Foreign physicians questioned on drug product selection, physicianpharmacist consultation
One of the most controversial issues in health care today is the extent to which foreign medical graduates (FMGs) are being used to meet the need for physician services in the United States. Although physician immigration to this country has taken place since early this century, a drastic increase occurred at the time of the Korean War in order to fill posts vacated by drafted American physicians. After the cessation of hostilities many physicians returned to school rather than praCtice. At about the same time hospitals in this country underwent rapid expansion due to the availability of Hill-Burton funds. These two factors, as well as others, combined to create a situation in which there were many more internships and residencies than could be filled by U.S. medical graduates (USMGs). Spurred by economic incentives and encouraged by many American hospitals, large numbers of FMGs arrived in the U.S. each year so that by 1970 roughly one out of six of the 334,028 physicians in !he U.S. was a graduate of a foreign medical school. 1 Approximately 87 percent of the FMGs who immigrate to the U.S. remain permanently.2
Competence, effects on supply and demand, and relevance of U.S. training are three aspects of the FMG issue most often discussed and analyzed. Regarding the first of these, the competence of graduates of foreign medical schools is reported to be lower than that of USMGs. 3 One recent article went so far as to proclaim that the U.S. is returning to pre-Fiexnerian standards by the relatively uncontrolled entrance of so many FMGs into the health care system. 4 The U.S. often is criticized on two counts concerning the effects on supply and demand. First, we are charged wjth taking physicians from areas of the world where they are desperately needed5 and that heavy reliance on foreign MDs will dampen our will to adequately increase physician output. 6 Secondly, it has been suggested that for the small number of FMGs who do return to their own country, a substantial portion of what is learned in the U.S. is simply not applicable or even relevant. 7 Research to date has placed the FMG under considerable scrutiny. On the other hand, little effort has been expanded in determining how the FMG views the system of health care in this country. The present survey, conducted among FMG residents and interns in a large urban county, attempted to establish their views on (a) the U.S. health care system in general and (b) the profession of pharmacy in particular.
Vol. NS 16, No. 10, October 1976
By John H. Kilwein and Foreign Medical Joseph D. McEvilla Graduates' Views on Some Pharmacy Issues
The general views of this group on the U.S. health care system will be reported in detail elsewhere. In brief, a large majority felt the U.S. health care system placed too much of a financial burden on patients and needed restructuring away from the solo practice model. A majority also favored establishment of a comprehensive national health insurance plan and felt the U.S. government should be more involved in seeing that its citizens receive good health care. This article is concerned with the views of the FMGs on a number of issues of importance to the pharmacy profession. Procedures and Population The purpose of the study was to conduct a descriptive, exploratory survey of all residents and interns in Allegheny County, Pennsylvania, who were graduates of a foreign medical school. Allegheny County is the second most populous county in the state and includes the Greater Pittsburgh area. Administrators of each of the 32 hospitals in the county were asked to provide the investigators with a list containing the names of all residents and interns in their hospitals who were FMGs. Out of the 32 hospitals, 14 had FMG residents and interns. Eleven of these provided the requested list of names while three hospitals refused to participate in the survey. A total of 228 names were received. Each physician was then sent a copy of the research questionnaire. A first and second follow-up questionnaire were sent to nonrespondents. A total of 139 (61 percent) were completed and returned.* Consistent with expectations derived from the literature, the majority of physicians participating in the survey graduated from medical schools in the developing areas of the world. Specifically, 17 percent graduated in Latin America, 65 percent in Asia, 13 percent in Europe, 3 percent in Africa, and 2
percent in Oceania. Fifteen percent of the respondents were interns while 85 percent were residents. Ninety-two percent of the group was within the 25-39-year age range. Survey Results
* Percentages in the text are rounded off to the nearest whole number.
Over two-thirds of the group believed the prices for prescribed medications to be "high" or "excessively high" (Table I, below). On the other hand, none of the responses on this item fell within the "low" or "somewhat low'' categories. Thus there is no even distribution of responses but rather a pronounced clustering toward the "high" end of the spectrum. Among the total group of 139 physicians, 113, or 81 percent, indicated that they were familiar with the difference between generic and brand name prescribing. Fifty-five percent of those familiar with generic prescribing were in favor of it whereas 12 percent opposed it (Table II, below). However, the situation reversed itself when the respondents were asked their views on a system of
Table I
Table II
FMG Views on Prescription Medication Prices
FMG Views on Generic Prescribing*
Views
Frequency
Percentage
Views
Frequency
Percentage
Excessively high High About right Somewhat low Low No opinion Total
20 73 26 0 0 17 136
14.7 53.7 19.1 0 0 12.5 100.0
In favor Mixed feelings Opposed No opinion Total
62 34 13 4 113
54.9 30.1 11.5 3.5 100.0
*Table II includes only those respondents familiar with generic prescribing.
555
Foreign Medical Graduates' Views on Some Pharmacy Issues
Tabl.e Ill
Views A great deal A moderate amount Very little Not at all No opinion Total
FMG Views on Physicians Consulting Pharmacists Regarding Drug Therapy Frequency Per.centage
18
12.9
57
41.0
42
30.2 10.8 5.0 99.9
15 7 139
prescribing that would permit the pharmacist to substitute a brand of a drug other than the one prescribed by the physician. Overall, 12 percent expressed approval of such a system. When the subject of an expanded role for pharmacists is discussed, it is not uncommon to hear mention o_f having the pharmacist renew prescription medication orders for maintenance drugs or modffy maintenance medication dosage within specified ranges for patients with chronic diseases. The physicians in this sample were questioned on these two points. A sizable majority (69 percent) opposed permitting the pharmacist to renew prescription medication orders for maintenance drugs. An even larger majority (88 percent) opposed permitting the pharmacist to modify maintenance medication dosage, within specified ranges, for patients with chronic diseases.
However, opinion was rather evenly divided over whether or not pharmacists should be involved in instructing patients on medication dosage regimens. Forty-eight percent favored such instruction by the pharmacist while 47 percent opposed it. The remainder had no opinion on this issue. When asked the extent to which physicians should consult pharmacists regarding drug therapy, over half of the group responded "a great deal" or "a moderate amount'' (Table Ill, at left). Thus a majority of this group appears to recognize that pharmacists have a specialized drug knowledge that can be of use to the physician. Summary The majority of physicians in the survey felt that (a) prices for prescribed medications in the U.S. are too high, (b) physicians should have the right to determine the brand of a drug dispensed, (c) renewing and/or modifying prescription medication orders is not the prerogative of the pharmacist, (d) physicians should consult with pharmacists regarding drug therapy. A majority of those respondents familiar with generic prescribing were in favor of it. In view of the fact that most of the physicians favored establishment of a national health insurance plan and considered the cost of prescribed medication to be high, they might be receptive to having drugs covered by such a plan. By supporting generic prescribing they are taking a position consonant with that of the American Pharmaceutical Association. On the other hand, in opposing
John H. Kilwein, PhD, is an assistant professor in the department of pharmaceutical practice at the University of Pittsburgh school of pharmacy. Prior to his current position, Kilwein was a research associate at the university's graduate school of public health. He also has been a sociology instructor at the Community College of Allegheny County, and a training supervisor and social worker with the Allegheny County Board of Assistance. Kilwein received an MSW from the University of Maryland, and an MPH and a PhD (in social work) from the University of Pittsburgh.
John H. Kilwein
Joseph D. McEvilla, PhD, is dean of the school of pharmacy and professor of pharmaceutical economics at Temple University. He received his BS, MS and PhD from the University of Pittsburgh, where he also was professor of pharmaceutical economics and chairman of the department from 1955 to June 1974. McEvilla's major fields of research are medical-pharmaceutical economics, health care delivery, industry pricing, competition and management. He has served as chairman of the APhA Academy of Pharmaceutical Sciences Section on Economics and Administrative Science and as a member of the Academy's Executive Committee, and as chairman of the AACP Conference on Teachers, Section of Pharmaceutical Economics. He also has been a consultant to a number of national organizations.
Joseph D. McEvilla
556
drug product selection their position coincides with that of the American Medical Association. Given the physicians' views on drug product selection, their opposition to pharmacists renewing and/or modifying prescription medication orders is not surprising. Yet, it has been demonstrated that under the right circumstances the pharmacist can effectively assume charge of drug therapy for patients with chronic diseases. Miller and Corcella8 describe a community mental health center in which a clinical pharmacist was successfully involved in determining drug therapy for patients at the center. Reports on such programs should be widely disseminated among MDs as well as pharmacists. A disheartening finding was that less than half the respondents thought pharmacists should be involved in instructing patients on medication dosage regimens. This is an area of health care in which the pharmacist should be making a strong contribution. Perhaps this finding is more indicative of the way FMGs view pharmacist-patient relations in their native lands rather than in the U.S. More communication between pharmacists and physicians on this issue is clearly needed. The trends observed in the survey clearly call for more research. For example, how might the views on these and related issues differ among those FMGs in training and those already in practice? How might they differ from the views of a comparable group of USMGs? Is the choice of residency related to the manner in which physicians view health care in general and pharmacy in particular? Since the views of physicians can directly and indirectly influence the practice of pharmacy, they merit scrutiny. We hope this exploratory survey will stimulate further research in this area. e
References 1. Haug, J. N., and Martin, B. C., "Foreign Medical Graduates in the United States, 1970," American Medical Association, Chicago, Ill. (1971) 2. Haug, J. N., and Stevens, R., "Foreign Medical Graduates in the United States in 1963 and 1971," Inquiry, 10, 26-32, (March 1973) 3. Margulies, H., and Bloch, L., Foreign Medical Graduates in the United States, Harvard University Press, Cambridge, Mass. (1969) 4. Weiss, R. J., and Kleinman, J. C., "The Effect of Importing Physicians: Return to a Pre-Fiexnerian Standard, N. Engl. J. Med., 290, 1453-1458, (June, 27 1974) 5. Stevens, R., and Vermeulen, J., Foreign Trained Physicians and American Medicine, Department of Health, Education, and Welfare Publication No. (NIH) 73-325, U.S. Government Printing Office, Washington, D.C., (1972) 6. Lockett, B., Foreign Medical Graduates and Physician Manpower in the United States, Department of Health, Education, and Welfare Publication No. (HRA) 74-30, U.S. Government Printing Office, Washington, D.C. (1974) 7. Roza, F., A Doctor for Newly Developed Countries," J. Med. Educ., 39, 918-924, (Oct. 1964) 8. Miller, W. A., . and Corcella, J., "Professional Pharmacy Functions in Community Mental Health Centers," JAPhA, NS12, 68-73 (Feb. 1972)
Journal of the American Pharmaceutical Association
One of the most controversial issues in health care today is the extent to which foreign medical graduates (FMGs) are being used to meet the need for physician services in the United States. Although physician immigration to this country has taken place since early this century, a drastic increase occurred at the time of the Korean War in order to fill posts vacated by drafted American physicians. After the cessation of hostilities many physicians returned to school rather than praCtice. At about the same time hospitals in this country underwent rapid expansion due to the availability of Hill-Burton funds. These two factors, as well as others, combined to create a situation in which there were many more internships and residencies than could be filled by U.S. medical graduates (USMGs). Spurred by economic incentives and encouraged by many American hospitals, large numbers of FMGs arrived in the U.S. each year so that by 1970 roughly one out of six of the 334,028 physicians in !he U.S. was a graduate of a foreign medical school. 1 Approximately 87 percent of the FMGs who immigrate to the U.S. remain permanently.2
Competence, effects on supply and demand, and relevance of U.S. training are three aspects of the FMG issue most often discussed and analyzed. Regarding the first of these, the competence of graduates of foreign medical schools is reported to be lower than that of USMGs. 3 One recent article went so far as to proclaim that the U.S. is returning to pre-Fiexnerian standards by the relatively uncontrolled entrance of so many FMGs into the health care system. 4 The U.S. often is criticized on two counts concerning the effects on supply and demand. First, we are charged wjth taking physicians from areas of the world where they are desperately needed5 and that heavy reliance on foreign MDs will dampen our will to adequately increase physician output. 6 Secondly, it has been suggested that for the small number of FMGs who do return to their own country, a substantial portion of what is learned in the U.S. is simply not applicable or even relevant. 7 Research to date has placed the FMG under considerable scrutiny. On the other hand, little effort has been expanded in determining how the FMG views the system of health care in this country. The present survey, conducted among FMG residents and interns in a large urban county, attempted to establish their views on (a) the U.S. health care system in general and (b) the profession of pharmacy in particular.
Vol. NS 16, No. 10, October 1976
By John H. Kilwein and Foreign Medical Joseph D. McEvilla Graduates' Views on Some Pharmacy Issues
The general views of this group on the U.S. health care system will be reported in detail elsewhere. In brief, a large majority felt the U.S. health care system placed too much of a financial burden on patients and needed restructuring away from the solo practice model. A majority also favored establishment of a comprehensive national health insurance plan and felt the U.S. government should be more involved in seeing that its citizens receive good health care. This article is concerned with the views of the FMGs on a number of issues of importance to the pharmacy profession. Procedures and Population The purpose of the study was to conduct a descriptive, exploratory survey of all residents and interns in Allegheny County, Pennsylvania, who were graduates of a foreign medical school. Allegheny County is the second most populous county in the state and includes the Greater Pittsburgh area. Administrators of each of the 32 hospitals in the county were asked to provide the investigators with a list containing the names of all residents and interns in their hospitals who were FMGs. Out of the 32 hospitals, 14 had FMG residents and interns. Eleven of these provided the requested list of names while three hospitals refused to participate in the survey. A total of 228 names were received. Each physician was then sent a copy of the research questionnaire. A first and second follow-up questionnaire were sent to nonrespondents. A total of 139 (61 percent) were completed and returned.* Consistent with expectations derived from the literature, the majority of physicians participating in the survey graduated from medical schools in the developing areas of the world. Specifically, 17 percent graduated in Latin America, 65 percent in Asia, 13 percent in Europe, 3 percent in Africa, and 2
percent in Oceania. Fifteen percent of the respondents were interns while 85 percent were residents. Ninety-two percent of the group was within the 25-39-year age range. Survey Results
* Percentages in the text are rounded off to the nearest whole number.
Over two-thirds of the group believed the prices for prescribed medications to be "high" or "excessively high" (Table I, below). On the other hand, none of the responses on this item fell within the "low" or "somewhat low'' categories. Thus there is no even distribution of responses but rather a pronounced clustering toward the "high" end of the spectrum. Among the total group of 139 physicians, 113, or 81 percent, indicated that they were familiar with the difference between generic and brand name prescribing. Fifty-five percent of those familiar with generic prescribing were in favor of it whereas 12 percent opposed it (Table II, below). However, the situation reversed itself when the respondents were asked their views on a system of
Table I
Table II
FMG Views on Prescription Medication Prices
FMG Views on Generic Prescribing*
Views
Frequency
Percentage
Views
Frequency
Percentage
Excessively high High About right Somewhat low Low No opinion Total
20 73 26 0 0 17 136
14.7 53.7 19.1 0 0 12.5 100.0
In favor Mixed feelings Opposed No opinion Total
62 34 13 4 113
54.9 30.1 11.5 3.5 100.0
*Table II includes only those respondents familiar with generic prescribing.
555
Foreign Medical Graduates' Views on Some Pharmacy Issues
Tabl.e Ill
Views A great deal A moderate amount Very little Not at all No opinion Total
FMG Views on Physicians Consulting Pharmacists Regarding Drug Therapy Frequency Per.centage
18
12.9
57
41.0
42
30.2 10.8 5.0 99.9
15 7 139
prescribing that would permit the pharmacist to substitute a brand of a drug other than the one prescribed by the physician. Overall, 12 percent expressed approval of such a system. When the subject of an expanded role for pharmacists is discussed, it is not uncommon to hear mention o_f having the pharmacist renew prescription medication orders for maintenance drugs or modffy maintenance medication dosage within specified ranges for patients with chronic diseases. The physicians in this sample were questioned on these two points. A sizable majority (69 percent) opposed permitting the pharmacist to renew prescription medication orders for maintenance drugs. An even larger majority (88 percent) opposed permitting the pharmacist to modify maintenance medication dosage, within specified ranges, for patients with chronic diseases.
However, opinion was rather evenly divided over whether or not pharmacists should be involved in instructing patients on medication dosage regimens. Forty-eight percent favored such instruction by the pharmacist while 47 percent opposed it. The remainder had no opinion on this issue. When asked the extent to which physicians should consult pharmacists regarding drug therapy, over half of the group responded "a great deal" or "a moderate amount'' (Table Ill, at left). Thus a majority of this group appears to recognize that pharmacists have a specialized drug knowledge that can be of use to the physician. Summary The majority of physicians in the survey felt that (a) prices for prescribed medications in the U.S. are too high, (b) physicians should have the right to determine the brand of a drug dispensed, (c) renewing and/or modifying prescription medication orders is not the prerogative of the pharmacist, (d) physicians should consult with pharmacists regarding drug therapy. A majority of those respondents familiar with generic prescribing were in favor of it. In view of the fact that most of the physicians favored establishment of a national health insurance plan and considered the cost of prescribed medication to be high, they might be receptive to having drugs covered by such a plan. By supporting generic prescribing they are taking a position consonant with that of the American Pharmaceutical Association. On the other hand, in opposing
John H. Kilwein, PhD, is an assistant professor in the department of pharmaceutical practice at the University of Pittsburgh school of pharmacy. Prior to his current position, Kilwein was a research associate at the university's graduate school of public health. He also has been a sociology instructor at the Community College of Allegheny County, and a training supervisor and social worker with the Allegheny County Board of Assistance. Kilwein received an MSW from the University of Maryland, and an MPH and a PhD (in social work) from the University of Pittsburgh.
John H. Kilwein
Joseph D. McEvilla, PhD, is dean of the school of pharmacy and professor of pharmaceutical economics at Temple University. He received his BS, MS and PhD from the University of Pittsburgh, where he also was professor of pharmaceutical economics and chairman of the department from 1955 to June 1974. McEvilla's major fields of research are medical-pharmaceutical economics, health care delivery, industry pricing, competition and management. He has served as chairman of the APhA Academy of Pharmaceutical Sciences Section on Economics and Administrative Science and as a member of the Academy's Executive Committee, and as chairman of the AACP Conference on Teachers, Section of Pharmaceutical Economics. He also has been a consultant to a number of national organizations.
Joseph D. McEvilla
556
drug product selection their position coincides with that of the American Medical Association. Given the physicians' views on drug product selection, their opposition to pharmacists renewing and/or modifying prescription medication orders is not surprising. Yet, it has been demonstrated that under the right circumstances the pharmacist can effectively assume charge of drug therapy for patients with chronic diseases. Miller and Corcella8 describe a community mental health center in which a clinical pharmacist was successfully involved in determining drug therapy for patients at the center. Reports on such programs should be widely disseminated among MDs as well as pharmacists. A disheartening finding was that less than half the respondents thought pharmacists should be involved in instructing patients on medication dosage regimens. This is an area of health care in which the pharmacist should be making a strong contribution. Perhaps this finding is more indicative of the way FMGs view pharmacist-patient relations in their native lands rather than in the U.S. More communication between pharmacists and physicians on this issue is clearly needed. The trends observed in the survey clearly call for more research. For example, how might the views on these and related issues differ among those FMGs in training and those already in practice? How might they differ from the views of a comparable group of USMGs? Is the choice of residency related to the manner in which physicians view health care in general and pharmacy in particular? Since the views of physicians can directly and indirectly influence the practice of pharmacy, they merit scrutiny. We hope this exploratory survey will stimulate further research in this area. e
References 1. Haug, J. N., and Martin, B. C., "Foreign Medical Graduates in the United States, 1970," American Medical Association, Chicago, Ill. (1971) 2. Haug, J. N., and Stevens, R., "Foreign Medical Graduates in the United States in 1963 and 1971," Inquiry, 10, 26-32, (March 1973) 3. Margulies, H., and Bloch, L., Foreign Medical Graduates in the United States, Harvard University Press, Cambridge, Mass. (1969) 4. Weiss, R. J., and Kleinman, J. C., "The Effect of Importing Physicians: Return to a Pre-Fiexnerian Standard, N. Engl. J. Med., 290, 1453-1458, (June, 27 1974) 5. Stevens, R., and Vermeulen, J., Foreign Trained Physicians and American Medicine, Department of Health, Education, and Welfare Publication No. (NIH) 73-325, U.S. Government Printing Office, Washington, D.C., (1972) 6. Lockett, B., Foreign Medical Graduates and Physician Manpower in the United States, Department of Health, Education, and Welfare Publication No. (HRA) 74-30, U.S. Government Printing Office, Washington, D.C. (1974) 7. Roza, F., A Doctor for Newly Developed Countries," J. Med. Educ., 39, 918-924, (Oct. 1964) 8. Miller, W. A., . and Corcella, J., "Professional Pharmacy Functions in Community Mental Health Centers," JAPhA, NS12, 68-73 (Feb. 1972)
Journal of the American Pharmaceutical Association
