3
Lessons from Successful Programs

A number of foundations and state and federal agencies have tried to solve the problems outlined in Chapter 2. Nonetheless, the designers of new intervention programs may find that few models have been rigorously and effectively evaluated. Throughout the various levels of the educational system, however, there are examples of well-regarded efforts to increase the number of underrepresented minority students in medicine and other health professions. Some of these programs are described in this chapter.

The programs chosen by the committee illustrate efforts to confront the issue; they do not constitute a definitive list of answers. Programs at different academic levels, beginning with the medical school, are presented.

In light of what has been learned from these programs and others over the past 20 years, researchers now understand many of the factors that help in attracting minority students and in retaining them in courses that lead toward health careers and, later, in assisting them at the health professions schools. Enough is now known to design and implement programs with a high likelihood of success. The most important message each of these programs offers is that "if the gap between the potential and the actual participation of minorities in medicine is not bridged, it will be because as a nation we have held the blueprints, yet not constructed the plan" (Robert Wood Johnson Foundation, 1987). The same can be said for the other health professions.

MEDICAL SCHOOL LEVEL

The Admissions Process

Until recently, the University of Tennessee at Memphis ranked near the bottom one-fourth of U.S. medical schools in recruiting underrepresented



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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions 3 Lessons from Successful Programs A number of foundations and state and federal agencies have tried to solve the problems outlined in Chapter 2. Nonetheless, the designers of new intervention programs may find that few models have been rigorously and effectively evaluated. Throughout the various levels of the educational system, however, there are examples of well-regarded efforts to increase the number of underrepresented minority students in medicine and other health professions. Some of these programs are described in this chapter. The programs chosen by the committee illustrate efforts to confront the issue; they do not constitute a definitive list of answers. Programs at different academic levels, beginning with the medical school, are presented. In light of what has been learned from these programs and others over the past 20 years, researchers now understand many of the factors that help in attracting minority students and in retaining them in courses that lead toward health careers and, later, in assisting them at the health professions schools. Enough is now known to design and implement programs with a high likelihood of success. The most important message each of these programs offers is that "if the gap between the potential and the actual participation of minorities in medicine is not bridged, it will be because as a nation we have held the blueprints, yet not constructed the plan" (Robert Wood Johnson Foundation, 1987). The same can be said for the other health professions. MEDICAL SCHOOL LEVEL The Admissions Process Until recently, the University of Tennessee at Memphis ranked near the bottom one-fourth of U.S. medical schools in recruiting underrepresented

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions minorities. The school now ranks among the top one-fourth of medical schools in terms of African-American student enrollment. The school's success lay in a series of steps taken by the administration. It made an institutional commitment to adequate funding, added more minorities to the admissions committee, and sent its admissions personnel to a workshop conducted by the Association of American Medical Colleges (AAMC) to learn about noncognitive variables that influence successful completion (Taylor et al., 1990). Known as the Simulated Minority Admissions Exercise, the AAMC program was developed to help admissions committees recognize minority students who would succeed in medical school despite relatively low test scores and grade point averages (GPAs). The workshop, whose techniques have been applied at medical schools throughout the United States, taught the admissions committee at the University of Tennessee to look for the following noncognitive variables in students who were being considered for admission: a positive self-concept, an ability to focus on long-range goals, a supportive person in the student's life, leadership qualities, a background of community service, and demonstrated medical interests. Fostering Academic Careers Harvard Medical School's Minority Faculty Development Program sponsors visiting clerkships for fourth-year and qualified third-year minority medical students. The students may take 1-month clerkships in any discipline at any of the 13 hospitals affiliated with the medical school. The goal of the program is to make minority students aware of the opportunities open to them in academic medicine, to increase the likelihood they will choose academic training programs for their internships and residencies, and to increase the number of minority students applying to hospital training programs affiliated with Harvard Medical School. Each participant is assigned a faculty advisor and is enrolled in the medical school's Exchange Clerkship Program. Cosponsored by Bristol-Myers Squibb Company and the Commonwealth Fund, the Fellowships Program in Academic Medicine for Minority Students has allowed more than 200 minority medical students to spend up to 3 months working on research projects under the guidance of experienced biomedical researchers. The program's goal is to encourage more minority students to consider careers in academic medicine. An application must include a statement about the student's career goals and a letter of commitment from the proposed mentor outlining the research program and the role the mentor will play in guiding the student during his or her medical training.

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Every year, 35 fellowships are awarded to qualified second- and third-year medical students who are U.S. citizens of African-American, mainland Puerto Rican, Mexican American, or Native American descent. Participants each receive an award of $6,000, from which the mentor may draw up to $2,000 to cover the costs of the internship. The program provides each fellow with a close-up view of academic medicine and access to a major biomedical library. Initial results of an AAMC survey of this program showed several positive outcomes. Fellowship recipients were more likely to take part in research activities in medical school than any other minority or nonminority student interested in a career in academic medicine. Fellows were also more likely to have authored, or coauthored, research papers in medical school than were other classmates who shared their career interests. As they continued their chosen careers, almost 90 percent of the students who participated in the program said they called on their mentors for guidance and support. The development of the relationship between these medical students and the noted academic physicians and researchers who mentor them is considered the key element of success in the fellowship program (AAMC, 1993b). The program is administered by National Medical Fellowships, Inc., which provides need-based scholarships and special programs for underrepresented minorities. Faculty Development The Robert Wood Johnson Foundation Minority Medical Faculty Development Program offers minority physicians 4-year, postdoctoral research fellowships. Each of the fellows must have demonstrated superior academic and clinical skills and be committed to a career in academic medicine. The foundation provides each fellow with an annual stipend of up to $50,000 and a $25,000 grant to support research. Working under the supervision of a senior faculty member at an academic health center, the fellow spends at least 70 percent of his or her time in a research activity. POSTBACCALAUREATE PROGRAMS Among the most promising experiments to increase the pool of qualified minority applicants are those that attempt to bridge the gap between college and medical school. The programs vary in length from a summer experience to a full postgraduate year. Three years ago the federal Health Career Opportunities Program (HCOP) began funding postbaccalaureate programs in 14 medical schools. Minority and

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions disadvantaged students who have unsuccessfully applied to medical school are enrolled in a 1-year course of study. They receive training in basic sciences and learn study skills. If academic performance is satisfactory, they are admitted automatically to the next year's entering class. About 100 minority and disadvantaged students are admitted to medical schools every year in this way. Michigan State University (MSU) offers the Advanced Baccalaureate Learning Experience (ABLE) program for a small group of students from underrepresented and disadvantaged backgrounds (Cregler et al., 1993). Over a summer and the academic year that follows, students receive the necessary preparation they need to gain entry into the College of Human Medicine at MSU. If the students complete the program successfully, they are admitted automatically into the college of medicine. The 7 to 10 students chosen to take part in the program must also attend a 6-week summer session just before they matriculate into the college. COLLEGE PROGRAMS Many of the programs to increase minority representation at the college level are based on the Professional Development Program (PDP) of the University of California at Berkeley. The program, which was developed in 1978, has helped hundreds of minority students do well in calculus. Its founders examined the study habits of Asian students, who ''coalesced into loosely knit social/study groups. . . . Their success appeared to be a direct result of their participation in group learning activities" (Fullilove et al., 1988). Their findings led to the creation of the Professional Development Program Mathematics Workshop. The PDP sells itself to students as an honors program, because the participants agree to strive for honors in all subjects. Students are organized in small groups and work together on difficult problems assigned at the start of each workshop. As the students explain their findings to each other, they become more articulate and more comfortable with the material. A camaraderie develops along with the skills that have allowed participants to outperform fellow Asian and white students in freshman mathematics at the university. The participants also earn higher mean grades in the university's rigorous first-year calculus course for engineering and science majors. Two-thirds of the students in the program graduate. This success is attributed to two factors. The students learn to study "efficiently and effectively with others . . . and workshop membership provides students with stable, long-lasting friendships that serve as anchors in the University community" (Fullilove et al., 1988). The Science Educational Enhancement Services Program in Pomona, California, uses faculty advisors, tutors, group study centers, student clubs, and academic excellence workshops to help minorities flourish in the science fields.

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions The program, sponsored by the California State Polytechnic University, tries to foster a sense of community and to help students with their academic work. Students attend academic excellence workshops in subjects such as math, chemistry, physics, and engineering, which are based on the PDP. The sense of community plays an important role in overcoming the sense of social isolation felt by many minority students. The Meyerhoff Scholars, a 4-year-old program at the University of Maryland, Baltimore County, takes the best African-American students from high schools in Maryland and turns them into scientists and engineers. The program, which provides scholarships and free room and board to promising students, has produced more African-American students with A's and B's in science and engineering than has been done by the university in its history. The students have a GPA of 3.5, and were chosen for their academic abilities. Most of them scored in the top 2 percent in the math section of the Scholastic Aptitude Test (SAT). From the beginning, the Meyerhoff scholars have shared a dormitory and have been encouraged to study as a group. The goal is to overcome the isolation felt by some African-American students who are studying at predominantly white institutions. The Meyerhoff Scholars program began with a gift from Baltimore philanthropists Robert and Jane Meyerhoff. It now has a budget of $4 million, which is partly funded by the National Aeronautics and Space Administration and the National Science Foundation (NSF). The program's first six graduates have been accepted on full scholarships for graduate study at schools such as Princeton University, the University of Pennsylvania, and Northwestern University (Leff, 1993). Half of the students at Xavier University in New Orleans are studying natural sciences. With 3,100 students, the relatively small institution is second in the nation at putting African Americans into medical school. Among its efforts, the university conducts a sequence of summer programs for high school students in grades 9 to 12. Almost 50 percent of Xavier's students graduate with degrees in mathematics and science, compared to a national average of 7 percent. School administrators argue that the strong science background they provide to premedical students is necessary to free them to confront the psychological, nonacademic pressures many minorities face in their first year of medical school. Xavier provides "a clear, unambiguous vision of the primary objective of the program—the preparation of students to enter post-graduate studies leading to a career in the health professions" (Ready and Nickens, forthcoming). The school places great importance on introductory science courses, a point at which many colleges lose students who had been interested in science. Students are encouraged to study in groups and seek help from professors. The premedical office monitors each student's progress and works hard to prevent the student from dropping out of the program. Xavier maintains an unusual amount of

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions cross-disciplinary collaboration and centralized control over curriculum. A group of faculty from several science departments meets regularly to discuss ways of improving the quality of instruction. The summer enrichment programs in mathematics, chemistry, and biology are known collectively as the Summer Science Academy. A fourth program called Stress on Analytic Reasoning (SOAR) is a 4-week summer program that acts as a bridge to college courses. Students work on building their vocabulary and on increasing their problem-solving skills. Through laboratory work they learn methods of discovery, experimentation, and concept building. College-Level Summer Program The Minority Medical Education Program (MMEP) of the Robert Wood Johnson Foundation was designed to help promising, highly motivated minority (college) students gain admission to medical schools. Begun 5 years ago, the summer program at seven medical schools around the country provides experience in both the academic and the practical aspects of medicine and assigns each student to work with a mentor. Most students are introduced to both the clinical and the research sides of medicine. The program was developed after analysis of the foundation's 17 years of experience in funding projects for minority health professions students. The objective was to include in the MMEP the components that have been most effective in preparing students for medical school admission. The MMEP helps students prepare for the Medical College Admissions Test and sharpen their skills in biology, mathematics, and problem solving. Students also learn to understand the medical school application process and how to finance a medical school education. Since its inception, the program has received more than 6,000 applications and has enrolled more than 2,900 students. Applicants must have completed at least 1 year of college and have a GPA of 2.75 overall and 3.00 in the sciences. Many of the participants subsequently gained admission to medical school. Faculty Development To institutionalize programs for students, it is sometimes necessary to focus on faculty development. An example of one such effort is the Minority ACCESS to Research Careers Program. It is one of several programs supported by the National Institutes of Health (NIH) to encourage biomedical research training for students and faculty members at 4-year colleges and universities with large minority populations. The Faculty Fellowship component provides opportunities for advanced research training to full-time faculty members. The

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions program also provides 12-month stipends to outstanding teacher-scientists to visit minority institutions, and includes an Honors Undergraduate Research Training component, which helps to interest undergraduates in biomedical research. UNIVERSITY OUTREACH Some colleges and universities have begun programs to reach out to communities around them. The Minority High School Summer Research Apprentice Program (MHSSRAP) is funded by the NIH and is designed to foster interest in science and mathematics among minority youth. Students accepted into the program earn money while performing laboratory work with biomedical researchers who act as their mentors. The program was expanded several years ago to include high school teachers as part of the teaching team. More than 3,000 students and 600 teachers have participated in the program. At the Medical College of Georgia, every one of the students in its NIH-funded MHSSRAP program has gone on to college. Almost 65 percent of those students who earned undergraduate degrees pursued careers in medicine or research. The same program at the University of Alabama at Birmingham has grown from 18 students in 1989 to 60 students in the 1993 summer session. Most of the students are African American, as are the five high school teachers who supplement the work of the mentors. The 12-year-old program is so well known that the university does little to publicize it. Last year, for example, 250 students applied for the 60 slots in the program. The program chooses two-thirds of its participants because they have excelled academically. One-third of the participants are picked after interviews show them to have other qualities that compensate for their academic weaknesses. As an offshoot of this program, the university has started a 4-week, graduate-level summer session for high school teachers to improve their skills in teaching biology. In 1991, the University of California at San Francisco, in collaboration with the San Francisco Unified School District, developed a 4-year program to introduce a hands-on science curriculum to elementary school teachers in the local public schools entitled "City Science." The purpose of the program is to increase the involvement of the scientific community in the life of the elementary school child. Funded by the National Science Foundation, and with supplemental grants from the Genentech Foundation for Biomedical Sciences, the program each year trains 100 elementary school teachers of kindergarten through fifth grade. During the summer the teachers take a 20-day course in teaching the curricula, followed by monthly, all-day sessions on Saturday during the school year. The

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions sessions address techniques and problems associated with hands-on science instruction; how to do science in cooperative groups; how to couple hands-on science with hands-on assessment; and how to integrate science with writing, reading, and mathematics. The course is taught by "master teachers," each of whom is assigned a scientist for help in improving and expanding the lesson. The teachers who take the course are required to teach the material they learned during the summer to their classes; a full-time science resource teacher evaluates the teachers' performances. During the school year, the scientists assigned to the program help the teachers in the classroom and serve as role models to the students. The program designers hope to create a "large team of lead teachers" who will help other local public school teachers improve the quality of the science taught in the schools. The University of California at Berkeley, in partnership with Oakland Technical High School, developed the MESA program, for Mathematics, Engineering, Science Achievement, to increase the number of minority students in science-related fields. Almost all of the first 25 students in the program, who were mostly poor and African American, went on to graduate from 4-year colleges. The founders of the program used the Socratic method, asking questions to make sure the students understood basic concepts and requiring the students to work together in study groups. Today MESA reaches 14,000 California students in grades three through college. Participants are required to take challenging courses and to submit to intensive tutoring. They are also encouraged to develop a peer group that says "it's okay to be a good student." In addition to their work during the school year, students in the program spend every Saturday for 2 months in the summer studying English, science, and mathematics (Gibbons, 1992b). The program has produced notable results. More than 70 percent of the high school students who participate go on to 4-year colleges, compared to a 13 percent college enrollment rate for minorities statewide. At the college level, the MESA Minority Engineering Program (MEP) is responsible for two-thirds of the bachelor's degrees awarded to African Americans, Hispanics, and Native Americans in California, producing a total of 600 engineers in 1992. Most of the college and high school students in the MESA program are either African American or Mexican American; a small percentage is Puerto Rican and Native American. More than half the students in the program are female. The program is supported by the state, school districts, and private foundations, with contributions of offices and staff from the universities that sponsor MESA in the local schools. The California business community has also played an important role. In 1990, for example, corporations contributed nearly $2 million in in-kind and monetary support to MESA programs (Carnegie Corporation, 1990).

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions HIGH SCHOOL PROGRAM In 1981, Ventures in Education, with funding from the Josiah Macy, Jr., Foundation, began in five high schools around the country to give average minority and economically disadvantaged students the academic background necessary for acceptances to major colleges and universities. The program, which has now expanded to 83 schools in seven states and the District of Columbia, insists that each participating student take 4 years of science and mathematics, in an effort to encourage students to follow careers in science and the health professions. To satisfy counseling and tutoring needs, each participating school agrees to extend the school day by at least one period; to keep program students together as a group throughout their high school years in order to reinforce a "culture of achievement"; to prepare the students properly for SAT and other standardized tests; and to offer advanced placement courses in biology, calculus, English, and social studies. The schools also agree to provide highly personalized and intensive guidance to program participants in their academic and personal lives. Of the 1,036 participating students who graduated from high school in 1991, 95 percent enrolled in 4-year colleges, and of those who have been in college for 1 year or more, 45 percent are majoring in the sciences. Close to 41 percent have earned a GPA of 3.00 or better. The Ventures program describes its role as that of a coach to the schools—encouraging, cheering, and cajoling so that all administrators and teachers perform at their best. In addition to support from the Macy Foundation, the program receives funding from several other sources, including the NSF and the U.S. Department of Education. COMPREHENSIVE PROGRAMS Unlike most of the programs in place around the country, the Chicago Area Health and Medical Careers Program (CAHMCP) is a comprehensive effort that starts in sixth grade and moves up through doctoral programs in the health care professions. The CAHMCP, which currently has about 1,000 participants, is a cooperative project offered by seven area medical schools to increase the number of qualified minority applicants. The program receives funding from a combination of sources: federal and state governments, private foundations, and the medical schools involved in the program. The program identifies and recruits its participants early in their school years and provides structured academic, financial, and social support until the students have obtained a doctorate in one of the health care professions. In 1987, realizing that it was getting more difficult to identify and recruit young

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions students into its high school program, CAHMCP began its Young Scientist Program to target minority students from grades six through nine who display exceptional interest and ability in the sciences. The program first recruited 23 Chicago elementary and junior high schools whose staffs, in turn, nominated students to the Young Scientist Program. For 4 to 5 weeks every summer, 350 sixth through ninth graders in the program take part in hands-on group projects in the chemistry, physics, and biology laboratories of local colleges. The program goes on to provide instruction and support to these students throughout their academic careers. CAHMCP is one of the sites of the Minority Medical Education Program of the Robert Wood Johnson Foundation. In 12 years of effort, CAHMCP claims that 98 percent of the participants who enter the program at the high school level or earlier earn their baccalaureate degree within 5 years after entering college. According to program literature, 48 percent of the students who took part in the program from 1980 to 1985 went either to medical school or to another health professions school. Another 12 percent have graduated from or are now attending law school (Chicago Area Health and Medical Careers Program, 1992). The Charles R. Drew University of Medicine and Science in Los Angeles oversees a comprehensive program that begins with 3-year-old children at a university-administered Head Start program and continues to work with area students through high school, college, medicine, and postgraduate training in the health professions. Known as the Extended Science Pipeline, the program uses state, federal, and private funds to give students a practical understanding of science, as well as counseling, tutoring, mentoring, job training, career placement, financial assistance, and scholarships. In elementary school and junior high school, students take part in the Saturday Science Academy, which exposes them to science in both the laboratory and the classroom. Parents attend a series of workshops and seminars to reinforce the decision they made in enrolling their children in the program. The King/Drew Medical Magnet High School is located on the campus of the university. The university says that 90 percent of the graduates of the magnet school go on to college and compete well in national, state, and local scholastic competition (Charles R. Drew University of Medicine and Science, 1992). The Center for Educational Achievement at the university also provides for a series of summer workshops for high school students to guide them into the study of medicine and related health professions. The Allied Health Careers Opportunity Program (AHCOP), for example, sponsors a 6-week summer science institute and provides tutoring and counseling to students interested in studying, or already studying, in a school of allied health.

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Under the umbrella of its Minority and School Based Programs, Baylor College of Medicine in Houston, Texas, administers, or is a major partner, in 18 different initiatives at the elementary, secondary, and undergraduate college levels. Baylor has put its greatest effort into the high school level. It founded the High School for the Health Professions in 1972 in the basement of the medical school. The high school now has its own building and has an enrollment of 750 students. Between 1975 and 1990, 2,581 people had graduated from the school. According to a 1990 survey of the 1986 graduates, 4 percent had gone on to medical school or were physicians at the time of the survey, six times the nation's average for minority high school students (Butler et al., 1991). Nationally, high school graduates entering medical school make up only 0.6 percent of all graduates. Ninety-two percent of the 1986 graduates had gone on to college, and 75 percent of those attending had majored in science or in a health discipline. Baylor also participates in the Robert Wood Johnson Minority Medical Education Program to prepare undergraduates for medical school. With funding from the NSF and various other sources, Baylor is also developing, testing, and overseeing the implementation of a new science curriculum for grades seven and eight. In partnership with Rice University, Baylor also sponsors a program that brings 30 grade school teachers to Baylor to learn to do hands-on science projects in their classrooms. Upon returning to their respective schools, the teachers then teach what they have learned to their colleagues. SUMMARY The efforts described above share many elements that can contribute to a successful program to increase the number of minority youth channeled into the health professions. At a 1992 forum hosted by the Kaiser Family Foundation on preparing minorities for the health professions, participants listed the ingredients without which a program could not succeed (Ready and Nickens, forthcoming): solid academic preparation at the precollege level; a high-caliber undergraduate college curriculum taught in a supportive environment; experiential, hands-on learning opportunities; availability of accurate, reliable counseling and resource materials; financial security; and social access (to overcome the pressures of "culture shock" and isolation often felt by minorities studying in majority institutions).

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Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions Students who lack social access to the institution, for example, may find themselves isolated and unable to continue their studies, regardless of how talented they might be and how well their financial needs have been met. The programs discussed above create among their student participants a culture of success, in which the students move forward as a group. The focus is not on one or two stars, but on the successful completion of the program by each student. Comprehensive "pipeline" programs represent an important alternative for the future. No one institution can alone change the social and educational system that has led to the underrepresentation of minorities in science, particularly in the health professions. Academic medical centers, under the leadership of the AAMC, are being encouraged to focus on themselves as "an integral part of the communities they serve" (Petersdorf, 1991). The AAMC ''Project 3000 by 2000" envisions increasing the number of minority students in medical school through both short-term and long-term strategies. Medical schools, for example, would work with 4-year colleges to decompress the preclinical years, allowing students to take courses at both the undergraduate campus and the medical school during the senior year of college. Among the long-term projects suggested by the AAMC for its members is the creation of magnet health science high schools that would operate in partnership with colleges and medical schools to "create an integrated educational pathway" (Petersdorf, 1991). Such partnerships would give students the chance to take part in a rigorous curriculum in a hospitable environment, while providing the students with mentors and role models who would give relevance to the students' academic work.