.3% African American/ Black, 0.5% American Indian or Alaskan Native, and 6.8% Hispanic/Latino residents.16,17 MMMP is a semester-long internship experience for selected local public high school seniors of color who have an interest in a future high-level health professions career. The program enrolls 6–8 students per academic year. MMMP participants receive honors course credit for engaging in a minimum of 135 intern hours. All MMMP students are assigned a mentor and shadow a wide range of health care providers in a variety of disciplines and settings including neurology, hematology, family medicine, urology, internal medicine, obstetrics, dental, pharmacy, urgent care, emergency medicine, anesthesiology, surgery, sports medicine, public health, and others as conditions and opportunities allow. To further learn about the medical field and the day-to-day experience of clinicians, MMMP students attend didactics, grand rounds, and table talks with medical students and residents. Students also participate in forums on micro-aggressions and health equity and are assigned books to read, including Medical Apartheid by Harriet Washington and Black Man in a White Coat by Dr. Damon Tweedy. MMMP students are also exposed to the medical literature through meetings with librarians and through a group-based literature review and project presentation. MMMP students participate in the greater community by serving on community-based health action teams and attending health board meetings at the local, state, and national level. The MMMP program also provides support for college planning and career development. The long-term goal of MMMP is to attract and retain students of color in the health professions in Western North Carolina. In the shorter term, through mentorship and experiential learning, MMMP strives to bolster confidence, professional skills, academic opportunities, and support systems for these students. Seventy-seven students have completed MMMP since the program’s inception.
This evaluation aimed to assess program participants’ perceptions of program components, identify areas for improvement, and assess the perceived effect of the program on participants’ shorter-term outcomes. The survey also expands the evidence base of pathway program outcomes.
Methods
Survey Design
A survey was created and input into the SurveyMonkey survey platform (Momentive Inc., San Mateo, CA). MMMP’s Theory of Change, which included the program’s activities and desired short- and long-term outcomes, and a review of findings of previous studies were used to develop the survey (Appendix 1). In accordance with best practice guidelines for survey development, several MMMP graduates pretested the survey to ensure that the question wording and response options were comprehensible, comprehensive, and relevant.18 The survey included the following sections: 1) demographics; 2) closed- and open-ended health-related career questions; 3) assessment of the value of the MMMP program overall and of each of its components (1–5 Likert scale from Not at All Valuable to Extremely Valuable); 4) likelihood that alumni would recommend the program (1–5 Likert scale from Very Unlikely to Very Likely); 5) rating of the statement, “The MMMP program increased my…” for each of MMMP’s outcomes (1–5 Likert scale from Strongly Disagree to Strongly Agree); 6) open-ended questions to describe the most important ways the MMMP program has influenced them personally and their career goals; 7) their recommendations for the program. This assessment was determined to be exempt from Institutional Review Board (IRB) oversight by HCA Healthcare IRB.
Survey Distribution
A link to the online survey was distributed via email to the 73 MMMP graduates for whom the program had working email addresses. Two reminder emails with the survey link were also sent; the survey was open for 3 weeks during August 2020. A $25 gift card incentive was offered to each survey respondent. In addition, the first 25 respondents were entered into a drawing for a $75 gift card.
Analysis
Descriptive statistics were generated using SAS v9.4 (SAS Institute Inc., Cary, NC). For Likert scale questions, both the frequency of specific answers and average scores were calculated.
Open-ended responses were analyzed using thematic analysis (TA), a flexible method that allows researchers to examine perspectives of all participants, identify differences and similarities, and gather unexpected insights.19 Three authors (JH, RB, JF) each independently identified themes for each open-ended question. The authors met and came to agreement on themes. To maximize reliability, each author then separately coded responses using predetermined themes (with flexibility to add and revise themes if deemed necessary). They then met several times to compare their coding; discrepancies were remedied and a consensus was reached.
Results
Forty-six of the 73 MMMP alumni to whom we emailed the survey responded (63.0% response rate). The majority of respondents self-reported their race/ethnicity as Black or African American (26; 56.5%) and 15 (32.6%) self-reported as Hispanic/Latinx (Table 1). The majority were female (41; 89.1%). More respondents were from later cohorts, with 22 of the 46 (47.8%) respondents graduating in the 2016–2020 time period. This corresponds to the program’s acceptance of more interns in later years. At the time of survey completion, a third of the respondents listed high school as their highest degree (32.6%), more than a third had finished their bachelor’s degree (37.0%), and 7 (15.2%) had advanced degrees; a large portion of respondents graduated from high school too recently to have obtained a college or advanced degree.
All respondents reported that the MMMP was very or extremely valuable to them overall, with 42 (91.3%) reporting that the program was very or extremely valuable to their career goals (Table 2). The program components most identified as extremely valuable were clinical shadowing, having mentors/mentors of color, and exposure to a variety of health professionals (Table 2).
A majority of program participants agreed or strongly agreed that the MMMP increased awareness of health disciplines, confidence to pursue other similar opportunities, professional skills, and self-confidence to succeed in professional goals (Table 3). Interestingly, fewer participants marked Agree or Strongly Agree for questions asking if the program increased their interest in becoming a physician or a non-physician health professional.
When asked to describe the most important ways the MMMP influenced their career goals and personal lives, several themes emerged, shown in Table 4. While multiple participants credited MMMP with reinforcing their decision to have a career in medicine, others stated that MMMP enabled them to recognize health career interests outside of clinical care, such as in public health. Notably, for others, the MMMP catalyzed their passion for a career completely outside of the health field. In the personal realm, most highlighted MMMP’s contribution to their confidence, skills in leadership, and personal growth; participants reported that MMMP allowed them to “see what they can be.”
Overall, 27 (59%) alumni surveyed are currently in a health-related career, with 17 (37%) providing direct patient care; 40 (87%) respondents are planning to enter the health workforce in the future, with 31 (67%) in direct patient care roles.
Participants also described barriers they have encountered in pursuing their educational goals (Table 5), including discrimination, inequities in job networks, and lack of mentors of color. Financial and academic barriers were also noted.
Discussion
Graduates reported that the MMMP is highly beneficial, with 100% of respondents rating the program as “very” or “extremely” valuable overall, and 91% reporting that the program was “very” or “extremely” valuable to their career goals. One participant stated, “It has been one of the best things in my life.” In the short term, participants believed that the MMMP increased not only their awareness of health disciplines, but also their skills and self-confidence to succeed in the professional world. The long-term goal of the MMMP is to recruit and retain health professionals of color. Ninety percent of respondents plan to be in a health career in the future.
Research has shown that pathway programs are associated with positive outcomes, including increased test scores, interest in pursuing medical careers, and medical school admission and sense of preparedness.10,20–22 As with other pathway programs, the majority of MMMP alumni surveyed were pursuing or planning to pursue health care careers.21,23 Graduates credited the MMMP program with bolstering their interest in pursuing medical practice as well as non-physician health professional careers. This outcome was also found in graduates of a 5-week immersion course set in California21 and was in line with our program goals of presenting participants with broad exposure to health-related careers. Our study extended prior research by asking alumni about the program’s impact on short-term outcomes.
Responses to an open-ended question about educational and career-related barriers shed light on pervasive discrimination, inequities in job networks, lack of mentors of color, and financial and academic barriers with which these graduates contend. This is supported by other literature showing that medical students of color have reported similar negative experiences in medical school24 and that students of color are less likely than White students to be admitted to medical school, secure medical residency positions, and become department chair.25 MMMP continues to address these systemic problems. We have recently partnered with the Western Carolina Medical Society to increase connections to preceptors and role models of color. Additionally, as a silver lining of COVID-19 influences, our program now utilizes more virtual connections. This change has increased our access to preceptors and role models of color and has expanded our programming to a national level through interactions with the National Association of Medical Minority Educators.
Program leaders credit several logistical considerations with the its success. Based on the North Carolina Department of Public Instruction’s criteria, students can get school credit for program completion because the MMMP includes 135 hours of programmed attendance and is covered by liability insurance. Further, the MMMP is also officially classified as an honors program in the local school district, which facilitates recruitment.
Several study limitations must be noted. First, we note that there may be selection bias in that respondents may differ in their experiences from those who did not respond to the survey. We did, however, have a 63% response rate to our survey. Recall bias is another potential challenge to validity; participants may have retrospectively over- or underestimated the positive nature of their experiences. Another potential limitation is social desirability bias, whereby alumni may have chosen responses they believe to be more preferable to the program. Similar to other studies of pathway programs,23 participants apply to the MMMP based on their interest in health care and medicine; thus, while it is impressive that 90% of participants plan to go into a health-related career, the MMMP’s influence on this decision may be less than it appears. Open-ended responses, however, helped to overcome this threat to validity by illuminating the MMMP’s impact on participants’ career choices. Future studies can follow students prospectively over time to assess the impact of similar programs on intended versus actual career choices. A control group, such as one made up of those accepted into the program who decided not to attend, could also be utilized to further understand the MMMP’s effectiveness.
Implications
Pathway programs like the MMMP are a critical step in shaping career paths, increasing self-awareness, and building self-confidence for success. Partnering with a local high school to give academic honors credit elevates the experience. Area Health Education Centers (AHECs), which serve over 85% of counties in the United States, are well positioned to replicate the MMMP. There are over 300 AHEC program offices throughout the country, focused on increasing the supply and distribution of health care professionals through recruitment, training, and retention.26
While pathway programs garner positive outcomes for participants, the realities of systemic racism and discrimination still exist upon graduation. Graduates of color often face barriers and challenges in securing a job where the population of color is less represented.26 By combining pathway programs with community and regional initiatives, as well as policy changes that address systemic racism, we can continue to build equity in health care and health outcomes.
Acknowledgments
Jacquelyn Hallum is the director for the Department of Health Careers and Diversity Education at the Mountain Area Health Education Center, which includes the Minority Medical Mentorship Program. Rachel Bemis is the administrative director for the Department of Community and Public Health, overseeing the department of Health Careers and Diversity Education. The other authors declare no competing interests.
We would like to acknowledge the founders of the MMMP: Jacquelyn Hallum from the Mountain Area Health Education Center, Bill Mance and Sharon K. West from Mission Hospital, Alan McKenzie from the Western Carolina Medical Society (then Buncombe County Medical Society), Dr. Albert Anderson Sr., and the late Dr. John P. Holt.