AAMC Reporter: January 2010

Med Students Feel Unprepared for Health Care System

By Mike Martin, special to the Reporter

The U.S. health care system—like the 2,000-page reform bill proposed to change it—is a mountain of complexity. And less than half of graduating U.S. medical students comfortably understand it.

Citing inadequate education, a University of Michigan Medical School (UMMS) study of 58,294 AAMC medical student graduation questionnaires revealed that, while 92 percent of respondents were confident with their clinical training, nearly 60 percent felt unprepared for the managerial demands of medical practice.

"Everyone benefits when medical students are introduced to key concepts regarding health care systems," said AAMC Chief Academic Officer John Prescott, M.D.

"That is why, when students say they believe their knowledge in this area is not where it should be, we take it very seriously. Our goal is for systems-based practice to be a core competency at every medical school and across the continuum of medical education. As students become aware of real-world issues and concerns, they can become active participants in finding solutions."

Published in the September 2009 issue of Academic Medicine, the study, which covered graduates from 2003 to 2007, found lagging student confidence in practice management, record keeping, insurance, medical economics, and managed care.

This may be especially important as health care reform legislation makes its way through Congress.

"Our patients expect us to understand the system," said study coauthor Matthew M. Davis, M.D., associate professor of pediatrics and internal medicine at the University of Michigan Medical School (UMMS). "If we don't, that can result in poor patient care."

Medical schools do offer instruction about the system, but with "great variability," explained coauthor Mitesh Patel, M.D., an internal medicine resident at the Hospital of the University of Pennsylvania in Philadelphia.

Although researchers suspected some students would report inadequate systems preparation, they were struck by the size of that proportion, an unexpectedly large number that helped drive part two of the study: taking a closer look at medical schools "with great differences in their health care systems curriculum, from lectures and group discussions to student projects," Patel explained.

Comparing responses of 1,045 medical school graduates from two similar medical schools—one of which focused more intently on health care systems—the researchers found that students in the higher-intensity curriculum were three times more likely to report appropriate training in health care systems.

Apparently, however, the higher intensity did not mean sacrifices in other areas. Study coauthor Monica Lypson, M.D., UMMS assistant dean of graduate medical education, noted that curricula focused more on health systems preparation "did not lead to lower perceived levels of adequate training in other domains of instruction."

"Students in the higher-intensity curriculum were no less confident about other things," Davis added. "In other words, instead of a tradeoff, there is a payoff."

That is good news to Toni Ganzel, M.D., senior associate dean for students and academic affairs at the University of Louisville School of Medicine. Calling it a "wonderful study," Ganzel said the survey "helped dispel the myth that if we spend more time on health care systems, we diminish student confidence in health care."

Describing the practice of medicine as "art, science, and business," Ganzel underscored a study highlight.

"There's no uniform response to health care systems instruction," she said. "You have U.S. medical schools offering everything from a few electives to full M.D.-M.B.A. programs. While I don't think every student needs an M.B.A. to understand the business of medicine, it would be good for every school to offer instruction in core concepts."

The best core concept systems training will translate to improved clinical performance, said internist Henry Weil, M.D.

"Medical education needs a curriculum that not only delivers management skills, but also teaches students how to apply those skills to fix problems," said Weil, assistant dean of medical education for the Columbia-Bassett Medical School Program, a joint venture between New York City's Columbia College of Physicians and Surgeons and Bassett Healthcare, a hospital and physician network in Cooperstown, N.Y.

To integrate these issues into already jam-packed curricula, Weil said medical educators need to ask, "what is the minimum standard of management skills students need?" And after providing those skills, Weil said, how can students apply them not only to function in a complex system, but to deliver positive change?

Students at the University of Cincinnati College of Medicine have received health systems instruction since the school's inception. Working in small groups on patient cases, students discuss "ethical decision making, disparities in health care, impact of cost, and the economics of health care," said Michael Sostok, M.D., Cincinnati's assistant dean for medical education. Other options include a fourth-year "business in medicine" elective and an M.D.-M.B.A. program.

"Students run up against a need to know how the system works or doesn't work when they begin third-year clinical rotations," Sostok said. "Suddenly, the student needs to know the cost of the medicine prescribed because a real patient must pay a real bill, or when to call a social worker to help an individual who may need rehabilitation or longterm care."

Sostok said medical educator awareness of the need for better health care systems training has been steadily rising.

"This report speaks volumes about the need to provide health care leadership training to medical students, and part of that training requires a working knowledge of the health care system," Sostok said. "During their work in the first two years of medical school, the system may seem like a theory to many students. But when they begin their clinical clerkships, it becomes a day-to-day reality."