Health policy views of medical students in Ontario and in California

CMAJ OPEN
November 11, 2014
Attitudes and knowledge regarding health care policy and systems: a
survey of medical students in Ontario and California
By Sherif Emil, MDCM, Justine M. Nagurney, MD, Elise Mok, PhD, Michael
D. Prislin, MD

Abstract

Background Canada and the United States have similar medical education
systems, but different health care systems. We surveyed medical students
in Ontario and California to assess their knowledge and views about
health care policy and systems, with an emphasis on attitudes toward
universal care.

Methods A web-based survey was administered during the 2010–2011
academic year to students in 5 medical schools in Ontario and 4 in
California. The survey collected demographic data and evaluated
attitudes and knowledge regarding broad health care policy issues and
health care systems. An index of support for universal health care was
created, and logistic regression models were used to examine potential
determinants of such support.

Results Responses were received from 2241 students: 1354 from Ontario
and 887 from California, representing 42.9% of eligible respondents.
Support for universal health care coverage was higher in Ontario (86.8%)
than in California (51.1%), p < 0.001. In California, females,
self-described nonconservatives, students with the intent to be involved
in health care policy as physicians and students with a primary care
orientation were associated with support for universal coverage. In
Ontario, self-described liberals and accurate knowledge of the Canadian
system were associated with support. A single-payer system for practice
was preferred by 35.6% and 67.4% of students in California and Ontario,
respectively. The quantity of instruction on health care policy in the
curriculum was judged too little by 73.1% and 57.5% of students in
California and Ontario, respectively.

Interpretation Medical students in Ontario are substantially more
supportive of universal access to health care than their California
counterparts. A majority of students in both regions identified
substantial curricular deficiencies in health care policy instruction.

From the Interpretation

Whether the culture of many American medical schools promotes or
discourages support for universal health care can be debated. However,
most would agree that health policy education in North American medical
schools is poor. In our study, only one-third of all respondents
demonstrated accurate knowledge of the basics of their own health care
system, and fewer than 1 in 10 respondents understood the basics of the
neighbouring country's health care system. For example, less than 60% of
California respondents correctly answered the question regarding the
Patient Protection and Affordable Care Act of 2010, despite a recent
survey showing that 80% of students are supportive of the law. A large
majority of respondents in both locations rated the quantity of
instruction on health care policy as too little, and a minority rated
the quality as good or excellent. The medical curriculum ranked low as a
source of information. These deficits have been consistently reported in
previous medical student surveys. If students graduate without adequate
knowledge of health care policy or alternative health care systems, they
are unlikely to acquire that knowledge as physicians. Studies have shown
that American physicians, both primary practitioners and specialists,
have inaccurate impressions of the Canadian system. On the other hand,
there is evidence that integration of instruction on health care policy
into resident and student curricula results in increased knowledge,
participation and action.

Conclusion

The differences in health care systems between the US and Canada are
deep-rooted and embedded in the history, politics and cultural
traditions of both countries. These differences were reflected in our
comparison of Ontario and California medical students. The differences
in the level of physician support for universal access to health care
between Ontario and California start in medical school. Many of these
views, which are embedded early in a physician's formative experience,
are based on inadequate knowledge of health care systems. Like many, we
believe that medical schools and academic medicine in general have a
responsibility to train socially responsible physicians who will
advocate for universal health care access of appropriate quality and
cost. This can only be achieved if high-quality and sufficient quantity
instruction on health care policy and health care systems is integrated
into medical school curricula in the US and Canada, a challenge yet to
be met.

http://www.cmajopen.ca/content/2/4/E288.full

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Comment by Don McCanne

Two-thirds of medical students in Ontario and in California do not have
accurate knowledge of the policy basics of their own health care systems
and nine-tenths fail to understand the basics of the neighboring
country's health care systems.

However, Ontario students do show greater support for universal health
care coverage than do California students (86.8% versus 51.1%). Also,
support for a single payer health care system, which of course the
Canadians have and we do not, was greater amongst Ontario students than
it was amongst California students (67.4% versus 35.6%).

What might account for these differences? The authors state, "In
California, females, self-described nonconservatives, students with the
intent to be involved in health care policy as physicians and students
with a primary care orientation were associated with support for
universal coverage. In Ontario, self-described liberals and accurate
knowledge of the Canadian system were associated with support."

We can only speculate that if these students were better informed on
health policy that their views of their own country's system and
especially of the neighboring country's system might change. It may be
that ideology is a greater driving force of opinion, especially when
unencumbered with facts of which they are unaware. If so, it seems that
Canadian medical students have more egalitarian views than those in the
United States.

Can a better understanding of the facts change ideological stances? The
Ontario students with more accurate knowledge of the Canadian system
were more supportive of universal health care coverage. There is hope
that PNHP's mission of educating our colleagues and the public could help.