The personal health care of medical students is a neglected issue in medical education that has important ramifications for future physicians and their patients.1,2,3,4 Although several studies have documented the psychiatric and substance use problems of medical students, few data exist to clarify the general health care access and care-seeking practices of medical students during their training.3,4,5,6 To explore these considerations, a preliminary study was undertaken in 1993-94 to characterize the physical and mental health care concerns and experiences of students at one school, the University of New Mexico School of Medicine.2 That study involved 112 students, nearly all of whom (95%) desired some form of health care during medical school for health needs such as health maintenance (70%), infections (46%), depression and stress symptoms (42%), and reproductive health (30%). Women students and students in their clinical years of medical school training expressed greater need for health care than did their male and preclinical counterparts. Twenty-four percent of the students had experienced difficulties in obtaining care, and 16% were not insured. The majority (55%) had at one time or another not sought care because of training demands; others had not sought care because of worries about cost (31%) and desire for confidentiality (12%). Roughly half of the students had received treatment at their training institution, and nearly a fourth had used informal consultations (“curbsiding”) to obtain medications or other forms of care for health matters. Building upon this pilot work, we sought to document the personal health care access issues and care-seeking practices of a broader sample of medical students from across the United States.
Design and survey instrument. We revised a questionnaire on medical students' health care issues that had been developed and pilot tested in an earlier study.2 To determine the one-month test-retest reliability of the revised questionnaire, we administered it to 33 medical students at the University of New Mexico. Their two sets of responses demonstrated overall stability of the measures: responses regarding their overall need for health care during medical school were perfectly constant (r = 1.00, p < .001), while specific service-access items (e.g., items related to needing health care, day surgery, or hospitalization) were highly consistent (r = 0.86, p < .001), as were reports of having had difficulty in obtaining care (r = 0.86, p < .001). Specific student care-seeking practices showed greater variability: not seeking care for health problems (r = 0.45, p < .05); seeking informal care (r = 0.56, p < .05); and reason for informal care (r = 0.69, p < .05).
Participants and procedure. In 1996–97, we administered the questionnaire via mailbox or classroom to 1,964 preclinical and clinical students at a sample of nine medical schools. The medical schools (Emory University, Johns Hopkins University, Loma Linda University, University of Chicago, University of Colorado, University of New Mexico, Oregon Health Sciences University, University of Utah, and West Virginia University) were selected to represent all major geographic regions of the United States and to include four private and five public institutions of varying class sizes. Collaborators at each site distributed the questionnaires, then collected and returned the completed questionnaires to the University of New Mexico, where we performed data entry and analysis. The project received prospective institutional review board approval at each school. Study participation was voluntary, and the privacy of respondents was safeguarded by using a confidential survey coding method at eight schools and an anonymous method at one school.
Sample characteristics. A total of 1,027 students from the nine medical schools participated (Table 1). Response rates by site ranged from 20% to 87% (p < .0001). Ninety-four percent of the responding students were less than 30 years of age; only 2% were 40 years old or older. Seventy-four percent of the respondents were white, 11% Asian, 3% black, 5% Hispanic, 1% Native American, and 7% other/unspecified. Sixty-five percent of the respondents described themselves as “never married,” and 31% reported being currently married; 13% had children. The 599 preclinical students responded at a greater overall rate than did the 428 clinical students (60% versus 45%; p < .0001). The 483 women responded at a greater rate than did the 539 men (58% versus 47%, p < .001). To assess for bias, we conducted all analyses first using the entire nine-school sample and then again using a trimmed sample that excluded the responses from the two low-responding schools. Comparison of the outcomes from these samples did not reveal significant differences.
Health care access and care-seeking practices. Ninety percent of the respondents indicated that they had needed health care during medical school. In terms of health care service access and care-seeking behaviors (Table 2), 96% of the respondents reported having health insurance, and 35% believed that their insurance required treatment at their training institutions. Seventy-six percent had received health care at their training institutions, and 44% had received health care at other institutions. Nearly half (48%) reported difficulty getting health care. Reasons for difficulty included being too busy to take time off (37%); worrying about cost (28%); having excessive waits (24%); worrying about confidentiality (15%); having no access to health care (4%); and other reasons (4%). Many students reported that they had not sought care for health problems due to being “too busy” (57%), worries about cost (45%), or other factors. Almost two thirds (63%) of the students had obtained informal care from colleagues: 43% had asked a colleague to perform a physical examination; 33% had asked someone to diagnose their symptoms; and 23% had asked a colleague to prescribe medications. A small minority had asked someone to order or interpret lab tests (6%) or to perform other medical care (4%). Reasons for seeking informal care were that it was convenient or accessible (56%); required less time (48%); was less expensive (30%); protected confidentiality (6%); and other reasons (7%). As noted in Table 2, institution, level of training, and gender had significant effects on medical students' perceived access to health services and care-seeking practices. Hierarchical log-linear model tests revealed that variation across the nine schools was not attributable to differences in gender, age, or training level.
This collaborative study documents the personal health care access issues and care-seeking practices of 1,027 students at nine public and private medical schools in the United States. Particularly striking were the findings that 90% of the students felt they had needed health care during medical school, 96% had health insurance, and 48% had experienced difficulty in obtaining health care. These medical students commonly indicated problems with convenience, general accessibility of services, and worries about cost and confidentiality. Moreover, a majority of the students had opted to forgo desired care at some point during medical school, and the single greatest reason for this was the perceived inability to take time off from their daily schedules.
Most students had received treatment at their training institutions, reminding us that medical schools serve as a critical source of care for student-patients. The use of informal (curbside) consultation by most students to obtain services such as diagnostic evaluations, prescription medications, and lab tests was another novel and potentially ominous result in this multi-center study. We identified considerable institutional variability, suggesting that the medical schools' curricula and environments greatly affect the personal health care experiences of students. In addition, the women in our sample more often reported difficulty in securing care, worries about cost and confidentiality in seeking treatment, and obtaining care both inside and outside their training institutions. Clinical students reported greater frequencies of difficulty in obtaining care, of opting to forgo treatment, and of care-seeking through informal consultation. In light of these findings, the personal health care issues, service access, and care-seeking practices of medical students should be recognized as salient considerations in medical education.
Barriers to Health Services
Despite the remarkably high prevalence of health insurance reported by the medical students, most had encountered significant barriers to health services, and many reported concerns about cost. Confidentiality was another key concern identified. These appear to be actual constraints to care, as more than half of the 1,027 students in our study, including nearly three fourths of the students at one school, chose not to seek treatment for their health problems at some point during training. The level of unmet need for care disclosed by the medical students is far greater than that found in the general working-age population (20%), and it rivals the rates of unmet need among special and at-risk patient populations.7 Our data further indicate that medical schools serve as the principal providers of care for most students, an observation that may be seldom discussed at many academic medical centers. The frequency of barriers to care reported by our respondents also suggests that additional efforts to help medical student-patients are necessary, particularly at some institutions.
The extensive use of informal consultation by medical students, a care-seeking practice that appears to increase with progression through clinical training, is worrisome. While it fits within the tradition of professional courtesy in medicine, informal consultation creates the expectation that personal health care may be conducted outside usual professional boundaries, potentially leading to inappropriate self-diagnosis and self-prescription.1,2,6 Informal consultation precludes the development of a full physician-patient relationship and does not offer protections such as trust and thoroughness in communication, clinical care, and documentation. Finally, informal consultation perpetuates the myth that clinicians and trainees are, or should be, sturdier and more self-sufficient than other patients. Patterns that contribute to physician impairment may thus be grounded in medical school stresses and behaviors.
In sum, while it may be relatively inexpensive and time-efficient, informal consultation presents many problems for students. Our findings suggest that the phenomenon of informal curbside consultation may be influenced by acculturation, by heightened time pressure and financial concerns, and by greater access to clinicians during the last two years of medical school. For these reasons, it is imperative that this care-seeking practice, with its apparent advantages and its less obvious disadvantages, be addressed systematically in medical training.
The Impact and Value of Medical Student Health Experiences
The personal health experiences of medical students have key implications for their future patient care practices and attitudes. An emerging empirical literature indicates that the personal health behaviors of physicians directly bear upon their clinical practices: for instance, those related to their patients' alcohol intake, tobacco use, exercise, and weight maintenance.8,9 Narrative accounts of personal illness by physicians and physicians-in-training also reveal the profound value of health experiences in kindling compassion and combating cynicism in their clinical work.2,10 Taken together, these reports strongly support the notion that medical students' present health concerns and experiences may affect their enduring patient care patterns. Consequently, enriching the efforts to provide sound care for medical students may also enhance the care of generations of patients in the future.
Limitations of the Study
The validity of the findings from this collaborative study hinges upon several factors. First, because the survey inquired about potentially stigmatizing health matters, some students may have been unwilling to participate or to disclose their true concerns. Our findings therefore may underestimate some service-access difficulties and maladaptive care-seeking practices of students. Second, our sampling strategy included nine medical schools representing most geographic regions, both public and private institutions, and diverse class sizes, but was not derived by a randomized method. Third, the variability in the rates of response at the nine study sites (30% to 87%) warrants consideration. Because seven of the nine schools had strong response rates, and analyses excluding the low-responding two schools did not reveal any substantive differences in our findings, our conclusions are potentially generalizable. Finally, data collection occurred over approximately seven months at the various institutions involved with the study. This time course may have diluted the still-significant comparisons between responses of preclinical and clinical students.
For the sake of future physicians and their patients, the personal health care issues of medical students merit close attention. Our findings suggest that medical schools shoulder the responsibility not only of educating but also of providing health services for their students. Some medical students in this study reported having difficulty in securing care, in part due to the training circumstance. The access issues and care-seeking practices of students, moreover, appear to be greatly influenced by institutional milieu and by training stage.
In light of these data, medical school faculty may wish to pursue several initiatives. First, medical educators should seek to develop inexpensive, confidential student health services that fit with students' rigorous schedules. Availability of care services should be well publicized, beginning with medical school orientation, and revisited at critical training points such as entry into the clinical clerkships. Second, the topics of physician/trainee health and well-being, appropriate self-care practices, and attitudinal barriers to care should be addressed explicitly in the curriculum. Potential problems associated with informal consultation should be considered in detail. Discussions of personal health issues of medical students in the classroom should be undertaken with sensitivity to the students' desire for privacy, however, and should never be conducted in a manner that may be experienced as coercive or as requiring self-disclosure. Third, care-giving faculty should engage in dialog with their student-patients to help them assimilate the formative, positive lessons of personal health experiences. Fourth, targeted interventions such as small-group discussions or workshops to address the special concerns of women (e.g., issues related to taking time off from school work, confidentiality, cost, and coordinating multiple sources of care) should be implemented. Finally, efforts should be undertaken to educate housestaff and faculty members about institutional policies, health services, and attitudes relevant to medical student health care. In so doing, the unspoken curriculum reinforcing the perceived barriers to care and supporting maladaptive self-care practices of students may be constructively addressed.
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