MILITARY MEDICINE, 180,4:61,2015
Medical Student Attitudes Toward the Medically Underserved: The USU Perspective CAPT Mark B. Stephens, MC USN*; Grace Landers, M D f; Stephen W. Davis, M A f; Steven J. Durning, MD, PhDp, Sonia J. Crandall, P h D f
ABSTRACT This study examined a cohort of students attending the Uniformed Services University regarding their attitudes toward medical care in underserved populations. Using the previously validated Medical Student Attitudes Toward the Underserved (MSATU), repeated measures analysis of variance showed that student attitudes toward care in underserved populations was less favorable than limited national data at entry and declined over time (Mean MSATU total score Year 1: 46.2 [SD 10.95]; Year 4: 41.7 [SD 12.3] p < 0.01). Differences in medical school debt, exposure to underserved populations, and the definition of “service” in the context of active duty military status might explain some of our findings. Providing broad service learning opportunities within the curriculum could increase student exposure to underserved populations and strengthen the social contract between community and institution.
INTRODUCTION According to U.S. Census Bureau estimates, nearly 1 in 6 Americans are uninsured.1 Low-income, minority, and other traditionally underserved populations are less likely to have adequate access to health care.2 With continued changes in population demographics across the United States, the need for medical care in underserved populations continues to expand. Concurrently, the United States is confronting a looming phy sician shortage, particularly in primary care. It is estimated that by 2020, nearly 100,000 additional physicians will be needed to provide adequate primary care for the U.S. population.1 These factors combine to make the need to find physicians willing to serve in underserved communities particularly acute. Medical schools have a social obligation to train compe tent health care professionals capable of providing high qual ity health care to all Americans.4 Students are often idealistic and eager to serve underserved populations when they enter medical school.5 Experiences that expose students to a diverse patient population help to develop professional and interper sonal skills necessary for a comprehensive and compassionate medical practice.6'7 Unfortunately, as students’ progress through their medical education, issues within the “hidden curriculum” of medical education may negatively impact atti tudes toward care for underserved patients.8 Specifically, prior work has shown that medical student attitudes toward under served populations tend to decline after matriculation.9'10 For some institutions, work with underserved populations occurs in “free clinics” outside of the formal (graded) medi *Department of Family Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda. MD 20814. tDepartment of Family Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157. ^Department of Medicine and Pathology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of Defense or the U.S. Government. doi: 10.7205/MILMED-D-14-00558
MILITARY MEDICINE, Vol. 180, April Supplement 2015
cal school curriculum. Work in clinics serving disadvantaged populations requires students to devote personal time to the activity and they often receive no formal academic grade or “credit.” Students can see this as extra work and, as a result, fail to take advantage of robust volunteer clinical opportuni ties in underserved areas.5 Specific factors have been found to predict who will engage with underserved populations in the future. These include a strong desire to practice in an underserved commu nity before entering medical school and students who come from a minority background themselves.11 Currently, many medical students come from privileged backgrounds, with family incomes and educational levels well above national census averages.12 Although, physicians are generally sensi tive to medical issues confronting underserved populations, they may also have a poor image of underserved patients’ attitudes toward their personal health and illness.13 Exposure to underserved communities in medical school, therefore, represents one way to confront this bias and potentially increase student interest in helping to provide care for under served populations in the future. With this background in mind, the present study used the Medical Student Attitudes Toward the Underserved (MSATU) questionnaire8 to describe attitudes of students at the Uniformed Services University of the Health Sciences (USU) regarding health care in traditionally underserved com munities. The MSATU is a previously validated instrument that has been specifically created to assess medical student attitudes regarding medical care and underserved populations.8
METHODS Study participants were students enrolled at the F. Edward Hebert Uniformed Services University School of Medicine (USU) (« = 170). USU is the nation’s only federal medical school. All students are commissioned officers in the uniformed services. As such, they are salaried government employees with health care benefits and no incumbent tuition
61
Medical Student Altitudes Toward the Medically Underserved
burden. Institutional Review Board approval was obtained before beginning the investigation. Participation in the study was voluntary. Interested students were verbally consented and given the MSATU questionnaire in the first year of med ical school, and again during their fourth year. To preserve anonymity, students created an acrostic using a unique mix ture of letters and numbers. This acrostic served as a unique identifier that allowed investigators to match individual responses from Year 1 and Year 4. Outcome Measure: The MSATU The MSATU assesses student attitudes regarding medical care in underserved populations.'1'11 The total MSATU score combines two subscales, one that explores general attitudes toward underserved care and one that explores issues relating to access and payment for medical services. The first subscale assesses societal expectations and professional responsibility. Questions from this subscale target attitudes involving per sonal (respondent) roles and responsibilities as well as orga nizational responsibilities for underserved care. Respondent attitudes regarding access to care for patients regardless of their ability to pay is assessed by the second subscale (14 items). Both subscales use a 5-point Likert scale to quan tify the extent to which respondents agree or disagree with each statement (5 = strongly agree, 1 = strongly disagree).9 The MSATU subscales are standardized using T-scores, which facilitates comparison of the magnitude of effects. Tscores have a mean of 50, and a standard deviation of 10. A T-score of 58, therefore, is 0.8 standard deviation above the mean. The change in T-score can be interpreted as an effect size. Previous studies have gathered evidence supporting the reliability and validity of the MSATU.11,12 Data Analysis MSATU scores were calculated using established scoring methods.9 Responses were analyzed using SPSS, Version TA B LE I. Measure
19.0 (SPSS, Chicago, Illinois). Baseline demographics were examined to assure that the sample was representative. Repeated measures ANOVA matching each student’s Year 1 and Year 4 response was used to analyze longitudinal data and control for baseline differences. RESULTS Baseline 170 students enrolled in the class of interest. The mean matriculate age was 24. 65% were male and 78% were Caucasian. Table I displays MSATU scores for matched pairs (Year 1/Year 4) and for those students with only Year 1 data. The response rate for students completing the MSATU at both Year 1 and Year 4 was 35%. Compared to limited normative data from the literature,8-10 USU respondents had less favorable MSATU total scores as well as scores on both subscales (Attitudes and Access). We examined age, gender, race, and MSATU scores for responders and nonresponders (students who completed only Year 1 administration) to determine whether the samples were representative and there were no significant differences between groups (responders and nonresponders). Table II displays the Year 1 to Year 4 comparison of responders. Repeated measures analysis of variance showed that Atti tudes and Access scale scores declined over time. There were main effects for time for the MSATU Total scale and Set 1 (Attitudes). In both settings, MSATU scores declined signif icantly from Year 1 to Year 4. For the second MSATU subscale (Set 2, Access), there was a main effect of time. Attitudes declined significantly (from 47.7 to 44.2, a 0.35 standard deviation change) from Year 1 to Year 4. DISCUSSION Our findings suggest that medical students attending a federal medical school (USU) have generally less favorable attitudes
MSATU Total and Subscale Scores by Year of Training
Year 1 Mean (SD)
Year 4 Mean (SD)
Both Years EMM
Both Years SE
46.2(10.95)
41.7 (12.38)
43.9
1.28
45.7 (10.98)
41.22 (13.34)
43.5
1.31
47.7 (10.95)
44.2(10.95)
46.0
1.22
MSATU Total USU Set 1 USU Set 2 USU
P
Medical Student Attitudes Toward the Medically Underserved: The USU Perspective CAPT Mark B. Stephens, MC USN*; Grace Landers, M D f; Stephen W. Davis, M A f; Steven J. Durning, MD, PhDp, Sonia J. Crandall, P h D f
ABSTRACT This study examined a cohort of students attending the Uniformed Services University regarding their attitudes toward medical care in underserved populations. Using the previously validated Medical Student Attitudes Toward the Underserved (MSATU), repeated measures analysis of variance showed that student attitudes toward care in underserved populations was less favorable than limited national data at entry and declined over time (Mean MSATU total score Year 1: 46.2 [SD 10.95]; Year 4: 41.7 [SD 12.3] p < 0.01). Differences in medical school debt, exposure to underserved populations, and the definition of “service” in the context of active duty military status might explain some of our findings. Providing broad service learning opportunities within the curriculum could increase student exposure to underserved populations and strengthen the social contract between community and institution.
INTRODUCTION According to U.S. Census Bureau estimates, nearly 1 in 6 Americans are uninsured.1 Low-income, minority, and other traditionally underserved populations are less likely to have adequate access to health care.2 With continued changes in population demographics across the United States, the need for medical care in underserved populations continues to expand. Concurrently, the United States is confronting a looming phy sician shortage, particularly in primary care. It is estimated that by 2020, nearly 100,000 additional physicians will be needed to provide adequate primary care for the U.S. population.1 These factors combine to make the need to find physicians willing to serve in underserved communities particularly acute. Medical schools have a social obligation to train compe tent health care professionals capable of providing high qual ity health care to all Americans.4 Students are often idealistic and eager to serve underserved populations when they enter medical school.5 Experiences that expose students to a diverse patient population help to develop professional and interper sonal skills necessary for a comprehensive and compassionate medical practice.6'7 Unfortunately, as students’ progress through their medical education, issues within the “hidden curriculum” of medical education may negatively impact atti tudes toward care for underserved patients.8 Specifically, prior work has shown that medical student attitudes toward under served populations tend to decline after matriculation.9'10 For some institutions, work with underserved populations occurs in “free clinics” outside of the formal (graded) medi *Department of Family Medicine, Uniformed Services University, 4301 Jones Bridge Road, Bethesda. MD 20814. tDepartment of Family Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157. ^Department of Medicine and Pathology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of Defense or the U.S. Government. doi: 10.7205/MILMED-D-14-00558
MILITARY MEDICINE, Vol. 180, April Supplement 2015
cal school curriculum. Work in clinics serving disadvantaged populations requires students to devote personal time to the activity and they often receive no formal academic grade or “credit.” Students can see this as extra work and, as a result, fail to take advantage of robust volunteer clinical opportuni ties in underserved areas.5 Specific factors have been found to predict who will engage with underserved populations in the future. These include a strong desire to practice in an underserved commu nity before entering medical school and students who come from a minority background themselves.11 Currently, many medical students come from privileged backgrounds, with family incomes and educational levels well above national census averages.12 Although, physicians are generally sensi tive to medical issues confronting underserved populations, they may also have a poor image of underserved patients’ attitudes toward their personal health and illness.13 Exposure to underserved communities in medical school, therefore, represents one way to confront this bias and potentially increase student interest in helping to provide care for under served populations in the future. With this background in mind, the present study used the Medical Student Attitudes Toward the Underserved (MSATU) questionnaire8 to describe attitudes of students at the Uniformed Services University of the Health Sciences (USU) regarding health care in traditionally underserved com munities. The MSATU is a previously validated instrument that has been specifically created to assess medical student attitudes regarding medical care and underserved populations.8
METHODS Study participants were students enrolled at the F. Edward Hebert Uniformed Services University School of Medicine (USU) (« = 170). USU is the nation’s only federal medical school. All students are commissioned officers in the uniformed services. As such, they are salaried government employees with health care benefits and no incumbent tuition
61
Medical Student Altitudes Toward the Medically Underserved
burden. Institutional Review Board approval was obtained before beginning the investigation. Participation in the study was voluntary. Interested students were verbally consented and given the MSATU questionnaire in the first year of med ical school, and again during their fourth year. To preserve anonymity, students created an acrostic using a unique mix ture of letters and numbers. This acrostic served as a unique identifier that allowed investigators to match individual responses from Year 1 and Year 4. Outcome Measure: The MSATU The MSATU assesses student attitudes regarding medical care in underserved populations.'1'11 The total MSATU score combines two subscales, one that explores general attitudes toward underserved care and one that explores issues relating to access and payment for medical services. The first subscale assesses societal expectations and professional responsibility. Questions from this subscale target attitudes involving per sonal (respondent) roles and responsibilities as well as orga nizational responsibilities for underserved care. Respondent attitudes regarding access to care for patients regardless of their ability to pay is assessed by the second subscale (14 items). Both subscales use a 5-point Likert scale to quan tify the extent to which respondents agree or disagree with each statement (5 = strongly agree, 1 = strongly disagree).9 The MSATU subscales are standardized using T-scores, which facilitates comparison of the magnitude of effects. Tscores have a mean of 50, and a standard deviation of 10. A T-score of 58, therefore, is 0.8 standard deviation above the mean. The change in T-score can be interpreted as an effect size. Previous studies have gathered evidence supporting the reliability and validity of the MSATU.11,12 Data Analysis MSATU scores were calculated using established scoring methods.9 Responses were analyzed using SPSS, Version TA B LE I. Measure
19.0 (SPSS, Chicago, Illinois). Baseline demographics were examined to assure that the sample was representative. Repeated measures ANOVA matching each student’s Year 1 and Year 4 response was used to analyze longitudinal data and control for baseline differences. RESULTS Baseline 170 students enrolled in the class of interest. The mean matriculate age was 24. 65% were male and 78% were Caucasian. Table I displays MSATU scores for matched pairs (Year 1/Year 4) and for those students with only Year 1 data. The response rate for students completing the MSATU at both Year 1 and Year 4 was 35%. Compared to limited normative data from the literature,8-10 USU respondents had less favorable MSATU total scores as well as scores on both subscales (Attitudes and Access). We examined age, gender, race, and MSATU scores for responders and nonresponders (students who completed only Year 1 administration) to determine whether the samples were representative and there were no significant differences between groups (responders and nonresponders). Table II displays the Year 1 to Year 4 comparison of responders. Repeated measures analysis of variance showed that Atti tudes and Access scale scores declined over time. There were main effects for time for the MSATU Total scale and Set 1 (Attitudes). In both settings, MSATU scores declined signif icantly from Year 1 to Year 4. For the second MSATU subscale (Set 2, Access), there was a main effect of time. Attitudes declined significantly (from 47.7 to 44.2, a 0.35 standard deviation change) from Year 1 to Year 4. DISCUSSION Our findings suggest that medical students attending a federal medical school (USU) have generally less favorable attitudes
MSATU Total and Subscale Scores by Year of Training
Year 1 Mean (SD)
Year 4 Mean (SD)
Both Years EMM
Both Years SE
46.2(10.95)
41.7 (12.38)
43.9
1.28
45.7 (10.98)
41.22 (13.34)
43.5
1.31
47.7 (10.95)
44.2(10.95)
46.0
1.22
MSATU Total USU Set 1 USU Set 2 USU
P
