The changing perceptions of junior medical students about the current U.S. health care system after a seminar series.

In the last few years dramatic changes have occurred in the way health care is delivered and financed in the United States. Academic medical centers have been slow in helping students understand what these changes will mean. We developed a series of student-run seminars and attempted to study what effect these seminars had on the students' attitudes towards many aspects of the current health care environment. We used recent journal articles as the basis for a student-led seminar series addressing many issues in the current health care environment. A previously developed 33-item survey was administered to the students before and after the seminars to evaluate any changes that occurred in their attitudes towards the evolving health care system. The students' responses showed significant changes on eight of the items surveyed. These included a more negative feeling about non-physician health care providers, a greater appreciation of the need for physicians to become more actively involved with social issues, and a greater understanding of the financial aspects of medicine. After a student-led seminar series there were significant changes in students' attitudes regarding several aspects of the changing health care environment in the United States.

Critical factors for designing programs to increase the supply and retention of rural primary care physicians.

CONTEXT: The Physician Shortage Area Program (PSAP) of Jefferson Medical College (Philadelphia, Pa) is one of a small number of medical school programs that addresses the shortage of rural primary care physicians. However, little is known regarding why these programs work. OBJECTIVES: To identify factors independently predictive of rural primary care supply and retention and to determine which components of the PSAP lead to its outcomes. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: A total of 3414 Jefferson Medical College graduates from the classes of 1978-1993, including 220 PSAP graduates. MAIN OUTCOME MEASURES: Rural primary care practice and retention in 1999 as predicted by 19 previously collected variables. Twelve variables were available for all classes; 7 variables were collected only for 1978-1982 graduates. RESULTS: Freshman-year plan for family practice, being in the PSAP, having a National Health Service Corps scholarship, male sex, and taking an elective senior family practice rural preceptorship (the only factor not available at entrance to medical school) were independently predictive of physicians practicing rural primary care. For 1978-1982 graduates, growing up in a rural area was the only additionally collected independent predictor of rural primary care (odds ratio [OR], 4.0; 95% CI, 2.1-7.6; P<.001). Participation in the PSAP was the only independent predictive factor of retention for all classes (OR, 4.7; 95% CI, 2.0-11.2; P<.001). Among PSAP graduates, taking a senior rural preceptorship was independently predictive of rural primary care (OR, 2.5; 95% CI, 1.3-4.7; P =.004). However, non-PSAP graduates with 2 key selection characteristics of PSAP students (having grown up in a rural area and freshman-year plans for family practice) were 78% as likely as PSAP graduates to be rural primary care physicians, and 75% as likely to remain, suggesting that the admissions component of the PSAP is the most important reason for its success. In fact, few graduates without either of these factors were rural primary care physicians (1.8%). CONCLUSIONS: Medical educators and policy makers can have the greatest impact on the supply and retention of rural primary care physicians by developing programs to increase the number of medical school matriculants with background and career plans that make them most likely to pursue these career goals. Curricular experiences and other factors can further increase these outcomes, especially by supporting those already likely to become rural primary care physicians.

Health beliefs and attitudes toward the prevention of osteoporosis in older women.

OBJECTIVE: A pilot study to determine health belief factors associated with osteoporosis prevention behaviors in peri-and postmenopausal women. DESIGN: We administered a survey to a convenience sample of 60 women aged 40-95 years old in an urban family practice center and an associated retirement community. The self-reported questionnaire addressed demographics, osteoporosis risk factors, current preventive behaviors for osteoporosis, and health beliefs. RESULTS: The majority of women (89%) believed that osteoporosis is a serious condition, but only 29% perceived a personal susceptibility. Women were less concerned about osteoporosis when compared with cancer, cardiovascular disease, and neurologic disorders. Only 40% of women were taking active measures to prevent osteoporosis. There was no significant relationship between active osteoporosis prevention behaviors and five health belief factors (motivation, barrier, active participant in health care, frustration, and benefit) (p >or= 0.43). However, active behaviors to prevent osteoporosis were found to correlate with the single item "I am worried about developing osteoporosis" (p = 0.03). Most women surveyed would be willing to exercise and take calcium and a multivitamin to prevent osteoporosis. CONCLUSION: Few women are taking active measures to prevent osteoporosis despite their belief that it is a serious condition. Our data suggest that most women do not perceive a personal susceptibility to the disease. Only women who reported actively worrying about developing osteoporosis were more likely to be engaged in significant osteoporosis preventive behaviors.

The impact of multiple predictors on generalist physicians' care of underserved populations.

OBJECTIVES: This study examined the relative and incremental importance of multiple predictors of generalist physicians' care of underserved populations. METHODS: Survey results from a 1993 national random sample of 2955 allopathic and osteopathic generalist physicians who graduated from medical school in 1983 or 1984 were analyzed. RESULTS: Four independent predictors of providing care to underserved populations were (1) being a member of an underserved ethnic/minority group, (2) having participated in the National Health Service Corps, (3) having a strong interest in practicing in an underserved area prior to attending medical school, and (4) growing up in an underserved area. Eighty-six percent of physicians with all 4 predictors were providing substantial care to underserved populations, compared with 65% with 3 predictors, 49% with 2 predictors, 34% with 1 predictor, and 22% with no predictors. Sex, family income when growing up, and curricular exposure to underserved populations during medical school were not independently related to caring for the underserved. CONCLUSIONS: A small number of factors appear to be highly predictive of generalist physicians' care for the underserved, and most of these predictive factors can be identified at the time of admission to medical school.

The use of conjoint analysis to study patient satisfaction.

Previous research has identified aspects of the outpatient interactions between patients and physicians that are important for patient satisfaction. In this study, conjoint analysis was used to determine the relative importance of these factors to patients. This study found the perceived skill of the physician to be the most important factor and waiting time in the office the least important. The use of conjoint analysis should help both patients and physicians to maximize patient satisfaction while minimizing costs as much as possible.

Hypertension, cardiovascular disease, and health care dilemmas in the Philadelphia Vietnamese community.

BACKGROUND AND OBJECTIVES: Prior studies have shown low awareness of hypertension and cardiovascular disease and low health care utilization in the US Vietnamese community. This study assessed awareness and understanding of these chronic conditions, health care barriers, and cultural beliefs in the Philadelphia Vietnamese community. METHODS: This qualitative study analyzed data collected from focus groups, family interviews, and individual interviews of community members and health care providers during 1996 and 1997. RESULTS: Awareness of hypertension was higher than expected but low for heart disease. Understanding of the cause and primary prevention of these illnesses was low, as was health care utilization. Major barriers to receiving health care included problems with language, medical insurance, and transportation. Desired resources were interpreter services, increased medical insurance, translated educational materials, health education classes, and community health fairs. The community widely held the belief that Western medicine is "stronger, faster, and curative" while folk medicine is "weaker, slower, but preventive." CONCLUSIONS: The Vietnamese community appreciates the importance of hypertension and cardiovascular disease and believes that traditional, Western medicine is necessary for care but perceives significant barriers. Providing needed services and specific intervention programs could improve access and understanding, as well as enable health promotion, disease prevention, and appropriate care.

Asthma controller medications: what do patients want?

Our goal was to understand which features of asthma controller medications are important to patients. We used a cross-sectional survey of primary care patients (N = 394) with the diagnosis of asthma. Using conjoint or "trade-off analysis," we measured patient preferences for hypothetical asthma controller medications based upon their route and frequency of administration, and need for blood test monitoring. Patients were not willing to use medications that required blood test monitoring. Preference regarding blood test monitoring was the strongest of any medication attribute that we studied, accounting for 45% of the variation. Patients' decisions were also highly affected by the frequency of dosing (40% of the variation). Patients did not have strong preferences regarding the route of administration (15% of the variation). Understanding these patient preferences may lead to increased compliance with treatment plans and promote physician-patient partnership.

Demographic, educational and economic factors related to recruitment and retention of physicians in rural Pennsylvania.

While prior studies have identified a number of factors individually related to physician practice in rural areas, little information is available regarding the relative importance of these factors or their relationship to rural retention. Extensive data previously collected from the Jefferson Longitudinal Study were analyzed for 1972 to 1991 graduates of Jefferson Medical College practicing in Pennsylvania in 1996, as were recent self-reported perceptions of Jefferson Medical College graduates in rural practice. Rural background was overwhelmingly the most important independent predictor of rural practice, and freshman plans to enter family practice was the only other independent predictor. No other variable, including curriculum or debt, added significantly to the likelihood of rural practice. None of these variables, however, including rural background, was predictive of retention, which appeared to be more related to practice issues such as income and workload. These results suggest that increasing the number of physicians who grew up in rural areas is not only the most effective way to increase the number of rural physicians, but any policy that does not include this may be unsuccessful.

Health beliefs and compliance with inhaled corticosteroids by asthmatic patients in primary care practices.

The aim of this study was to determine factors associated with regular use of inhaled corticosteroids (ICS) by asthmatic patients in primary care practices. A cross-sectional survey was carried out over 12 family practices in the Philadelphia greater Metropolitan area. A total of 394 patients aged 18-49 years, who received medical care for asthma from their primary care physician and had been prescribed ICS between 1 January 1995 and 31 December 1996, were included. The study measured self-reported demographics, experience with asthma, use of and attitudes about ICS, and health beliefs in six domains. Only 38% of patients reported using ICS at least twice a day almost every day. The most frequently cited reasons for inconsistent or non-use of ICS were related to a belief that ICS were unnecessary during asymptomatic periods and to a general concern about side-effects. By logistic regression, factors associated with regular use of ICS were two patient health beliefs, namely the health belief of 'Active' participation in clinical decision-making with their physician (OR = 4.6, 95% CI 2.8, 7.5), and the health belief that asthma was a 'Serious' health problem (OR = 2.3, 95% CI 1.4, 3.7), and hospitalization for asthma within the previous 12 months (OR = 2.3, 95% CI 1.6, 4.6). Patients were more likely to report regular use of ICS if they saw themselves as active participants in their treatment planning and conceptualized asthma as a potentially serious illness. These results support the themes of patient education and shared decision-making between patients and physicians that are promoted by the Asthma Guïdelines from the National Heart, Lung and Blood Institute (NHLBI).

Diabetes education program use and patient-perceived barriers to attendance.

BACKGROUND AND OBJECTIVES: Although self-management education is an essential component of optimal diabetes care, diabetes education programs are greatly underused. This study examined the use of diabetes education programs by a university-based family practice patient population in Philadelphia. Predictors of program attendance, as well as patient-perceived barriers to attendance, were identified. METHODS: A survey designed to collect information on demographics, clinical factors associated with diabetes, experience with diabetes education, and reasons for nonattendance at education programs was administered to 150 patients with diabetes. RESULTS: Twenty-two percent of the subjects had attended a diabetes education program. Female gender, insulin use, and higher degree of obesity were positively associated with education program attendance. Physician recommendation was an important predictor of attendance. Significant barriers to attendance included lack of awareness of programs, misperceptions about what programs involved, structural barriers, and health beliefs. CONCLUSIONS: Diabetes education programs are underused. Physicians can improve program attendance and outcomes for people with diabetes by implementing interventions designed to address the identified barriers.

Patterns and correlates of tobacco use among suburban Philadelphia 6th- through 12th-grade students.

BACKGROUND AND OBJECTIVES: Tobacco use among teenagers is increasing, even in the face of an understanding of its harmful effects. Data suggest that tobacco use often begins before entrance to eighth grade. This study examined the prevalence of tobacco use among students in 6th grade and compared it to the prevalence of tobacco use among 8th, 10th, and 12th graders in a northeastern suburban community and to national data. METHODS: We used a survey that measured selected tobacco and smokeless tobacco use, demographic variables, school-related factors, and social influences on the use of tobacco products. RESULTS: Sixth-grade tobacco use existed but was minimal compared to the rates seen in 8th, 10th, and 12th graders. Only 1% of 6th graders reported they were current smokers, compared with 41% of 12th graders. Risk factors for becoming a smoker were smoking habits of parents, siblings, and friends. CONCLUSIONS: Cigarette experimentation and use begins as early as sixth grade and increases substantially by eighth grade. Our data suggest that efforts toward primary prevention of smoking should be pursued between sixth and eighth grade.

A program to increase the number of family physicians in rural and underserved areas: impact after 22 years.

CONTEXT: The shortage of physicians in rural areas is a longstanding and serious problem, and national and state policymakers and educators continue to face the challenge of finding effective ways to increase the supply of rural physicians. OBJECTIVE: To determine the direct and long-term impact of the Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) on the rural physician workforce. DESIGN: Retrospective cohort study. PARTICIPANTS AND SETTING: A total of 206 PSAP graduates from the classes of 1978 to 1991. MAIN OUTCOME MEASURES: The PSAP graduates currently practicing family medicine in rural and underserved areas of Pennsylvania, compared with all allopathic medical school graduates in the state, and with all US and international allopathic graduates. All PSAP graduates were also compared with their non-PSAP peers at JMC regarding their US practice location, medical specialty, and retention for the past 5 to 10 years. RESULTS: The PSAP graduates account for 21% (32/150) of family physicians practicing in rural Pennsylvania who graduated from one of the state's 7 medical schools, even though they represent only 1% (206/14710) of graduates from those schools (relative risk [RR], 19.1). Among all US and international medical school graduates, PSAP graduates represent 12% of all family physicians in rural Pennsylvania. Results were similar for PSAP graduates practicing in underserved areas. Overall, PSAP graduates were much more likely than their non-PSAP classmates at JMC to practice in a rural area of the United States (34% vs 11%; RR, 3.0), to practice in an underserved area (30% vs 9%; RR, 3.2), to practice family medicine (52% vs 13%; RR, 4.0), and to have combined a career in family practice with practice in a rural area (21% vs 2%; RR, 8.5). Of PSAP graduates, 84% were practicing in either a rural or small metropolitan area, or one of the primary care specialties. Program retention has remained high, with the number of PSAP graduates currently practicing rural family medicine equal to 87% of those practicing between 5 and 10 years ago, and the number practicing in underserved areas, 94%. CONCLUSIONS: The PSAP, after more than 22 years, has had a disproportionately large impact on the rural physician workforce, and this effect has persisted over time. Based on these program results, policymakers and medical schools can have a substantial impact on the shortage of physicians in rural areas.

Psychosocial beliefs of medical students planning to specialize in family medicine.

The psychosocial orientation of fourth-year medical students planning careers in family medicine was compared to those selecting other specialties using the Physician Belief Scale. This scale has shown that practicing family physicians have a greater psychosocial orientation than those in other specialties such as internal medicine. The current study was done to see whether students choosing family medicine already have this greater orientation before they begin training as residents. 664 fourth-year medical students received surveys during their senior year and 378 (57%) returned completed surveys. Female students had a significantly greater psychosocial orientation than their male peers, but there were no significant differences between students planning residencies in family medicine and those selecting other residencies. The greater orientation of family doctors would appear to be a product of further training and experience either during residency or later during the actual practice of family medicine.

Attitudes toward sexual responsibility and parenting: an exploratory study of young urban males.

The self-reported sexual and parenting behaviors and attitudes of 42 urban males aged 16-22 who had fathered a child were compared with those of 49 demographically similar young men who were not fathers when they sought medical care at a public health center. Use of a questionnaire and structured interviews established that both groups had similar levels of self-esteem and similar ages at first intercourse. Fathers were less likely than the other respondents to feel that parenthood would interfere with their future (71% vs. 92%) or to have a concrete five-year plan (57% vs. 90%). They were more likely to believe that family (62% vs. 37%) and peers (68% vs. 40%) looked favorably upon early parenthood, to have a mother who was a teenage parent (74% vs. 47%) and to state that they lacked an adequate father figure while growing up (50% vs. 18%). Fathers also reported more frequent sexual activity and less consistent contraceptive use than did the others.

PIP: An exploratory study conducted at a health center in a low-income neighborhood in Philadelphia, Pennsylvania (US), in 1995 compared the characteristics of and attitudes toward sexual responsibility and parenting on the part of young fathers (n = 42) and their counterparts who were not fathers (n = 49). The average age of fathers at the time of their child's birth was 18.1 years. Mean age at first intercourse and mean number of current sexual partners were similar in both groups; however, fathers were less likely to have used contraception at last intercourse than non-fathers (43% vs. 70%). 64% of fathers reported they were happy when they learned their partner was pregnant, while only 36% of non-fathers anticipated such a response to this news. Fathers were more likely than non-fathers to believe that family (62% vs. 37%) and peers (68% vs. 40%) regarded early parenthood favorably. Fathers were also less likely than non-fathers to believe that fatherhood would interfere with their future (71% vs. 92%) or to have a 5-year career or educational plan (57% vs. 90%). 74% of fathers but only 47% of non-fathers were offspring of a teenage mother. Although both groups reported positive relationships with their own mothers, 50% of fathers compared with only 18% of non-fathers reported unsatisfactory relationships with their own fathers during childhood. Larger sample size and a prospective study design are required to confirm the validity of these results. Nonetheless, many of these findings provide information that can be incorporated into pregnancy prevention programs and services for teen parents.

Disagreement among health care professionals about the urgent care needs of emergency department patients.

STUDY OBJECTIVE: To assess agreement among health professionals with regard to the need for urgent care among emergency department patients. METHODS: We conducted a chart review of 266 ED patients in an urban teaching hospital. Eight health professionals (four emergency nurses, two emergency physicians, two family physicians) used identical criteria to retrospectively rate urgency. Agreement was measured for all reviewers, as well as among health professionals of the same specialty. Agreement was also measured between one ED nurse's retrospective assessment and the prospective assessments of the triage nurses who had seen the patients on presentation. RESULTS: The percentage of patients rated as needing urgent care by the retrospective reviewers ranged from 11% to 63%. Agreement among the retrospective reviewers was fair (kappa = .38; 95% confidence interval, .30 to .46) and was no better among reviewers of the same specialty. We found only slight agreement between the nurse reviewer's retrospective assessment and the triage nurses' prospective assessments (kappa = 19; 95% confidence interval, .07 to .31). CONCLUSION: Even when using the same criteria, health professionals frequently disagree about the urgency of care in ED patients. When retrospective reviewers disagree with a prospective assessment of urgency, the potential exists for denial of payment or even lawsuits. Because the subjectivity of urgency definitions may increase disagreement, the development of more objective and uniform definitions may help improve agreement.

Effect of primary care referral on emergency department use: evaluation of a statewide Medicaid program.

BACKGROUND AND OBJECTIVES: Medicaid recipients without a regular source of care frequently use hospital emergency departments (EDs) for minor problems. This study examined whether referring Medicaid patients to primary care physicians and obstetricians results in a decrease in ED use and an increase in physician office visits. METHODS: The statewide Voluntary Initiative Program (VIP), which referred Medicaid patients to primary care physicians and obstetricians without any managed care component, was examined. Claims data were reviewed for Medicaid clients 0-64 years old who obtained VIP referrals during the first five months of the program. The change in rate of visits to hospital EDs and physician offices was compared for the study group (n = 444) and for the state's overall Medicaid population (n = 40,860). RESULTS: After referral, ED use decreased 24 percent for the VIP group and 4 percent for the Medicaid population. During the same period, physician office visits increased 50 percent for the VIP group but decreased 13 percent for the Medicaid population. CONCLUSIONS: Even in the absence of managed care, referral to primary care physicians and obstetricians resulted in fewer ED visits and more physician office visits. These findings confirm the importance of primary care in improving the efficiency of health care delivery for the Medicaid population.

Trends along the debt-income axis: implications for medical students' selections of family practice careers.

PURPOSE: To examine whether medical students' levels of debt have an influence on selection of family practice careers, independent of other factors. METHOD: Data from the Jefferson Longitudinal Study were analyzed for 1,350 graduates from the classes of 1987-1993 at Jefferson Medical College of Thomas Jefferson University; a focused analysis for 326 graduates from the classes of 1992 and 1993 was specifically performed to identify recent trends. A binary logistic regression equation was used to predict the probability of a graduate's entrance into a family practice residency based on first-year preference for family practice, income expectation, debt level, age, and gender. RESULTS: A high level of indebtedness (at least $75,000) was a significant independent predictor of specialty choice (away from family practice); first-year preference for family practice and income expectation were also significant independent predictors. Combining these three factors (debt, specialty preference, and income expectation) led to a greater than 12-fold difference in specialty selection of family practice. Notably, 36% of the students graduating in 1992-1993 had debts of at least $75,000, more than three times the percentage in the classes graduating in 1987-1989. CONCLUSION: High levels of debt had a significant negative effect on family practice specialty, choice among recent Jefferson graduates. An increase in the number of students with such debt carries strong implications for the selection of careers in family practice.

Medical students' specialty choice and the need for primary care. Our future.

Recent changes in the health care environment have directed increasing attention to the recognized oversupply of specialists and relative lack of primary care physicians. Despite this imbalance and the need for more primary care physicians, US medical schools are not producing them in adequate numbers. To effect change in the production of primary care physicians, a comprehensive approach that addresses key factors in medical student specialty choice is needed. This article discusses such factors and how they affect medical students during the course of their training. Issues concerning primary care specialty choice and the physician work force are important to the development of the future US health care system.