Knowledge of the health care system delivery and financing
We asked students where the United States ranked in the well-publicized 2000 World Health Organization's (WHO) ranking of 191 nations based on “overall health systems performance,” defined as health-achievement (measured in population disability-adjusted life expectancy) related to health system expenditure.22 Eleven percent of respondents correctly identified the answer (37th or “near 40th place”), while 89% overestimated U.S. performance. Regarding U.S. performance on key health indexes in comparison to other nations, 32% incorrectly answered that the United States had the highest life expectancy of any nation, and 34% answered that the United States had the lowest infant mortality rate. When asked about health care costs, 27% were not aware that the United States spends more per person on health care than any other nation. With regard to health care financing, 61% were not aware that the administrative costs of private health insurance exceed those of Medicare.
Knowledge of health care access
Overall, 90% of respondents correctly answered that the numbers of the uninsured have grown over the past decade, and 83% recognized that the proportion of uninsured Americans increased during and immediately prior to the study period. In contrast, 28% were able to quantify accurately the number of uninsured in the United States, with 40% of both first- and fourth-year students underestimating the numbers of uninsured.17 Most respondents (87%) knew that working people and their families are the majority of uninsured individuals in the United States. Most respondents also knew that African Americans (92%) and Latinos (96%) are at greater risk of not having health insurance, but only 25% were aware that a high number of Asian Americans are uninsured. Nearly all students (96%) recognized that being uninsured may lead to adverse health consequences, including unnecessary hospitalizations, delayed diagnoses, and lack of a regular source of care. A total of 90% were aware that out-of-pocket costs could be a barrier to health care access, even for those with insurance. Most students (60%), however, did not know that the United States is the only industrialized nation without some form of universal coverage system (see Table 3).
Differences in knowledge by year in medical school
Overall, 90% of students correctly answered more than half of the true/false questions; however, less than half of the respondents in each class correctly answered eight or more of the 12 questions. Performance varied significantly by year of medical school on three of the 12 questions (see Table 3); however, the average number of correct true/false responses was similar among first-year and fourth-year students (7.17 vs. 7.29; p = .23). Furthermore, similar proportions of first- and fourth-year students correctly located the United States in the WHO's ranking of health care systems (13% vs. 10%; p = .73). We found no statistical difference in the proportion of first-year and fourth-year students who correctly estimated the number of uninsured in the United States (31% vs. 26%; p = .80).
Medical student satisfaction with teaching in health policy
Nearly all respondents (96%) felt that understanding health policy was important to practicing medicine. Roughly half of all respondents expressed dissatisfaction with both premedical (48%) and medical school coursework (54%) related to health policy, health care delivery, and health care reform issues, with no statistically significant differences between first- and fourth-year students.
Suggestions for curricular reform on health policy
Overall, 89% of all respondents wanted increased exposure to health policy, health care delivery, and options for health care reform. When students who expressed this view were asked in what format(s) they wanted to have this exposure, fourth-year students were more likely than first-year students to indicate a desire for required medical school coursework (67% vs. 48%, p < .01), whereas first-year students were more likely than fourth-year students to want additional premedical coursework (27% vs. 17%, p < .01), elective medical school coursework (60% vs. 54%, p = .01), and extracurricular experiences (63% vs. 54%, p < .01).
In this nationally representative survey of first- and fourth-year medical students, we identified important gaps in their knowledge about the U.S. health care system. While the vast majority of students recognized that access to health care for the uninsured was a major problem, most students demonstrated incomplete knowledge of the magnitude and demographics of that problem, the performance of the U.S. health care system in comparison with other countries, and the financing of health care in the United States. In this cross-sectional study, we observed no appreciable difference in performance between first- and fourth-year students, raising concerns about the content and effectiveness of existing curricula in health policy and health care financing.
Our study's principal strengths are its national scope and the sampling method, which allowed generalizability to the population of first- and fourth-year medical students in the United States. In addition, we assessed students’ knowledge directly by asking them to answer a series of questions about core health policy issues. This approach to knowledge assessment may be more valid than questionnaires asking students to rate their own level of knowledge, a method that may be subject to social desirability bias.
As with many surveys of physicians and medical students, our study's main limitation is the potential for response bias. In this case, the high number of respondents reporting an interest in learning about health policy may be the result of students with greater general interest in health policy completing the questionnaire. If this response bias did occur, then the knowledge deficiencies observed among these motivated students are even more striking.
Consistent with a prior survey,23 medical students in our survey acknowledged their inadequate training in health care policy issues during medical school. Our respondents widely agreed that knowledge of health policy is important to their future careers, and they advocated for additional exposure. Medical educators should consider expanding and enhancing health policy curricula to improve students’ satisfaction with their education and to produce a physician work force prepared to function and improve the system in which they work.
Support for this project was provided by a grant from The Robert Wood Johnson Foundation in Princeton, New Jersey. The authors also acknowledge Paul R. Wright and the American Medical Student Association Foundation for support in the development of project goals, as well as Ryan Hubbard at the University of Virginia Center for Survey Research for assistance in questionnaire development, administration, and data analysis.
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© 2005 Association of American Medical Colleges
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