An insider’s view

It’s nearly 1 a.m. on Sunday morning of the July 4 weekend, and the constellation of examination cubicles and work stations in the Yale-New Haven Hospital emergency department is as peaceful as a library. Patients who have already been treated rest comfortably on stretchers while awaiting rooms upstairs. Meanwhile, doctors and nurses review files, check e-mail messages and talk quietly about fireworks displays and holiday traffic. Suddenly the triage nurse gets a radio dispatch. “How many?” she asks, and then immediately activates the trauma response. Spines straighten and conversation stops as everyone in the room is ordered to gown up in sterile clothing.

Minutes later the doors fly open and a platoon of firefighters and EMTs wheel in a stretcher carrying a young man who is screaming in pain. The trauma team moves the patient to a hospital bed, cuts off his clothing and crowds around to assess his condition: “He’s nonverbal.” “He has blood in his mouth.” “130 over 90.” “Two broken teeth.” “Anesthesia to trauma room stat!” While this is going on, another victim from the same car accident is rushed in. She is even younger and is also howling in pain. “How many more?” somebody yells. “They’re saying three,” answers a nurse.

Standing on the periphery of this scene, but watching with the owl-eyed intensity of judges, are three college students. They are here as part of an intensive six-week summer course designed to encourage diversity in the physician workforce, in part by helping underrepresented minority students improve their chances of getting into medical schools.

“Seeing someone my own age in so much pain was kind of upsetting,” Leonie Prao, a Howard University junior, says later that night. Upsetting, but also invaluable, as she and her fellow classmates gain exposure to real-life medical situations and decide whether they’re cut out to be doctors. “I just tried to tune out the screaming and focus on what the doctors were saying,” she says.

“It kind of threw me,” admits Rochelle Chijioke, a Georgetown University junior. “But I’m pretty calm in stressful situations, so I don’t think it’s anything I couldn’t handle.”

Students attend this intensive course, the Summer Medical Education Program (SMEP), tuition-free and receive a small stipend to offset the income they would have earned at a summer job. The program, now offered at 11 sites around the country, was started in 1988 by The Robert Wood Johnson Foundation with the specific aim of increasing the number of medical students from underrepresented minorities, especially African-Americans, Hispanics and Native Americans. Originally called the Minority Medical Education Program (MMEP), it has since expanded to include members of other groups not thought of as minorities but which may be underrepresented in the medical profession. For example, white students from rural areas lacking in health care resources have participated, as have non-minorities from economically or educationally disadvantaged backgrounds. At one program site, organizers say, the presence of a disadvantaged white student changed the outlook of classmates who said they had assumed all white people were wealthy.

This gradual broadening of the program’s focus was reinforced last June, when the U.S. Supreme Court ruled in two affirmative action cases involving the University of Michigan. The court upheld the Michigan law school’s “narrowly tailored use of race in admissions decisions” because it treated all the applicants as individuals. In contrast, the university’s undergraduate admissions policy, which also encouraged diversity, was rejected by the court because it took an approach that was deemed mechanistic, automatically awarding bonus points, for example, to applicants on the basis of their race or ethnicity.

The foundation and the Association of American Medical Colleges (AAMC), which administers SMEP, used the Supreme Court ruling as an occasion to reexamine the summer program’s goals and operations. In December, they dropped “Minority” from the name and rechristened it the Summer Medical Education Program. The announcement on the program website said that SMEP “will no longer identify itself solely as a program for applicants from historically underrepresented racial and ethnic groups.” While affirming the need for a pipeline to help these applicants enter careers in medicine, the sponsors said that “the benefits of diversity cannot be fully realized by a program that focuses narrowly on certain groups by excluding others.”

A transforming experience

Since 1988, more than 10,000 students have participated in the program, and of the 5,500 who have applied to medical school, 63 percent were accepted, according to the AAMC. A 1998 study published in JAMA: The Journal of the American Medical Association found that among students with identical GPAs and MCAT scores, program graduates were more likely to get into medical school than others. The largest improvement was seen in the acceptance rate for African-American males.

“It definitely gives applicants a certain edge. It helps them present themselves as a much better candidate to medical schools,” says Richele Jordan-Davis, director of diversity and minority affairs at Columbia University’s College of Physicians and Surgeons, which has accepted graduates from Yale’s program and became a program site itself three years ago.

Kevin Harris, a senior staff associate with the AAMC’s division of community and minority programs, says about one in every six underrepresented minority students enrolled in U.S. medical schools is an SMEP graduate. “That’s a pretty large piece of the pie, so we feel very strongly that SMEP is a good program that we hope will continue.”

SMEP combines clinical exposure—such as spending a shift in the emergency department or observing an operation or an autopsy—with course work in the biological and physical sciences. A wide-ranging lecture series, a writing and communications course, career counseling and a medical school recruitment fair are other major components of the program. The aim is not simply to give students the nuts-and-bolts information they’ll need to get into medical school, but to demystify a world that to many seems as rarefied and unapproachable as Mount Olympus.

“A lot of SMEP students are working two or three jobs to pay for college. They don’t come from a long family line of physicians, and they think there’s no one like them at Yale,” says Andre R. Matthews, a program graduate who is now in his third year at the School of Medicine. “But then they come here and see that it’s less homogeneous than they thought.”

Forrester A. Lee, M.D. ’79, HS ’83, the medical school’s assistant dean for multicultural affairs and co-director of Yale’s program, sees a transformation occur in many of the students. “I guarantee by the end of those six weeks, you have fundamentally altered their view of the world,” he says. “This is a group who never dreamed they could come to Yale, and now they’re here and succeeding, and they can honestly see themselves as medical students here.”

Last summer’s class of 124 students came from 76 colleges across the country. African-Americans constituted 48 percent of the class, 38 percent were Latino, and 10 percent were either Native American, Native Hawaiian or Southeast Asian. A concerted effort was made to attract more Latino students, resulting in a jump from 19 percent in 2002 to 38 percent last year.

While the program began with a focus on underrepresented minority students, others have benefited from it at Yale, as at other sites. For example, seven white students were enrolled in 2002 and two participated last year. Lee says that in most cases what binds students isn’t race or ethnicity so much as coming from an educational system that failed to equip them with the necessary skills to get into medical school.

“It’s a socioeconomic problem that is particularly severe in ethnic minority communities,” he says. “The nurturing has largely been left to the schools because the community and the family aren’t functioning well. But this is a job the schools aren’t prepared to do, and they’re overwhelmed. Not surprisingly, the result is kids who are not learners.”

But sometimes, despite the educational disadvantages and deprivations, a kid manages to learn anyway. These are the ones the program wants to reach before they fall by the wayside—students like Elvis Rodriguez.

“This I have a passion for”

“Coming here to Yale is the first time I ever slept in a dorm,” says Rodriguez, a compact 28-year-old with soft brown eyes. He and his brother and sister were raised by their mother in the South Bronx. Public assistance was the family’s main source of income, but Rodriguez, being the eldest child, helped out by working at McDonald’s and as a porter at Tavern on the Green in Central Park.

“After graduation from high school, I worked full time. Then one day I got a call from my high school counselor. He wanted to talk to me about my future,” Rodriguez recalls. “He told me I should go to college. I was grateful someone else cared, that someone was there to tell me, so I did.”

At around the same time Rodriguez enrolled in the City College of New York, his twin sons were born, so he had to work the midnight shift as a security guard while taking courses and commuting to school in upper Manhattan. “I thought I wanted to be an architect, but I found it wasn’t as appealing as I’d imagined,” Rodriguez says. “Then I made friends with an emergency room doctor who suggested I volunteer at a local hospital. This exposed me to the medical field for the first time and I thought, ‘Wow! This I can do. This I have a passion for.’”

Still, there was his family to support, so Rodriguez hedged his bet by getting a master’s degree in secondary science education from Lehman College. That was in 2001, and he’s been teaching high school biology since then. “But it’s not where my heart is,” he says. “In both careers you do good, but medicine is a different level of good.”

Happy Wyche, another student in the program, says she’s determined not to become the cultural stereotype everyone expects: “A single mother with a bunch of kids and a low-paying job.” What Wyche wants to be is an obstetrician. “When we were in the maternity ward and I saw the mothers with their new babies, I was like, ‘Oh, my gosh. I can see myself doing this every day.’ Obstetrics inspires me.”

Wyche, who at 24 has the sleek elegance of a model, lived in the Dominican Republic until she was eight. Then her mother moved the family to a low-income neighborhood in Miami. “The teachers in our school had no time to guide us. You had to teach yourself. At first I didn’t speak a word of English,” Wyche recalls of her early education in the United States. Eventually she enrolled at Florida State University and volunteered at a local hospital and in nursing homes. She earned a degree in business finance, married and gave birth to a son, who is now a toddler.

Her life was on the move, but still something was missing. “I got a job helping people invest their money, but I wasn’t as caring and compassionate as I wanted to be. It was too cutthroat,” Wyche says. So when her husband was sent to Afghanistan with the 82nd Airborne Division, she and her son moved home with her mother in Charlotte, N.C., and she began mapping her route to medical school. “People said just relax and raise your kid, but I have too much energy. I was ready to go back to school,” she says.

In 1970, only 2 percent of American medical school students were members of an underrepresented minority group, predominantly African-Americans, although they constituted 12 percent of the general population. That year, the AAMC set a goal of attaining population parity by significantly increasing minority representation in medical schools. By 1975, that initiative showed real results, with a fivefold increase in the number of African-American students—close to 1,000— enrolled in medical schools compared to 1968. But by 1974 the number leveled off at about 1,500 underrepresented minorities, or 9.4 percent, enrolling in American medical schools each year, out of a total enrollment of roughly 16,000 students.

Lee, who co-directs SMEP with Stephen J. Huot, Ph.D. ’81, M.D. ’85, HS ’87, associate professor of medicine, says that when he began his own medical studies at Yale in 1975, minority enrollment here was at its peak, with the school routinely admitting 10 to 12 minority students a year for every class of 100. “From my point of view, we had solved the problem,” he says. “Things were looking good.”

But the illusion of success faded as the demographics of the nation underwent seismic changes. “I don’t think people realized how dramatically society was changing,” Lee says. “The same goals weren’t relevant anymore.”

So, in 1990, with 1,470 underrepresented minority students entering first-year classes, U.S. medical schools rededicated themselves to boosting that number through a AAMC initiative called “Project 3000 by 2000.” The goal was to reach 3,000 students by the year 2000. According to Lee, during the first few years, significant progress was made, peaking in 1994 with just over 2,000 minority students. Since then, the numbers have dropped to about 1,775, “leaving us with a decade of zero progress,” Lee says. Among the 507 medical students at Yale, 91 are members of minority and other groups underrepresented in medicine.

Yale responded to the challenge of “Project 3000 by 2000” by implementing the program along with three other programs aimed at helping improve the competitiveness of minority students applying to medical schools.

The Biomedical Science Training and Enrichment Program (BioSTEP) is a summer research training program designed to interest undergraduates in careers in biomedical science. The Science, Technology and Research Scholars Program (STARS) assists Yale undergraduates, including women and minority students, who are pursing majors in science or engineering. The third, Science Collaborative Hands On Learning and Research (SCHOLAR), is a partnership between the School of Medicine and New Haven’s Hill Regional Career High School that prepares students for advanced academic work in biology and chemistry.

Thinking on their feet

Consistently, the most popular component of SMEP, according to Lee, is the writing and communications course. Seven instructors teach students how to tackle the logic-challenging MCAT essays. Students also spend a lot of time working on their personal essays, which can often be the tiebreaker used by admissions committees in deciding whether or not to accept a student into medical school. The third element of the communications program is the mock interview, which is intended to prepare students for another make-or-break element of the admissions process.

“Communication is not every doctor’s strong suit,” says writing instructor Susan Froetschel, M.P.A., who has a bachelor’s degree in journalism from Penn State and a master’s in public administration from Harvard. “But how effective can you be as a doctor if you can’t communicate in a clear, concise, compassionate way with your patients? That’s why the personal essay and the interview are so important.”

During one of her classes toward the end of the program, Froetschel began the dreaded mock interviews. Students took turns sitting in the front of the room, being grilled by the instructor and then having their performance critiqued by the rest of the class. Before she began, Froetschel reminded the edgy students, “Doctors interview patients at their most vulnerable. Patients have to expose the most embarrassing, painful parts of their lives to their physicians. This interview is nothing compared to what patients will go through in front of you if you are physicians.”

She asked questions that ran the gamut from “How will you know if you are a successful physician 10 years from now?” to “Will affirmative action still be necessary in 25 years?” One student who said she wanted to be an infertility specialist floundered when asked how that specialty helps society and not just the couple that wants a baby. Another struggled to answer a question that required knowledge of disease prevention programs. Asked about street life in the neighborhood where he grew up, a third student impressed Froetschel and classmates with the parallel he drew between gang behavior and some fraternity practices on his campus.

But the question that took everyone by surprise was when Froetschel asked one young man, “What’s your favorite ice cream?” He came up with an answer, “vanilla,” but it was clear he’d temporarily lost his footing. Later, Froetschel explained the reason for asking something so seemingly irrelevant: “I do that to fluster them. Interviewers will do that to see what happens when they encounter difficult patients. I had a student once who said an interviewer asked whether her mother had helped pick out the suit she was wearing. She got into the school, but she said she was totally jangled for the rest of the interview.”

As nerve-wracking as the mock interview can be, many students say writing the personal essay is even worse. “Not good,” is how Wesley Chambers, a Morehouse College sophomore, describes the instructor’s response to his personal statement. Chambers, who hopes to join his father’s gynecological practice one day, recalls, “It was hard for me. I felt like I was saying the same old stuff. I realized I need to get some more experience so I have something to write about and can show that I’d be a good doctor.”

Froetschel says that by the end of the six weeks, she sees a real improvement in the quality of the essays. “Revisions? A lot of students haven’t practiced repeated revisions, but they really do pay attention to the strategies we discuss in class. They are open to criticism, and when they’re done, they really have thought out the issues.”

But SMEP isn’t just six weeks of blunt lessons and sharp critiques. The social bonds that form are equally important. A water balloon fight between students and program staff on the lawn outside the student dining hall was “one of the best times I’ve had in a very long time,” Wyche says. “There is so much love and support that is shown to us. That’s been the best part.”

Rodriguez took advantage of a personal connection he made during the program to observe a gastric bypass operation, a surgical procedure for morbidly obese patients (typically 100 to 400 pounds overweight) to limit their food intake by reducing the size of their stomachs.

Dressed in scrubs and standing next to the patient, Rodriguez was able to watch on two video monitors as Robert L. Bell, M.D., HS ’01, carefully manipulated a retractor to move the patient’s liver so he could staple across the top of her stomach and reattach the small intestine. “Every time I’m exposed to something new, it adds fuel to my fire to pursue medicine,” Rodriguez said after the procedure, his eyes flashing with excitement.

As a former student in what was then MMEP and now a program instructor, Matthews knows well the passion, doubts, drive and insecurities students feel. “MMEP helps dispel a lot of myths about medical school,” he says.

The oldest of five children raised by a single mother on Chicago’s south side, Matthews says the program was just what he needed. “I doubted myself. I didn’t know if I could handle medical school, but MMEP serves to inspire people,” he says. “I’m not saying it’s easy, but it can be done.”

Matthews says what students need most, and what SMEP tries to provide, is a chance to have their questions answered by a wide range of people in the medical profession. “There are a lot of fears,” he says. “Everyone knows that person with the great MCAT scores who didn’t get in.” He says instructors stress that medical schools don’t just look at numbers; they look at the whole person, which is a welcome message for students who may have taken a circuitous route to medical school or who, on paper at least, may not seem like the most likely candidates.

But helping students fulfill their dreams of becoming doctors is only half the equation, says Lee. There is also the benefit to society that comes from making the medical profession more ethnically and racially diverse. “At a human, emotional level, there are three kinds of people with whom we want ethnic identification: those who provide safety, those who nourish our spiritual lives and those who take care of our health,” he says. “It’s not essential, but it helps a lot. It’s valid to seek and receive care from our own community.” YM