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Association of American Medical Colleges Tomorrow's Doctors, Tomorrow's Cures®

Hopkins Pilots Residency Program in Urban Health

AAMC Reporter: March 2011

—By Stephen G. Pelletier, special to the Reporter

Not all that long ago, Sara Mixter M.D., M.P.H., was a student at Bethesda-Chevy Chase High School in an upscale Maryland suburb. This year, though, she is practicing medicine in inner-city Baltimore.

Mixter, a graduate of Harvard Medical School, is one of four residents in the inaugural cohort of an innovative new program in urban medicine at the Johns Hopkins University. The initiative, the Johns Hopkins Internal Medicine–Pediatrics (Med-Peds) Urban Health Residency Program, combines residencies in internal medicine and pediatrics with the goal of producing physician leaders who can be change agents for practice and policy in urban primary care.

Health care challenges

Baltimore presents significant health care challenges. Just a few blocks from the Hopkins medical campus, the five top causes of death include HIV and urban violence. It is believed that as many as 10 percent of the city’s residents struggle with addiction. Rampant poverty compounds the quality of public health and overwhelms public infrastructure.

Even though the medical school and main hospital at Johns Hopkins are in the heart of a gritty Baltimore neighborhood, they haven’t always been an integral part of their community. Recognizing that Hopkins could and should be doing more locally, Myron Weisfeldt, M.D., chair of the department of medicine at The Johns Hopkins School of Medicine and physician-in-chief at The Johns Hopkins Hospital, sought new ways of outreach. He asked colleagues to develop a new approach that would better serve community needs.

Weisfeldt’s charge led to the creation of the Urban Health Residency Program. The program partnered with the university’s schools of nursing and public health and its Urban Health Institute, as well as with Johns Hopkins Community Physicians and the city of Baltimore’s health department. Initial financial support came from the Josiah Macy Jr. Foundation and the Osler Center for Clinical Excellence at Johns Hopkins. Leonard Feldman, M.D., an assistant professor of medicine and pediatrics, was appointed to direct the program. Rosalyn Stewart, M.D., an assistant professor of internal medicine and pediatrics, serves as associate director.

The program started this past July. Rooted in delivering primary care in the inner city, the program emphasizes family care and attention to the full continuum of an individual’s life. Residents also study the panoply of social issues that affect patient health in the community. In addition to the standard requirements, residents receive added training in specific urban challenges, such as sickle cell anemia.

Social determinants of health

In light of the reality that “many social determinants make more of a difference in people’s health than medical factors,” Feldman said the program also focuses on the social realities that contribute to health. Rotations cover areas that get little or no attention in a typical residency, including substance abuse care, mental illness, prison medicine, and urban violence.

“These are often seen as touchy-feely social issues,” Feldman said. “But if you don’t touch and feel those issues you’re not going to take good care of these patients.”

Another distinguishing factor is that the program is intentionally designed to create leaders in primary care. Feldman said the new program builds on Hopkins’ rich legacy of training medical leaders, but extends that emphasis to include primary care, where leadership development has tended to be overlooked.

After they complete their four-year program, in fact, graduates will be encouraged to stay for two additional years specifically to develop their leadership skills. They will use the extra time to both hone their medical skills in urban clinics and to earn master’s degrees with a leadership focus in such disciplines as public health, business, or public policy. In essence, Stewart said, they will use their clinical service as a laboratory.

Hopkins leaders also hope that the added clinical experience will help residents become so connected and invested in Baltimore that they will elect to continue providing primary care there after they complete the program. In that way, Stewart said, the program is seen as “a pipeline to grow a much-needed primary care workforce to help address health deficits in Baltimore.”

Robust interest

Feldman said that while a handful of similar programs exist, the Hopkins program is unique as “an urban residency program in Med-Peds.” That distinctive niche has helped the program attract robust interest from would-be participants. For four available slots, Feldman and colleagues received 175 applicants.

“If you look at any one of our applicants,” Feldman said, “you would say ‘wow, that person thinks big, with great vision,’ whether it’s influencing national policy or impacting one’s community.”

A number of the Hopkins applicants, Feldman noted, pursued a track in urban health during medical school. “The medical schools have in some ways led the way,” he said. “Residency programs need to pick up on that interest.”

This July, Hopkins intends to add four residents in a new three-year program component in internal medicine only. The expansion is funded in part through a federal grant under the Affordable Care Act of $3.84 million over five years. As currently designed, the programs will have a maximum of 28 residents at any one time.

Mixter views the program as marrying her interests in both primary care and policy.

“I am interested in ways that physicians and other health professionals can use health outcomes information to influence social policy,” she said. “One of the best ways to understand those issues is to see patients in the community who are living those realities.”