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Perspective: Medical Students’ Perceptions of the Poor: What Impact Can Medical Education Have?

Wear, Delese PhD; Kuczewski, Mark G. PhD

doi: 10.1097/ACM.0b013e3181782d67
Underserved Populations

There is currently little knowledge or understanding of medical students’ knowledge and attitudes toward the poor. Teaching hospitals bring students face-to-face with poor and uninsured patients on a regular basis. However, an overview of the research available suggests that this contact does not result in students’ greater understanding and empathy for the plight of the poor and may, in fact, lead to an erosion of positive attitudes toward the poor. A basic understanding of justice suggests that as the poor are disproportionately the subjects of medical training, this population should enjoy a proportionate benefit for this service. Furthermore, medicine’s social contract with the public is often thought to include an ideal of service to the underserved and a duty to help educate the general public regarding the health needs of our nation.

In their discussion, the authors situate medical students’ attitudes toward the poor within larger cultural perspectives, including attitudes toward the poor and attributions for poverty. They provide three suggestions for improving trainees’ knowledge of and attitudes toward the poor—namely, increasing the socioeconomic diversity of students, promoting empathy through curricular efforts, and focusing more directly on role modeling. The authors argue that service learning, especially efforts that include gaining detailed knowledge of a particular person or persons, coupled with critical reflection, presents a very promising direction toward achieving these goals. Finally, they posit an agenda for future educational research that might contribute to the increased efficacy of medical education in this important formative domain.

Dr. Wear is professor of behavioral sciences, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio.

Dr. Kuczewski is director and Father Michael I. English, S.J., Professor of Medical Ethics, Neiswanger Institute for Bioethics and Health Policy, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois.

Correspondence should be addressed to Dr. Kuczewski, Loyola University Chicago Stritch School of Medicine, 2160 S. First Ave., Bldg. 120, Room 280, Maywood, IL 60153; fax: (708) 327-9209; e-mail: (

The specialist “knows” very well his own tiny corner of the universe; he is radically ignorant of all the rest.

—José Ortega y Gasset, The Revolt of the Masses

What do physicians in training think about the poor, the uninsured, and the underserved? This may seem to be an irrelevant question and, quite possibly, several irrelevant questions. After all, physicians should be concerned with people who suffer from disease and illness, regardless of their social and economic status. Sick people are, after all, sick, and they need the help of physicians who do not harbor negative attitudes toward patients based on social or economic status. To address concerns about potential biases directly, medical educators frequently construct curricula aimed at identifying, questioning, and, ostensibly, lessening such biases in trainees, most notably through efforts in cultural competence, diversity and multicultural education, and, sometimes, service learning. The underlying assumption is that these biases may be a sort of misunderstanding that can be turned around through systematic curricular “interventions.” Yet this assumption is simplistic and needs far more elaboration.

In addition, the current emphasis on fostering professionalism among medical students and residents has renewed interest in the relationship between medicine and society. Medicine is often postulated to be a party to a social contract in which the profession receives a variety of public support. In return, medicine provides society with the benefits of its expertise, benefits that should include promoting the health of the public through education and advocacy. Thus, we expect that the medical profession will assist society in understanding what kinds of health policy measures are likely to help promote the well-being of all citizens, especially those least well served by current financing and delivery systems and, therefore, most in need. This requires that physicians understand the social and economic context in which they provide care. It also demands that physicians advocate the broad interests of the general public and not succumb to the temptation to promote policies that primarily serve physicians’ self-interest.

Medical educators have spent countless hours manipulating the curriculum to influence trainees’ attitudes and values, a complex task with little similarity to curricular efforts involving knowledge acquisition and skill development—particularly if we desire not simply students’ self-reports of attitude change, but behavioral evidence of such change. Deepening our understanding of students’ attitudes toward the poor is all the more complicated because of the context of so much of medical training. It is no secret that many teaching hospitals are located in economically disadvantaged areas and that students often learn medicine disproportionately on poor populations. The Association of American Medical Colleges has produced a variety of reports and data that document how teaching hospitals and hospitals affiliated with academic health science centers treat a disproportionate share of the uninsured. In fact, the percentage of uninsured patients treated by these hospitals is far greater than the percentage of total hospital beds these institutions represent in our nation.1

As a result, teaching hospitals bring medical students and residents face-to-face with poor and uninsured patients on a regular basis. This means that such patients will be those on whom medical students and residents will often practice and improve their skills, a situation that raises concerns of justice. Justice, as classically conceived in biomedical ethics,2 requires that those who take on risks and burdens should share proportionately in the benefits and rewards. If the poor and uninsured provide the opportunities for medical training, they should share in the benefits that this training produces. Although this principle cannot stipulate exactly what those benefits should be, such training should be expected to produce physicians who have knowledge of the plight of the poor and a dedication to advocating needed services for those who are disadvantaged in the current system. At a minimum, we should expect that exposure to the poor during training should not reinforce trainees’ existing stereotypes and prejudices. In other words, medical training should not result in dislike for the poor. After all, physicians who dislike their patients will be less likely to serve them well.3 Yet, there is prima facie cause for concern in this regard, at least in part because of the nature of trainees’ exposure to the poor.

Thomas Inui, a member of the Institute of Medicine committee that produced Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,4 notes that “often the only aspects that students see of the communities in which they work are what produces the circumstances that bring individuals to the hospital, [such as] violence and drug abuse.”5 (p6) Jeanette South-Paul observes in that same study that

the bulk of patients cared for by our medical students are suffering from poor lifestyle choices, a lack of insurance, and therefore a lack of access, and conditions that patients allow to get worse before they seek treatment. I don’t think there is any way you can discount the resulting contribution of bias on continuing disparities in health care.5 (p7)

In sum, medical training requires that we be clear about the goals of our educational agenda, particularly our hopes for the kind of physician we are educating, one who is knowledgeable, skilled, and compassionate—that is, one who is not merely “competent.” Here, we will argue that the obstacles to achieving these goals are formidable and that our knowledge of how to overcome them is limited, particularly if we seek understanding of how authentic attitude change is brought about. As we examine student knowledge and attitudes toward the poor, we place them within the context of the attitudes of the general population toward the poor in the United States. We also offer several curricular and teaching recommendations that may foster in medical students more thoughtful, compassionate attitudes toward the poor, and we make recommendations for future research.

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What Do We Know About Attitudes Toward the Poor?

Class as a category

We have to this point been using the conjoined terms poor and uninsured to describe the group of people toward which the attitude change we advocate is directed. Of course, although the classes of persons who are poor and those who are uninsured have significant overlap, some poor persons have health insurance via programs such as Medicaid, Medicare, and, in some instances, through private, employer-provided insurance. And, as is well known, the uninsured often have incomes significantly above the Federal Poverty Level (FPL). Because the income levels for the FPL are defined artificially low, the “working poor” earn more than the FPL but often do not have health insurance.

Of course, “the poor” cannot be precisely defined as a social class. That is, the category may be rooted in income levels, but it also encompasses a variety of other factors, such as expectations and aspirations regarding a host of social goods, such as education. The United States is often said not to be class conscious in the way many older societies are, and, as a result, medical education has been quicker to focus on practitioner biases associated with race and ethnic identity, advanced age, or particular sexual identities. In medicine, class-based biases are seldom addressed as such even as a significant national conversation seems to be under way regarding access to care. However, it is not immediately obvious that medicine gains an advantage by thinking about communication barriers with some patient populations as culturally grounded in the patients’ race or ethnic identity as opposed to being related to their socioeconomic status.

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Attitudes toward the poor and attributions for poverty and wealth

Attitudes have both affective components, which are feelings or other emotional responses about an entity, and cognitive components, which are also known as stereotypes.6 Much of the general research on attitudes toward the poor and poverty have focused on attributions that people make to explain why some people are poor and others are not. Attributions for poverty are likely to be positively correlated to attitudes toward poverty, although “attributions go beyond the favorable/unfavorable evaluation of an entity in that they consist of explicit causal beliefs.”6 In other words, one’s feelings toward a poor person can be a function of whether one sees the person as responsible (i.e., “to blame”) for being poor.

Most studies done in the United States about attitudes toward the poor find that people generally believe that there are multiple causes of poverty,6–10 although the majority of Americans believe that individualistic causes, such as lack of effort or laziness, drug use, or low intelligence, are more important factors than societal or structural ones, such as discrimination, low wages, or poor education.8 And, according to Bullock, the “myth of classlessness appears to be a central ideological tenet among most Americans,”9 which is why we are more apt to blame individuals for their poverty rather than societal or structural causes. This, of course, represents the age-old “bootstraps” belief that individuals are capable of and responsible for pulling themselves up. There are, this thinking goes, ample opportunities for anyone who is willing to work hard; if one chooses not to take advantage of these opportunities, one is penalized with poverty, often deservedly so.

In addition to the individualistic causes cited above, welfare dependency is also perceived as a reason some people do not take advantage of the opportunities available to them to get ahead, along with “weak, often broken family backgrounds, and the lack of drive on the part of the poor themselves.”9 In fact, in a survey that was given between 1982 and 1995, a “lack of one’s own effort” was cited by 43% of Americans as the cause of poverty.11 For most people, such beliefs

emanate from a mental concoction of daily observations, experiences, and lay philosophies … [they] filter social perceptions and provide the cognitive structure for a host of specific beliefs about the factors that cause (or do not cause) some people to become wealthy and others poor.9

In contrast, the structural attributions for poverty have less to do with individual culpability and more with broad, social structural forces that exist independently of individual traits, most notably restrictive social structures that “do not provide equal alternatives for all people…. Through their ownership or control of structures (such as education, the polity, labor, and capital), the wealthy maintain and legitimize control over other segments of the population.”9 And because most Americans do believe there are multiple explanations for poverty, they can simultaneously recognize that there are structural obstacles that make overcoming poverty difficult but that individuals who work hard enough can overcome these obstacles.8 Although one can understand the prima facie utility of this way of thinking, it ultimately places the locus of control for poverty within the individual and makes poverty a personal failure in virtually every instance.

In addition, one’s race, age, and political affiliation influence attributions for poverty. Studies have found that whites are more likely than blacks to use individualistic explanations for poverty over structural explanations; younger people are more likely to use individualistic attributions for poverty than older people; and political conservatives are more likely to make individualistic rather than structural attributions for poverty.7–9 In fact, individuals who are what Wagstaff12 calls right wing are more apt to make “dispositional attributions in accounting for poverty, and generally possess more negative attitudes to the poor than those with a more left-wing bias.” Gallup and Newport13 use the descriptors conservative and liberal to explain the same phenomenon: Liberals believe far more than conservatives (57% to 36%) that circumstances rather than individual efforts explain poverty. In that same poll, 46% of all Republicans surveyed thought that lack of effort was the most significant cause of poverty; 27% of Democrats surveyed believed the same. In fact, Bullock7 found that of all the sociodemographic variables, “political affiliation … [is] the most consistent predictor of … stereotypes and attributions.”

The literature on medical students’ attitudes toward the poor and attributions for poverty is spare and aging, with a few notable exceptions. In fact, perhaps the most striking finding of our attempt to review the literature is that most research that explicitly deals with attitudes of medical students toward poor persons per se is rather old. Nevertheless, the existing literature indicates that by the fourth year of medical school, students are

less willing to provide all services to those individuals who have no ability to pay for them; they do not believe to the same extent as [first-year students] that they can have an impact on society’s health care problems; they are less willing to become involved in providing care to indigent populations; and they have less favorable attitudes toward these groups.14

However, these changes are not as apparent in fourth-year female students who, regardless of level of training, are considerably more willing than their male counterparts to support offering health care services regardless of an individual’s inability to pay; they also express a greater sense of responsibility to get involved in providing such care. The same authors propose that it is the clinical training itself during the third and fourth years, often in large public hospitals with significant indigent patient populations, that leads students to become biased against those very patients.

Related to this phenomenon is the half-century of literature on the development of cynicism during medical training.15–22 In fact, one of the present authors (D.W.) was struck with the seeming redundancy of reportage when conducting a recent study of derogatory and cynical humor among medical students. For example, many students in that study

reported that “house” or clinic patients are sometimes objects of cynical humor arising from preconceptions surrounding their hygiene, insurance and job status, mental/cognitive status, or probability for adherence. A few students elaborated that house patients are the objects of derogatory humor because of the difficulties caring for patients who, in their minds, as one student put it, have “poor hygiene and do not comprehend or listen to what the physician is telling them.”23

These attitudes sounded remarkably consistent with those reported in Terry Mizrahi’s24 influential study of residency training conducted 20 years earlier, Getting Rid of Patients: Contradictions in the Socialization of Physicians. Mizrahi found a bias in favor of middle-class patients “that, in the eyes of the housestaff, they were more intelligent, cleaner, and more cooperative.”24 (p76) The residents also reported that middle-class patients were generally “more intelligent and articulate” and could

give better histories…. Lower-class patients, on the other hand, were usually considered poor historians requiring more initial time but often more passive and acquiescent. They required less time in explanations about procedures but were also considered passive-aggressive and occasionally suspicious.24 (p76–77)

In addition to becoming more cynical, there is some fairly old evidence suggesting that medical students become more conservative as they advance through medical training.25 Maheux and Béland26 asked whether such sociopolitical attitude change resulted from socialization or maturation, because medical students are, in fact, getting older and, ostensibly, more mature at the same time they are receiving greater exposure to the attitudes and values of medicine. They found that while both age and experience were working concurrently, “whatever the explanation given for the increased conservatism of medical students as they progress in their professional training, one thing stands out solidly: students’ sociopolitical attitudes are more related to their personal background characteristics.” It is no wonder, then, that this increasing conservatism among medical students (as a group already economically privileged), coupled with their growing cynicism as they progress through training, may lead them to hold individuals more accountable for their poverty than they do societal or other structural variables.

Not surprisingly, attending physicians have been identified as having similar perceptions. One recent study found that although doctors are generally sensitive to the larger social and structural context of poverty, “they sometimes have a rather negative image of the [indigent] patient’s attitude towards health and illness and act within a rather ‘paternalistic’ framework,”27 and, within the context of this study, doctors were more likely to explain poverty through individual effort (or lack of effort).

Such negative attitudes, along with the tendency to hold individualistic attributions for poverty, open the possibility that clinical decisions will be shaped by clinicians’ interpretations of patients’ behaviors and their expectations for patient adherence to these perceived behaviors; these subjectivities have clear implications for the health of patients. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 4 highlights the implications of providers’ attitudes—in this case, stereotypes and prejudices—on patient care more directly. Stereotypes, the generalizations or assumptions that people make about the traits and qualities of members of a group (such as poor people or wealthy people), give providers confidence in their capacity to understand members of that group and to predict how they will act. In many cases, two distinct groups are at play—for instance, black/white, male/female, wealthy/poor, doctors/laity. Individuals most often put themselves into one of these dualistic social categories and

upon social categorization … into in-groups and out-groups, people spontaneously experience more positive feelings toward the in-group … in-group membership increases the psychological bond and feelings of ‘oneness’ that facilitate the arousal of empathy in response to others’ needs or problems.4 (p170)

Most medical students are members of one or several of these dualistic categories, most often the in-group—white, economically privileged, and soon-to-be-doctors—and, thus, without the natural feeling of “oneness” with the circumstances of many of their patients’ lives.

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What Impact Can Medical Education Have?

The accomplishments we wish medical education to achieve in improving trainees’ attitudes toward the poor seem clear. We want medical education to foster a more nuanced understanding of the causes and implications of poverty so that physicians may be more effective in working with patients who are poor. Furthermore, we want medical professionals to feel a sense of duty to help those who are underserved and to be part of a profession that advocates the health-related needs of the poor. Three kinds of initiatives would seem to make sense: (1) increasing the socioeconomic diversity of the physician work force to increase the diversity of perspectives involved in medical training, (2) increasing trainees’ empathetic understanding of poverty through any of a variety of efforts (e.g., service work, reflective exercises, health policy and public health education), and (3) increasing the number of positive role models for trainees.

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Increasing socioeconomic diversity among medical students

When dealing with questions of racial and ethnic disparities in health care, a commonly advocated strategy is to increase the racial and ethnic diversity of the physician work force. It would seem to make sense that a similar recommendation would apply regarding socioeconomic status. Currently, the average parental income of matriculating medical students in 2005 was $145,552; indeed, 68% of all students’ parents had incomes over $100,000.28 So, although we would not necessarily characterize the average medical student as coming from a rich family, they are certainly well above the lot of the average American. Thus, it would seem that simply admitting a greater percentage of students from lower socioeconomic classes would positively contribute to the medical educational environment and, possibly, increase sensitivity to the perspectives of the poor. Magnus and Mick’s29 insightful commentary on the “neglected role of social class” in medical school admissions suggests weighing socioeconomic status more heavily in the admission process because of the heavily skewed pool and composition of students from the middle and upper classes. Moreover, increasing the number of students from lower socioeconomic origins would mean, the research suggests, that these students would be more likely to serve poor, minority, and Medicaid patients,30 particularly if “such recruitment efforts could work hand in hand with improved insurance coverage and more equitable reimbursement formulas in expanding access to care.”29 Unfortunately, this phenomenon is more complex than these suggested “fixes,” however essential they may be.

Beagan’s31 study of “everyday classism” in a Canadian medical school describes the difficulties of working-class students in fitting in with the social norms and expectations of the dominant culture of a medical school. Although much more work is needed in this area, the study suggested that simply having some students present from other social classes did not necessarily lead to greater understanding among the more privileged students but may have, in fact, resulted in anger and defensiveness. Berger’s32 recent article in this journal raises similar questions about the strong presumption that physician–patient demographic concordance always serves positive ends. Although he acknowledges that greater diversity among medical students may “stimulate greater self-examination of preconceptions and biases in professional behaviors and interactions…. [It] does not follow that this would moderate physicians’ individually and personally held biases.” In fact, he worries that the wholesale promotion of physician–patient concordance

may produce a series of serious and undesirable effects, including greater societal segregation and xenophobia, and more fragmented care from physicians according to [demographic] criteria, citing disadvantages in demographically discordant care and leading to an amplification of personally held prejudices. Care of patients in concordant dyads may be compromised particularly should clinicians reflexively presume that individual patients subscribe to the norms of the shared culture.32

Thus, we suspect that simply increasing socioeconomic diversity among medical students will not always do the job of changing students’ attitudes toward the poor. Such change may require more sophisticated techniques for promoting dialogue and understanding, which leads to the question: How can we promote empathy among medical students toward persons from differing social classes?

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Promoting empathy

Many medical schools now encourage their students to complete service work. Most of these experiences are voluntary or elective, and the reports of these programs have generated a vast literature. Service learning experiences are sometimes seen as promoting “professionalism” among medical students in the sense we noted earlier—educating physicians who are responsive to medicine’s social contract.33,34 The service learning literature generally emphasizes the idea that such curricula provide services to the community and so are of direct benefit. They also provide a controlled but real environment in which students can increase their medical knowledge regarding the particular needs of underserved patient populations and the challenges encountered by providers in those settings, and they might promote positive attitudes toward serving underserved patients.35–37 Educators hope that “service” work—volunteering to work with underserved populations during one’s medical training—may have an effect on the likelihood that one will do this kind of volunteer work later in one’s career. And, if students learn a bit about health systems and health economics and gain a public health perspective on disease and illness, they may be less likely to blame underserved populations for the prevalence and recalcitrance of their illnesses. However, such points are difficult to prove conclusively, especially with regard to long-term learning. Nevertheless, encouraging the habit of reflective practice may make this kind of learning more fruitful and stable.38

In fact, Hunt and Swiggum39 argue in their study, “Being in another world: Transcultural student experiences using service learning with families who are homeless,” that reflective experiences must be an integral part of service learning because of the emotional reactions students have to working with populations so different from their own. They found that nursing students working with homeless families were able to cross the “bridge to otherness” through relationships that allowed for the “recognition of similarity. This is where the transformation takes place.” Still, Spencer40 argues in his aptly titled article, “Decline in empathy in medical education: How can we stop the rot?” that cultivating empathic understanding, genuineness, and respect during medical education and beyond probably involves more than targeted educational experiences with specific populations. Instead, “a more sustained nurturing of self-awareness and broadening of vision would seem to be the key; students need to reflect on their own attitudes and prejudices (and to have them challenged).” Thus, if students are never asked to be honest about their attitudes and biases toward poverty and the poor, they are less likely to “arrive at an accurate diagnosis, prescribe appropriate treatment, and promote healing.”41 However,

this kind of self scrutiny often flies in the face of the medical mantra of “objectivity” that students come to believe they possess when working with patients, no matter what patients look like, how they act, what they believe, what they want, or what they will or will not do regarding their health. Curriculum experiences could be designed to help students see themselves as situated individuals who have a very specific social and economic location that influence each and every interaction they have with patients.42

Boler’s43 pedagogy of discomfort is one approach that asks, even insists, that students examine how the dominant culture shapes the ways we see the world. Here, students are urged to recognize the selectivity of what they see and to whom they give attention. They would scrutinize how selective sight is learned through the social status of one’s family, friends, and neighborhood, through one’s educational experiences and religion, and through medical training itself, which all have incentives and disincentives to construct the world in particular ways: people are poor because of these characteristics, people acquire wealth because of those characteristics, and so on.

If medical students were to engage in a pedagogy of discomfort,

they may begin to realize, undoubtedly with some discomfort, that they have great incentives to remain privileged, that their world view is based on their social status and medical training, and that the way they explain poverty … is based on selective sight arising from social status.43 (p96)

Rarely are medical students asked to study the oppressiveness of poverty, and what is at stake from this lapse is the “ability to empathize with the very distant other [and] to recognize oneself as implicated in the social forces that create the climate of obstacles the other must confront.”43 (p166) Thus, a pedagogy of discomfort urges medical students who use individualistic attributions for poverty to think larger about the social causes of their patients’ suffering, to look at their own behaviors and attitudes both inside and outside the examining room of patients who are poor—behaviors and attitudes that may inadvertently create “climates of obstacles” such patients face there, and everywhere. Moreover, a pedagogy of discomfort can be used in any number of classroom locations, most naturally in bioethics or medical humanities, but also in courses devoted to patient interviewing, or even in clinical clerkships.

David Hilfiker45 offers another curriculum experience that is rarely proposed in medical education. He argues that “medical students (and most physicians) don’t know about the desperation [of the poor] … because myths keep affluent people from knowing the burdens under which the poor labor.” How are such myths dismantled? Hilfiker, who speaks from vast experience with his work in poverty medicine, urges medical students to “get into a one-to-one relationship with at least one very poor person. I don’t care how you do it. It doesn’t matter whether it’s a helping relationship or what. And have a way to reflect upon it. That is a way to start, then be open to where that leads you.”46 Hilfiker’s proposal is a revolutionary thought when one considers the usual one-stop approaches to learning about uninsured and indigent patients outside of required clerkships. However admirable, food drives over holidays, occasional volunteer experiences at free clinics or hot-meal programs, and visits to homeless shelters or other service-oriented organizations may not offer students sufficient insight into the lived plight of persons in poverty.

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Role modeling

And, finally, the value of role modeling in changing attitudes cannot be overstated. Physician role models who believe deeply in compassionate, respectful care of indigent patients must be the leaders in bringing about change in individual and institutional attitudes toward care of the poor. In her study of physicians who try to role model empathy, Johanna Shapiro47 reported their use of open-ended questions after patient encounters such as “What did you notice? What was going on? What was I trying to accomplish? … [or] What specifically did you do to show empathy toward this patient?” That is, role modeling cannot speak for itself but should, instead, make note of itself. Physician role models must engage in an ongoing discussion with students regarding what they are doing and why regarding their behaviors and attitudes toward indigent patients, and how these behaviors and attitudes relate to their patients’ lives once they leave the hospital or clinic.48 Attendings cannot turn to a “passive conception of role modeling” that simply

demands performing the desired behaviors oneself in the hope that learners will somehow absorb them. But compassion and respect are not discrete, specifiable behaviors; rather, they are expressed in highly complex and contextualized social interactions. Both theory and empirical evidence suggest that role modeling in such complex situations is more effective when teachers call attention to what they are modeling.49

Moreover, attendings’ role modeling should not stop with their own behaviors and attitudes toward patients. It must also include the way they respond to students’ negative behaviors and attitudes toward indigent patients. If students show a lack of enthusiasm to pursue appropriate diagnostic, therapeutic, or follow-up for indigent patients, or use derogatory or cynical language regarding them, physician role models have an obligation to respond in thoughtful, nonpunitive ways that call attention to those behaviors and attitudes. Such interactions might engage students in discussion of the myriad contextual variables of individual patients’ lives that may lead to dismantling, patient by patient, the stereotypes and prejudices that students may bring to clinical encounters with uninsured and indigent patients.

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Directions for Further Research

It is clear that although medical education has certainly been more attentive in the last two decades to a variety of humanistic themes (e.g., health disparities, cultural competence, professionalism, etc.), much is not known about the way we develop physicians. Of course, this has not stopped, and should not impede, the many, many efforts to make more socially conscious, advocacy-oriented physicians. However, some basic research is needed to determine the success of these efforts.

The randomized, double-blind trial is the gold standard of clinical research. However, nothing approximating such outcome measures is possible when we consider the effects of pedagogical interventions. It is just such difficulties that have generated the vast but not deep pool of educational research available on these developmental issues in medical education. For example, Beach and colleagues’ systematic review of cultural competency educational interventions found that cultural competence training “shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals.”50 (p356) However, the most common attitude change measured was cultural self-efficacy, which measures learners’ confidence in their knowledge and skills concerning black, Asian, Latino, and Native American patients. This is an important dimension of attitude change, but it only scratches the surface of the complexity of attitudes toward the poor. Moreover, Beach et al50 found no evidence that cultural competency improves patient adherence, health outcomes, or equity of health care services across racial and ethnic groups. Other ways of investigating this phenomenon are needed.

We suggest quantitative and qualitative studies that compare the knowledge, skills, and attitudes of medical students toward the poor across a large number of schools. Although some might argue that this is more or less a recruitment and admissions issue, we hold on to the belief that education matters, that thoughtful, targeted experiences—both in classrooms and clinical settings—have the potential to deepen, enlarge, and even change the perspectives, attitudes, and career goals of trainees. It is likely that some schools are doing a significantly better job than others of helping students to understand and meet the needs of poor patients. For example, the UCLA/Drew Medical Education Program is one such example of a program whose graduates have far higher probability of practicing in underserved areas than those from a traditional curriculum, even after controlling for factors such as race and ethnicity.51 Migrant health initiatives represent another promising type of educational program that may encourage a commitment to caring for the poor.52

Ideally, we need to study first- and fourth-year students at each school in a cohort to determine possible relationships between admission processes and the impact of being educated at those schools, recognizing that medical students’ perceptions of the poor are a complex phenomenon not amenable to easy understandings or quick fixes in any one single area. By identifying schools that seem to be graduating students who are much better prepared to address these challenges than their peers, we can begin to identify the admissions, curricular, and other environmental factors that contribute to a positive ethos in this regard. Too much is at stake for us to avoid this aspect of trainees’ professional development.

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