Residents' preferences and preparation for caring for underserved populations

International Medical Graduates and the Physician Workforce

Importance

Physician shortages and the geographic maldistribution of general and specialist physicians impair health care delivery and worsen health inequity in the US. International medical graduates (IMGs) represent a potential solution given their ready supply.

Observations

Despite extensive clinical experience, evidence of competence, and willingness to practice in underserved communities, IMGs experience multiple barriers to entry in the US, including the immigration process, the pathways available for certification and licensing, and institutional reluctance to consider non-US-trained candidates. International medical graduates applying to postgraduate training programs compare favorably with US-trained candidates in terms of clinical experience, prior formal postgraduate training, and research, but have higher application withdrawal rates and significantly lower residency and fellowship match rates, a disparity that may be exacerbated by the recent elimination of objective performance metrics, such as the US Medical Licensing Examination Step 1 score. Once legally in the US, IMGs encounter additional obstacles to board eligibility, research funding, and career progression.

Conclusions and Relevance

International medical graduates offer a viable and available solution to bridge the domestic physician supply gap, while improving workforce diversity and meaningfully addressing the public health implications of geographic maldistribution of general and specialist physicians, without disrupting existing physician stature and salaries. The US remains unable to integrate IMGs until systematic policy changes at the national level are implemented.

Demographic Factors and Medical School Experiences Associated with Students' Intention to Pursue Orthopaedic Surgery and Practice in Underserved Areas

Physician shortages across the United States will affect access to orthopaedic care for patients. Orthopaedic surgery is predicted to have one of the largest shortages among surgical subspecialties by 2025, which will disproportionally affect patients in medically underserved areas. This study examines characteristics and experiences of graduating medical students interested in orthopaedic surgery who intend to practice in underserved areas (IPUAs).

Methods

We analyzed deidentified data of AAMC Graduation Questionnaire respondents who matriculated between 2007 to 2008 and 2011 to 2012. Forty-eight thousand ninety-six (83.91%) had complete demographic, financial, and medical school elective data and were included in the study cohort. Multivariable logistic regression was performed to determine the correlation between student characteristics and intention to pursue orthopaedic surgery and IPUAs.

Results

Of the 48,096 students with complete information, 2,517 (5.2%) intended to pursue a career in orthopaedic surgery. Among the orthopaedic students, men were less likely than women to report IPUAs (adjusted odds ratio [aOR], 0.6; 95% CI, 0.4-0.8). Students who identified as Black/African American (aOR, 5.0; 95% CI, 3.0-8.2) or Hispanic (aOR, 2.0; 95% CI, 1.1-3.5) were more likely than White students to report IPUAs. Medical students who intend to pursue orthopaedics and received a scholarship (aOR, 1.5; 95% CI, 1.1-2.0), participated in community research (aOR, 1.8; 95% CI, 1.4-2.3), or had a global health experience (aOR, 1.9; 95% CI, 1.5-2.5) were more likely to report IPUAs.

Discussion

If orthopaedic surgeons who reported as medical students who reported IPUAs actually do so, recruiting and retaining more sex and race/ethnically diverse orthopaedic surgeons could reduce the impact of the impending shortage of orthopaedic surgeons in underserved areas. IPUA is correlated to medical school experiences related to cultural competency including global health experiences and community-based research projects.

The impact of international medical graduates in dermatology

Underrepresented in medicine (URiM) are individuals from racial and ethnic populations that are underrepresented in the medical field relative to their numbers in the general population. International medical graduates (IMGs) compose a significant percentage of URiM individuals, with a meaningful role in the current US health care workforce. Currently, there is limited data on IMGs in dermatology. In this paper, we wish to showcase reliable data about the IMG pool and highlight their value in diversifying dermatology in order to better serve our patients and provide culturally competent care.

Medical students attitudes toward and intention to work with the underserved: a systematic review and meta-analysis

BACKGROUND

Experts in the field of medical education emphasized the need for curricula that improve students' attitudes toward the underserved. However, some studies have shown that medical education tends to worsen these attitudes in students. We aimed at systematically reviewing the literature assessing the change in medical students' attitudes toward the underserved and intention to work with the underserved throughout medical education, the sociodemographic and educational factors associated with favorable medical student attitudes toward and/or intention to work with the underserved and the effectiveness of educational interventions to improve medical student attitudes toward and/or intention to work with the underserved.

METHOD

We conducted a systematic review on MEDLINE, Scopus, and Web of Science databases. Three investigators independently conducted the electronic search. We assessed the change in medical students attitudes toward the underserved by computing a weighted mean effect size of studies reporting scores from validated scales. The research team performed a meta-analysis for the sociodemographic and educational factors associated with medical students attitudes toward and/or intention to work with the underserved.

RESULTS

Fifty-five articles met the inclusion criteria, including a total of 109,647 medical students. The average response rate was 73.2%. Most of the studies were performed in the USA (n = 45). We observed a significant decline of medical students attitudes toward the underserved throughout medical education, in both US and non-US studies. A moderate effect size was observed between the first and fourth years (d = 0.51). Higher favorable medical students attitudes toward or intention to work with the underserved were significantly associated with female gender, being from an underserved community or ethnic minority, exposure to the underserved during medical education and intent to practice in primary care. Regarding educational interventions, the effectiveness of experiential community-based learning and curricula dedicated to social accountability showed the most positive outcome.

CONCLUSIONS

Medical students attitudes toward the underserved decline throughout medical education. Educational interventions dedicated to improving the attitudes or intentions of medical students show encouraging but mixed results. The generalizability of our results is impeded by the high number of studies from the global-North included in the review.

Neighbourhood walking tours for physicians-in-training

Social and economic factors have a profound impact on patient health. However, education about these factors has been inconsistently incorporated into residency training. Neighbourhood walking tours may help physician-residents learn about the social determinants of health (SDoH). We assessed the impact of a neighbourhood walking tour on physician-residents' perceptions of SDoH, plans for counselling patients and knowledge of community resources. Using a community-based participatory research approach, in 2017 we implemented a neighbourhood walking tour curriculum for physician-residents in internal medicine, internal medicine/primary care, emergency medicine, paediatrics, combined internal medicine/paediatrics and obstetrics/gynaecology. In both pre-tour and post-tour, we asked participants to (1) rank the importance of individual-level and neighbourhood-level factors affecting patients' health, (2) describe strategies used to improve health behaviours and (3) describe knowledge of community resources. Eighty-one physician-residents participated in walks (pre-tour surveys (93% participation rate (n=75)), and post-tour surveys (53% participation rate (n=43)). Pre-tour, the factor ranked most frequently affecting patient health was 'access to primary care' (67%) compared with post-tour: 'income' (44%) and 'transportation' (44%). In describing ways to improve diet and exercise, among pre-tour survey respondents, 67% discussed individual-level strategies and 16% discussed neighbourhood-level, while among post-tour survey respondents, 39% of respondents discussed individual-level strategies and 37% discussed neighbourhood-level. Percentage of respondents aware of community resources changed from 5% to 76% (p<0.001). Walking tours helped physician-residents recognise the importance of SDoH and the value of community resources, and may have broadened frameworks for counselling patients on healthy lifestyles.

Factors influencing the intention of Indonesian nursing students to work in rural areas

Objective

The aim of this study was to analyse the factors associated with the intention of Indonesian nursing students to work in rural areas.

Design

This was a cross-sectional study. The instrument used was a self-developed questionnaire consisting of 13 questions. The data were analysed using the χ2 statistics test and binary logistic regression with a level of significance <0.05.

Setting

The study was conducted at a public nursing school located in urban Surabaya, East Java, Indonesia, in December 2017.

Participants

A total of 714 nursing students from four different programmes were involved.

Results

This study found that almost 60% of nursing students were reluctant to work in rural areas. Of the three variables which were significant in the χ2 analysis, only two were significant following the logistic regression test, namely the class programmes of undergraduate regulars (OR=2.274; 95% CI 1.326 to 3.900), profession regulars (OR=2.262; 95% CI 1.110 to 4.607) and rural place of origin (OR=1.405; 95% CI 1.036 to 1.906).

Conclusion

The education programme and place of origin were associated with the intention of nursing students to work in rural areas. Therefore, the recruitment of prospective nurses should consider these factors by considering the local context.

Long Term Outcomes of a Curriculum on Care for the Underserved

ACKNOWLEDGEMENTS

This work was funded by HRSA grants D16HP00067 and D08PE50097.

BACKGROUND

Evaluations of curricula to enhance ability to care for the underserved are often limited to short-term medical student outcomes.

PURPOSE

This study evaluates retention of short-term improvements in outcomes from post-curriculum to graduation.

METHODS

Third-year students on 2003-2004 pediatric clerkships were randomized to a curriculum on caring for the underserved in one of three formats: established "readings only", faculty-led, or web-based. Outcomes (knowledge, attitudes, self-efficacy and clinical skills) were assessed at three timepoints-pre- and post-curriculum and at graduation. Analyses, from 2009-2010, included Fisher's exact test to assess the relationship of curriculum group with response patterns, demographics, and outcomes at graduation. Multivariate regression was used to model the longitudinal relationship between outcomes and curriculum groups, adjusting for prior clerkship experiences, baseline scores, and clustering by student.

RESULTS

Of 137 students, 135 (99%) completed the pre-curriculum survey, 128 (93%) completed the post-curriculum survey and 88 (64%) completed the graduation survey. Post-curriculum improvements in self-efficacy and clinical skills seen among students receiving the faculty-led or web-based curricula were retained at graduation. At graduation, web-based curriculum students' self-efficacy was significantly greater for "establishing achievable goals with underserved families" compared to established curriculum students. With regard to skills relevant to caring for the underserved, few graduates had facilitated a referral to Women, Infants and Children (33%) or followed up to ensure a patient accessed a needed resource (56%).

CONCLUSIONS

Self-efficacy and skills gained through web-based and faculty-led curricula were retained at graduation. Data from items at graduation support targeted curricular improvement.

Racial Diversity in the Medical Profession: The Impact of Affirmative Action Bans on Underrepresented Student of Color Matriculation in Medical Schools

This study examines the impact of affirmative action bans in six states (California, Washington, Florida, Texas, Michigan, and Nebraska) on the matriculation rates of historically underrepresented students of color in public medical schools in these states. Findings show that affirmative action bans have led to about a 17% decline (from 18.5% to 15.3%) in the first-time matriculation of medical school students who are underrepresented students of color. This decline is similar to drops in the enrollment of students of color that have taken place across other educational sectors, including the nation's most selective public undergraduate institutions, law schools, and various graduate fields of study, after bans on affirmative action were enacted in some of these states. The findings suggest that statewide laws banning the consideration of race in postsecondary admissions pose serious obstacles for the medical profession to address the health-care crisis facing the nation.

Medicine Resident Preparedness to Diagnose and Treat Substance Use Disorders: Impact of an Enhanced Curriculum

BACKGROUND

The authors' previous study found that despite caring for many patients with addiction, most Massachusetts General Hospital (MGH) internal medicine residents feel unprepared to treat substance use disorders (SUDs) and rate SUD instruction during training as fair or poor. This follow-up study evaluates the impact of an enhanced curriculum on resident perceptions of the quality of instruction, knowledge base, and self-perceived preparedness to diagnose and treat SUDs.

METHODS

Based on the findings of the earlier study, an enhanced SUD curriculum was designed and delivered to MGH medicine residents. Impact of the curriculum was evaluated using the same Web-based survey that was administered in the earlier study to compare pre- and posttest results.

RESULTS

The authors' earlier study found that 75% of residents felt prepared to diagnose and 37% to treat SUDs and 45% of residents rated the overall quality of SUD instruction as good or excellent. Following the curriculum intervention, 87% of residents reported feeling prepared to diagnose (P=.028) and 60% to treat (P=.002) SUDs. Three quarters of residents rated the overall quality of instruction as good or excellent (P<.001), and 98% reported residency curriculum had a positive impact on their preparedness to care for patients with a SUDs. Residents who reported receiving an adequate amount of SUD instruction were more likely to feel prepared to diagnose and treat addiction (P<.001). Thirty-one percent of residents still rated the overall amount of SUD instruction as too little. The intervention did not significantly improve answers to knowledge questions.

CONCLUSIONS

An enhanced SUDs curriculum for medicine residents increased self-perceived preparedness to diagnose and treat SUDs and educational quality ratings. However, there was no significant change in knowledge. Implementation of a more comprehensive curriculum and evaluation at other sites are necessary to determine the ideal SUD training model.

Can a video curriculum on the social determinants of health affect residents' practice and families' perceptions of care?

INTRODUCTION

Screening and management of the social determinants of health (SDH) are critical for child health promotion. We sought to evaluate the impact of a facilitated video curriculum on resident SDH screening competence, parental perceptions of resident practice, resident-initiated referrals to a medical-legal partnership (MLP), and formula distribution to food-insecure families.

METHODS

This was a pre-post study with concurrent control performed at a large pediatric residency program. Second- and third-year residents were assigned to control and intervention groups on the basis of their continuity clinic day. The curriculum included videotaped vignettes of screening for SDH and a "day in the life" series of families describing the impact of intervention on their lives. Residents completed self-assessments on screening competence and resource knowledge. After a well-child encounter, families (3 per resident) assessed their level of trust and respect for the resident and the number of SDHs screened for. MLP referral rates and formula distribution were compared.

RESULTS

The intervention group's self-assessed competence in screening for housing, benefits, and educational concerns was significantly higher compared to controls (each P ≤ .05). Parents' rating of trust and respect was high and did not differ between groups. Screening for each SDH was higher in the intervention group with domestic violence (odds ratio 2.16, 95% confidence interval 1.01-4.63) and depression (odds ratio 2.63, 95% confidence interval 1.15-5.99), reaching statistical significance. MLP referral rates increased (P = .06), and formula distribution (P = .02) reached statistical significance in the intervention group.

CONCLUSIONS

This SDH video curriculum improved resident self-assessed screening competence, parental perception of screening, and both MLP referrals and formula distribution.

An experiential community orientation to improve knowledge and assess resident attitudes toward poor patients

BACKGROUND

Future physicians may not be prepared for the challenges of caring for the growing population of poor patients in this country. Given the potential for a socioeconomic "gulf" between physicians and patients and the lack of curricula that address the specific needs of poor patients, resident knowledge about caring for this underserved population is low.

INTERVENTION

We created a 2-day Resident Academy orientation, before the start of residency training, to improve community knowledge and address resident attitudes toward poor patients through team-based experiential activities. We collected demographic and satisfaction data through anonymous presurvey and postsurvey t tests, and descriptive analysis of the quantitative data were conducted. Qualitative comments from open-ended questions were reviewed, coded, and divided into themes. We also offer information on the cost and replicability of the Academy.

RESULTS

Residents rated most components of the Academy as "very good" or "excellent." Satisfaction scores were higher among residents in primary care training programs than among residents in nonprimary care programs for most Academy elements. Qualitative data demonstrated an overall positive effect on resident knowledge and attitudes about community resource availability for underserved patients, and the challenges of poor patients to access high-quality health care.

CONCLUSIONS

The Resident Academy orientation improved knowledge and attitudes of new residents before the start of residency, and residents were satisfied with the experience. The commitment of institutional leaders is essential for success.

The VALUE Framework: training residents to provide value-based care for their patients

National efforts to improve the value of health care must include graduate medical education (GME) if they are to succeed. Proposals to teach residents to provide value-based care have come from the Medicare Payment Advisory Commission (MedPAC), the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Physicians (ACP). Such proposals skip a key step: residency programs currently lack a clear strategy to prepare residents to assess and deliver value-based care. In this article, we present the VALUE Framework for programs to utilize to teach residents to assess and deliver value-based care for their patients. We then present more than 20 opportunities for residency programs to incorporate training in value-based care.

How prepared are our future doctors for HIV/AIDS?

Three cohorts (n = 391) of final-year medical students in Hong Kong were evaluated on their preparedness to provide HIV care. Through a self-administered questionnaire, half (53%) were assessed to be better prepared and had a lower perceived risk of infection at work, though unwillingness to manage HIV patients was reported in a minority (4.6%). For a majority of medical students (72.8%), a specially-designed clinic attachment offered the only opportunity to come face-to-face with HIV patients for the first time. With continued improvement in treatment effectiveness, HIV/AIDS is evolving to become a new chronic disease in most societies. Curriculum development in HIV medicine remains a challenge in this HAART era.

Residents' attitudes and behaviors regarding care for underserved patients: a multi-institutional survey

BACKGROUND

Resident physicians often encounter underprivileged patients before other providers, yet little is known about residents' attitudes and behaviors regarding these patients.

OBJECTIVE

To measure US resident physician attitudes regarding topics relevant to medically underserved patients, their behaviors (volunteerism) with underserved patients, and the association between attitudes and behaviors.

METHODS

In 2007 and 2008, 956 surveys on resident attitudes and behaviors about underserved patients were distributed to 18 residency programs in the United States. Survey content was based on existing literature and an expert needs assessment. The attitude assessment had 15 items with 3-point scales (range 0-1). The behavior assessment evaluated volunteering for underserved patients in the past, present, and future.

RESULTS

A total of 498 surveys (response rate  =  52%) were completed. Attitudes regarding underserved patients were generally positive and more favorable for women than men (overall attitude score 0.83 versus 0.74; P  =  < .001). Rates of volunteering for underserved patients were high in medical school (N  =  375, 76%) and anticipated future practice (N  =  409, 84%), yet low during residency (N  =  95, 19%). Respondents who volunteered regularly had more favorable attitudes than those who did not volunteer (overall average attitude score of 0.81 versus 0.73; P  =  <.001). Relationships between hours volunteered per-week and favorable attitudes about topics related to the underserved were significant across all 15 items in medical school and anticipated future practice (P value range of .035 to <.0001).

CONCLUSIONS

This survey revealed that US residents' attitudes towards topics regarding medically underserved populations are generally favorable. Rates of volunteerism for underserved patients were higher in medical school than during residency, and resident's anticipated rates of volunteerism in future practice volunteerism were approximately the same as rates of volunteerism in medical school. Resident attitudes are strongly correlated with volunteerism.

Recruiting and retaining primary care physicians in urban underserved communities: the importance of having a mission to serve

OBJECTIVES

We examined factors influencing physician practice decisions that may increase primary care supply in underserved areas.

METHODS

We conducted in-depth interviews with 42 primary care physicians from Los Angeles County, California, stratified by race/ethnicity (African American, Latino, and non-Latino White) and practice location (underserved vs nonunderserved area). We reviewed transcriptions and coded them into themes by using standard qualitative methods.

RESULTS

Three major themes emerged in relation to selecting geographic- and population-based practice decisions: (1) personal motivators, (2) career motivators, and (3) clinic support. We found that subthemes describing personal motivators (e.g., personal mission and self-identity) for choosing a practice were more common in responses among physicians who worked in underserved areas than among those who did not. By contrast, physicians in nonunderserved areas were more likely to cite work hours and lifestyle as reasons for selecting their current practice location or for leaving an underserved area.

CONCLUSIONS

Medical schools and shortage-area clinical practices may enhance strategies for recruiting primary care physicians to underserved areas by identifying key personal motivators and may promote long-term retention through work-life balance.

Family medicine residency training in community health centers: a national survey

PURPOSE

For more than 25 years, family medicine residencies (FMRs) have worked with community health centers (CHCs) to train family physicians. In light of the long history and current policy focus on this training model, the authors sought to evaluate comprehensively the scope and extent of family physician training occurring in CHCs.

METHOD

The authors conducted a cross-sectional survey of 439 U.S. FMR directors in 2007. FMR directors were asked to provide information regarding the number, type, location, and length of any CHC training affiliations and to rate their satisfaction with such affiliations.

RESULTS

Of 354 respondents (80% response rate), 83 FMRs (23.4%) provided some type of CHC training experience; 32 (9%) had their main residency continuity training site in a CHC. Respondents reported that 10.5% (788) of family medicine residents were trained in a CHC continuity clinic. The average length of affiliation was 10.2 years. Residency directors reported high satisfaction with CHC training affiliations.

CONCLUSIONS

Almost one-quarter of FMRs in 2007 provided some training in CHCs. However, the proportion of residencies providing continuity training in CHCs--the type of training associated with enhanced recruitment and retention of family medicine graduates in underserved areas--was limited and relatively unchanged since 1992.

Care of the underserved: faculty development needs assessment

INTRODUCTION

Because role models are crucial to training physicians to care for the underserved, we examined pediatric faculty's knowledge, attitudes, self-efficacy, skills, and precepting behaviors regarding care for this population.

METHODS

Faculty knowledge, attitudes, self-efficacy, and skills/precepting behaviors were surveyed.

RESULTS

Fifty-five (65%) of 85 faculty responded. The mean (standard deviation) knowledge score was 5.9 (1.3) of 8 possible. More than one-third of faculty did not recognize the eligibility criteria, services, and outcomes associated with common resources serving the underserved. Overall attitudes toward underserved families were positive, mean 3.3 (0.3), as was mean self-efficacy, 3.0 (0.7). Self-efficacy was lowest for accessing community resources for underserved families, 2.4 (0.7). Although most faculty performed the surveyed skills, fewer than 50% reported, precepting of these same skills with students. Precepting was lowest for accessing public and community resources.

CONCLUSIONS

Low rates of student precepting as well as specific knowledge and self-efficacy deficits highlight potential targets for faculty development.

Training internal medicine residents in outpatient HIV care: a survey of program Directors

BACKGROUND

The care of patients with HIV is increasingly focused on outpatient chronic disease management. It is not known to what extent internal medicine residents in the US are currently being trained in or encouraged to provide primary care for this population of patients.

OBJECTIVE

To survey internal medicine residency program directors about their attitudes regarding training in outpatient HIV care and current program practices.

DESIGN

Program directors were surveyed first by email. Non-responding programs were mailed up to two copies of the survey.

SUBJECTS

All internal medicine residency program directors in the US.

MAIN MEASURES

Program director attitudes and residency descriptions.

KEY RESULTS

Of the 372 program directors surveyed, 230 responded (61.8 %). Forty-two percent of program directors agreed that it is important to train residents to be primary care providers for patients with HIV. Teaching outpatient-based HIV curricula was a priority for 45.1%, and 56.5% reported that exposing residents to outpatient HIV clinical care was a high priority. Only 46.5% of programs offer a dedicated rotation in outpatient HIV care, and 50.5% of programs have curricula in place to teach about outpatient HIV care. Only 18.8% of program directors believed their graduates had the skills to be primary providers for patients with HIV, and 70.6% reported that residents interested in providing care for patients with HIV pursued ID fellowships. The strongest reasons cited for limited HIV training during residency were beliefs that patients with HIV prefer to be seen and receive better care in ID clinics compared to general medicine clinics.

CONCLUSIONS

With a looming HIV workforce shortage, we believe that internal medicine programs should create educational experiences that will provide their residents with the skills and knowledge necessary to meet the healthcare needs of this population.

Pipeline programs in the health professions, part 1: preserving diversity and reducing health disparities

BACKGROUND

Racial and ethnic minorities are underrepresented in the health professions. Affirmative action and educational pipeline programs play a vital role in increasing the diversity of health professions, addressing educational opportunity gaps, and reducing health disparities. Part 1 of this 2-part series discusses the need for educational pipeline programs to assist underrepresented minorities (URMs) in entering the health professions and the importance of these programs in developing a cadre of diverse providers to reduce health care inequality.

METHODS

Part 1 presents an overview of diversity in the medical and health care workforce, educational enrichment programs, key components of successful pipeline programs, and notable pipeline examples for underrepresented students at the University of Nebraska Medical Center. Recommendations for improving and developing pipeline programs are also included. Part 2 reviews affirmative action case law and legislation along with recommendations for maintaining and reviewing diversity pipeline programs in light of recent anti-affirmative action challenges.

CONCLUSION

Pipeline programs are an important strategy for addressing the shortage of URMs in the health professions. Anti-affirmative action initiatives threaten the existence of these student preparation programs and the ability of our nation to produce physicians of color and other health care providers who are more likely to serve in underrepresented communities and work to reduce related health disparities. Programs at universities and academic medical centers must develop innovative partnerships with underserved communities, adopt strategies that demonstrate a strong commitment to increasing racial and ethnic minorities in the health professions, and develop viable funding mechanisms to support diversity enrichment programs.

Engaging student health organizations in reducing health disparities in underserved communities through volunteerism: developing a student health corps

One underutilized method for reducing health disparities and training culturally competent health care workers is the engagement of undergraduate student health organizations in conducting health screenings, promotion, and health education outreach activities in in underserved racial/ethnic communities. We conducted a needs assessment of 14 predominantly racial/ethnic minority undergraduate student-run health organizations. The 14 organizations annually served approximately 12,425 people (67% Hispanic, 25% African American, 6.33% Asian Pacific Islander), predominantly at health fairs within Los Angeles County (averaging 138 attendees). Student organizations provided screenings on general health conditions and diseases, with less emphasis on behavioral risk factors (e.g., drinking, smoking). Organizations indicated a need for increased and affordable training in preventive health screenings and help in understanding target populations' needs. Universities are in an excellent position to train, supervise, and organize volunteer health corps in order to engage students in reducing health disparities and to train culturally competent health care providers.

Personal characteristics associated with resident physicians' self perceptions of preparedness to deliver cross-cultural care

BACKGROUND

Recent reports from the Institute of Medicine emphasize patient-centered care and cross-cultural training as a means of improving the quality of medical care and eliminating racial and ethnic disparities.

OBJECTIVE

To determine whether, controlling for training received in medical school or during residency, resident physician socio-cultural characteristics influence self-perceived preparedness and skill in delivering cross-cultural care.

DESIGN

National survey of resident physicians.

PARTICIPANTS

A probability sample of residents in seven specialties in their final year of training at US academic health centers.

MEASUREMENT

Nine resident characteristics were analyzed. Differences in preparedness and skill were assessed using the chi(2) statistic and multivariate logistic regression.

RESULTS

Fifty-eight percent (2047/3500) of residents responded. The most important factor associated with improved perceived skill level in performing selected tasks or services believed to be useful in treating culturally diverse patients was having received cross-cultural skills training during residency (OR range 1.71-4.22). Compared with white residents, African American physicians felt more prepared to deal with patients with distrust in the US healthcare system (OR 1.63) and with racial or ethnic minorities (OR 1.61), Latinos reported feeling more prepared to deal with new immigrants (OR 1.88) and Asians reported feeling more prepared to deal with patients with health beliefs at odds with Western medicine (1.43).

CONCLUSIONS

Cross-cultural care skills training is associated with increased self-perceived preparedness to care for diverse patient populations providing support for the importance of such training in graduate medical education. In addition, selected resident characteristics are associated with being more or less prepared for different aspects of cross-cultural care. This underscores the need to both include medical residents from diverse backgrounds in all training programs and tailor such programs to individual resident needs in order to maximize the chances that such training is likely to have an impact on the quality of care.

The impact of public hospital closure on medical and residency education: implications and recommendations

BACKGROUND

Challenges around safety-net hospital closure have impacted medical student and resident exposure to urban public healthcare sites that may influence their future practice choices.

OBJECTIVE

To assess the impact of the closure of a public safety-net teaching hospital for the clinical medical education of Charles Drew University medical students and residents.

METHOD

Retrospective cohort study of medical students' and residents' and clinical placement into safety-net experiences after the closure of the primary teaching hospital.

RESULTS

The hospital closure impacted both medical student and residency training experiences. Only 71% (17/24) of medical student rotations and 13% (23/180) of residents were maintained at public safety-net clinical sittings. The closure of the public safety-net hospital resulted in the loss of 36% of residency training spots sponsored by historically black medical schools in the United States and an even larger negative impact on the number of physicians training in underserved urban areas of Los Angeles County.

CONCLUSION

While the medical educational program changes undertaken in the wake of hospital closure have negatively affected the immediate clinical educational experiences of medical students and residents, it remains to be seen whether the training site location changes will alter their long-term preferences in specialty choice and practice location.

Clinical skills and self-efficacy after a curriculum on care for the underserved

BACKGROUND

Despite calls for medical school curricula that address care for the underserved, published evaluations of such curricula are few and often do not assess clinical skills. This study assesses the changes in self-efficacy and clinical skills resulting from faculty-led or web-based curricula on care for the underserved.

METHODS

Third-year students on 6-week 2003-2004 pediatric clerkships were block-randomized to a curriculum on caring for the underserved in one of three formats: established (readings only), faculty-led, or web-based. Primary outcomes were pre- and post-curriculum changes in self-efficacy and clinical skills. ANCOVA was used to test differences among curriculum groups, adjusting for prior experiences with the underserved. Analyses were performed in 2007.

RESULTS

A total of 138 students participated, with 121 (88%) completing both pre- and post-tests. Compared to the established-curriculum students, both faculty-led and web-based students improved their self-efficacy in establishing achievable goals with underserved families, while web-based students improved their self-efficacy around knowledge of community resources. Significantly more new skills were performed by both faculty-led (mean [SD]=3.3[1.8]) and web-based curriculum students (2.9[1.5]), compared to established-curriculum students (1.5[1.4]). Compared to established-curriculum students, more faculty-led and web-based students also reported new skills in locating resources to meet the needs of underserved patients and in following up on referrals to ensure that families accessed needed care.

CONCLUSIONS

Web-based and faculty-led curricula improve medical student self-efficacy and clinical skills. Results from specific self-efficacy and skill items facilitate targeted curricular improvement.

Primary care resident perceived preparedness to deliver cross-cultural care: an examination of training and specialty differences

OBJECTIVE

Previous research has shown that resident physicians report differences in training across primary care specialties, although limited data exist on education in delivering cross-cultural care. The goals of this study were to identify factors that relate to primary care residents' perceived preparedness to provide cross-cultural care and to explore the extent to which these perceptions vary across primary care specialties.

DESIGN

Cross-sectional, national mail survey of resident physicians in their last year of training.

PARTICIPANTS

Eleven hundred fifty primary care residents specializing in family medicine (27%), internal medicine (23%), pediatrics (26%), and obstetrics/gynecology (OB/GYN) (24%).

RESULTS

Male residents as well as those who reported having graduated from U.S. medical schools, access to role models, and a greater cross-cultural case mix during residency felt more prepared to deliver cross-cultural care. Adjusting for these demographic and clinical factors, family practice residents were significantly more likely to feel prepared to deliver cross-cultural care compared to internal medicine, pediatric, and OB/GYN residents. Yet, when the quantity of instruction residents reported receiving to deliver cross-cultural care was added as a predictor, specialty differences became nonsignificant, suggesting that training opportunities better account for the variability in perceived preparedness than specialty.

CONCLUSIONS

Across primary care specialties, residents reported different perceptions of preparedness to deliver cross-cultural care. However, this variation was more strongly related to training factors, such as the amount of instruction physicians received to deliver such care, rather than specialty affiliation. These findings underscore the importance of formal education to enhance residents' preparedness to provide cross-cultural care.

Do religious physicians disproportionately care for the underserved?

PURPOSE

Religious traditions call their members to care for the poor and marginalized, yet no study has examined whether physicians' religious characteristics are associated with practice among the underserved. This study examines whether physicians' self-reported religious characteristics and sense of calling in their work are associated with practice among the underserved.

METHODS

This study entailed a cross-sectional survey by mail of a stratified random sample of 2,000 practicing US physicians from all specialties.

RESULTS

The response rate was 63%. Twenty-six percent of US physicians reported that their patient populations are considered underserved. Physicians who were more likely to report practice among the underserved included those who were highly spiritual (multivariate odds ratio [OR] = 1.7; 95% confidence interval [CI], 1.1-2.7], those who strongly agreed that their religious beliefs influenced their practice of medicine (OR = 1.6; 95% CI, 1.1-2.5), and those who strongly agreed that the family in which they were raised emphasized service to the poor (OR = 1.7; 95% CI, 1.0-2.7). Physicians who were more religious in general, as measured by intrinsic religiosity or frequency of attendance at religious services, were much more likely to conceive of the practice of medicine as a calling but not more likely to report practice among the underserved.

CONCLUSIONS

Physicians who are more religious do not appear to disproportionately care for the underserved.

A resident clerkship that combines inpatient and outpatient training in substance abuse and HIV care

Substance abuse and HIV infection are important medical problems that receive comparatively little attention in residency training programs and residents often feel unprepared to deal with them. We developed a month-long rotation that combined outpatient care for patients with HIV infection and addiction, with inpatient care for medically-ill patients on a detoxification unit. At the end of the rotation, residents reported greater comfort with caring for these patients and improved self-rated competence. They also rated the rotation highly. Our experience shows that a rotation combining inpatient and outpatient substance abuse and HIV care was valued by residents and increased their comfort and proficiency with caring for these underserved and stigmatized populations.

Caring for the underserved: using patient and physician focus groups to inform curriculum development

BACKGROUND

Training pediatric residents to care for the underserved is a recognized curricular need. A literature review revealed that curricula specific to caring for the underserved tend to focus on specific medical diagnoses rather than physician or patient behaviors.

OBJECTIVE

To collect and evaluate information essential for developing a curriculum to teach care for the underserved.

METHODS

Focus groups were conducted to identify themes responsive to the question, "What does a physician need to know to care for the underserved?" Each of 3 focus groups met twice. The physician group included 5 pediatricians and 3 family practitioners. There were 2 patient groups: one Spanish-speaking (N = 13) and one English-speaking (N = 8). Content analysis was used to identify themes from each of the focus groups.

RESULTS

Prevailing themes from the 3 groups were communication/respect, cultural issues, and frustration with systems, such as health insurance, transportation, and health delivery systems. Patients expressed an almost universal wish for physicians to listen to them and to attempt to "understand my life." Physicians expressed concerns with lacking the time to establish quality patient relationships and the need to serve multiple roles. The groups did not discuss issues related to specific medical conditions.

CONCLUSIONS

Physicians and underserved patients identified communication/respect, cultural issues, and frustration with systems, such as health insurance, transportation, and health delivery systems, as important factors in caring for the underserved. Curricula to teach care of the underserved should include these themes.