The influence of medical education on students' attitudes and career intentions is poorly understood. Previous studies have found senior-level medical students to be more conservative and less inclined towards providing care to indigent patients than are their younger counterparts.1 However, data also suggest that students and residents can develop more favorable attitudes and altruistic actions2 after a service experience. It is not clear whether these attitudes and actions can be sustained or influence career plans.
Method. We surveyed a cohort of second-year medical students (MSII) in 1996 and again in their fourth year (MSIV) in 1998. The confidential, self-administered survey contained unique identifiers, and consisted of four domains: demographics, prior volunteer and curricular experiences, attitudes towards indigent care, and factors influencing career plans, including residency selection. The two-part measure of career influences, scored using a bidirectional, five-point Likert scale, was: (1) 15 general statements about indigent-patient care grouped as professionalism, lifestyle, and social values statements, and rated as to their influence on the students' future career and patient-mix plans; and (2) 15 residency-specific factors rated on their relative influences on the students' residency site selections. Residency factors were grouped as patient population, program mission and values, program structure, and geo-ethnic/economic-based factors.
Results. Overall, 91 of 126 (72.2%) MSIV students completed the 1998 survey and 56.3% completed both the MSII and the MSIV surveys. Most respondents were white (75.3%), not married (74.4%), 25-28 years old (65.5%), and men (56.0%). Equivalent proportions entered primary care and specialty fields. Overall, 91.2% reported receiving some structured instruction on indigent care issues during medical school.
Only a few MSIV students (8.9%) believed they would spend 50% or more of their time working with indigent patients, while most (66.7%) believed they would spend 25% or less of their time working with indigent patients. Three factors were identified by a majority of MSIV students as influencing their future intentions to care for indigent patients: sense of professional responsibility (73.6%), physician role models (64.8%), and previous experiences with indigent patients (63.8%). Compared with their MSII responses, more MSIV students felt “personally responsible for providing care to indigent patients” (31% increase) and disagreed with “doctors working with indigent patients are more altruistic” (27% decrease) and “… earn much less” (40.8% decrease). For the majority, residency site selection were influenced by four factors: institution's social mission (57.3%), large underserved or indigent community (53.9%), degree of community outreach (52.8%), and VA or county health facility rotations available (50.6%). While only 35.6% of the students reported “community of origin” to be an encouraging factor in future intent to work with indigent patients, 57.1% of the minority students rated this an influential factor.
Discussion. Attitudes about and future plans to work with indigent patients are influenced and solidified by the medical school experience and the role modeling that occurs there.
REFERENCES
1. Crandall SJ, Volk RJ, Loemker V. Medical students' attitudes toward providing care for the underserved. Are we training socially responsible physicians? JAMA. 1993;269:2519–23.
2. O'Toole TP, Hanusa BH, Gibbon JL, Hamilton-Boyles S. Experiences and attitudes among residents and students influence voluntary service with homeless populations. J Gen Intern Med. 1999;14:211–6.
