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Urban engagement

Medical student Vanessa Ozomaro says she is thrilled to work at Broadway Family Medicine Clinic in North Minneapolis as part of her MetroPAP elective. (Photo: Brady Willette)

MetroPAP immerses students in inner-city medicine, where relationship-building is lesson No. 1

By Susan Maas

Brian Park, a third-year medical student at the time, had seen the patient, a morbidly obese woman with COPD and recurrent pneumonia, for three months. But he didn’t have the context he needed to understand her health struggles — until he saw her home, a very small house where she lived with at least three generations of her family, as well as several friends who tended to come and go.

“There’s something really intimate about inviting someone into your home. We looked in her fridge, and it became clear why her BMI was so high,” says Park. “Why does she keep coming in? Why isn’t she taking all of her medications? That kind of learning doesn’t really come in one week or two weeks or four weeks,” he says.

Park’s participation in MetroPAP, an innovative University of Minnesota program that trains medical students to work in urban, medically underserved communities for nine months, allowed him to get to know his patient well, gain her trust, and discover the insights he needed to understand her health challenges.

MetroPAP — short for Metropolitan Physician Associate Program — is now in its third year and is one of only a few of its kind in the nation.

Vanessa Ozomaro consults with MetroPAP mentor Shailendra Prasad, M.D., M.P.H., on care plans. (Photo: Brady Willette)

Proven approach, new setting

The program was inspired by the U’s internationally renowned Rural Physician Associate Program (RPAP). Launched in 1971, RPAP places third-year medical students in rural communities for nine-month rotations. So far, it has helped train more than 1,300 aspiring physicians to practice primary care in rural areas.

But Kathleen Brooks, M.D., M.B.A., M.P.A., director of RPAP, was concerned by the dearth of primary care doctors in urban communities, too.

“We thought, ‘wouldn’t it be interesting to take this educational model and apply it to urban underserved settings?’” says Brooks. “What would that look like?” So in 2008, then-Medical School dean Deborah Powell, M.D., challenged her to design a pilot program to find out.

Brooks — along with MetroPAP cofounders Michael Wootten, M.D., and Shailendra Prasad, M.D., M.P.H. — sought ideas from other institutions around the world and in their own backyard.

They followed the RPAP model to create MetroPAP, starting small, with just two participants each year (next year it will have three, compared with 40 for RPAP). The two programs have the same core requirements for clerkships and the same basic requirements in terms of final exams, explains Brooks, who now directs both MetroPAP and RPAP.

As with RPAP, interested students apply to MetroPAP in the winter of their second year of medical school. “It tends to be students who really have a passion for underserved medicine and students who are really interested in primary care,” Brooks says.

(The MetroPAP cofounders also learned from a similar but shorter U of M clerkship called Urban Community Ambulatory Medicine, or UCAM, established in 1994. Read more about that successful program.)

Current MetroPAP student Vanessa Ozomaro says she’s thrilled — and undaunted — by the chance to help shape a one-of-a-kind work in progress. This winter she participated in a new six-week psychiatry rotation that joins surgery, emergency medicine, family medicine, and a two-part elective at Broadway Family Medicine Clinic in North Minneapolis and north Memorial Medical Center in nearby Robbinsdale.

Vanessa Ozomaro, with MetroPAP mentor Shailendra Prasad, M.D., M.P.H., takes an active role with patients. (Photo: Brady Willette)

A rich way to learn

MetroPAP students genuinely want to get to know their patients and mentors. “Students see it as an educational opportunity to have continuity with patients and preceptors and the health care team over nine months,” says Brooks. “I think it’s appealing, just intuitively, as a rich way to learn clinical medicine.”

While RPAP often tends to attract students from rural areas, MetroPAP has drawn students from both urban and suburban areas. Park, for example, is from the northern Twin Cities suburb of Shoreview. Ozomaro, the daughter of a nurse who is a Nigerian immigrant, grew up in St. Paul and says her urban high school had “a very diverse” environment.

“A lot of my friends had immigrant backgrounds, east African or Hmong, and we often had conversations about their experiences with the health care system,” Ozomaro says. That upbringing convinced her that it’s important for patients to be comfortable with and able to communicate with their physicians.

“I never had an African, or an African American, physician see me. I always felt like there were a lot of people who didn’t look like me, in medical [settings] and in the sciences generally.”

MetroPAP students share a deep commitment to social justice and to developing the humanistic side of medicine, says Prasad, assistant professor of family medicine. “RPAP has shown us a different way. In medical school, you get to a point where you start looking at things in a very reductionist way: You look at the heart. You look at the lungs. Here, the focus is on the context of the patient and the family and the community — the big picture.”

There’s also ample opportunity to develop procedural skills. “Objectively, in terms of clinical competency, this program is great, too,” says Park, who is taking a break from medical school to earn his master’s degree in public health. “I was able to do a lot more procedures — knee injections, circumcisions, things that come with a bit of liability. They treat you more like an intern.”

That’s by design, Prasad says. “You are treated like part of the family.

“[MetroPAP] students participate in our research meetings. We call it the percolator; they come and sit with us in the percolator and bring their ideas. And they’re part of our noncurricular activities, too — going to a baseball game, being part of our book club. We don’t force them to. It’s just natural.”

This year's MetroPAP students, Vanessa Ozomaro and Andrew Pisansky, under the guidance of mentor Shailendra Prasad, M.D., M.P.H., are treated like part of the team at Broadway Family Medicine Clinic. (Photo: Brady Willette)

MetroPAP’s future is now

MetroPAP is built around mentorship, adds Prasad. The eager support of faculty preceptors and residents is essential. “When you look at why medical students choose disciplines, one common predictor usually is strong mentorship, strong role models. we tend to shape ourselves after folks we admire.”

Park, for one, plans to keep the trend going. “Developing strong relationships with mentors in MetroPAP gives me a framework for how I want to be a mentor to future [physicians],” he says.

“Any idea I had, they told me to run with it. I want to be involved in medical education and to help shape what it looks like.”

For now, say Brooks and Prasad, among the biggest challenges facing MetroPAP is figuring out how to expand it and make it replicable for other institutions.

“Is this an educational model we can expand, and if so, to what degree?” Brooks asks. The program’s capacity was initially limited both by design (“It’s easier to course-correct if you only have a couple of students,” she says) and by the availability of community sites. The faculty is working with the Central Avenue Neighborhood Health Source Consortium to find more participating clinics.

The time is right for MetroPAP, says Prasad: “I feel a synergy there.”

Participating faculty and students say MetroPAP reflects, as Brooks puts it, “a changing overall perspective on medical education.”

“We’re slowly doing away with the thinking that empirical knowledge is paramount to everything else,” says Park. “Scientific competency is just one tool in the toolbox. It’s about a bigger process: How do I go about building relationships in my community?”

Gradually, attentively, one patient at a time.

Susan Maas is a freelance writer who lives in Minneapolis.

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