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Subject: qotd: Medical students' attitudes regarding the uninsured and
underinsured
Date: Mon, 31 Dec 2012 12:09:22 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>
PLOS ONE
December 12, 2012
Videotaped Patient Stories: Impact on Medical Students' Attitudes
Regarding Healthcare for the Uninsured and Underinsured
By Richard Bruno, Allen Andrews, Brian Garvey, Kristin Huntoon, Rajarshi
Mazumder, Jaleh Olson, David Sanders, Ilana Weinbaum, Paul Gorman
The attitudes of medical students toward the current United States
healthcare system are not well described in the literature. A graded
survey was developed to assess awareness and motivation toward the care
of the uninsured and underinsured as well as the impact of a video
intervention on these attitudes.
Medical students from nine medical schools were invited to participate
and 895 completed the survey. Based on student coordinators' estimates
of their class size, reconciled with AAMC data, the response rate was 22.7%.
Our key findings were: (1) An overwhelming majority of medical students
responding agree or strongly agree that everyone should have access to
healthcare (96%) and that care should be provided regardless of ability
to pay (85%); (2) two thirds of medical students responding agree or
strongly agree that they have the personal responsibility to volunteer
time for underserved patients (67.4%) and expressed a willingness to
forgo a portion of income to provide healthcare to the underserved
(66.1%); (3) 72% of respondents agree or strongly agree that publicly
funded healthcare should be available to all citizens; (4) these values
were strongly correlated with older age and intention to pursue primary
care; (5) following a video montage of patient stories, respondents were
more likely to indicate a personal desire to be involved in providing
care to the underserved.
Ideas for Reform
Many students articulated a need for systemic healthcare reform. Most of
those responding were in agreement that there were a number of issues
within healthcare that need to be transformed, but they did not agree on
any single plan for change. Respondents proposed ideas for reform
ranging from changing payment structures, reducing cost of care,
incentivizing healthy behaviors, reforming health insurance, to shifting
toward a socialized or single payer approach to healthcare.
Physician vs. Government Responsibility
While several respondents stated that physicians across all specialties
have a responsibility to care for the underserved, a large number of
respondents felt strongly that physicians should choose whether or not
to volunteer their time serving the uninsured and should not be
obligated to do so. Others took this idea further, stating that
physicians already sacrifice a lot and should always be compensated for
their services. There seemed to be consensus that although physicians
must play a role in caring for the underserved, they should not bear the
entire responsibility of doing so. Respondents were split over whether
this should be the responsibility of the government or not.
Healthcare as a Right
While a significant group of respondents felt that healthcare should be
a right for all people, others felt that certain groups should be
excluded or that individuals should have to take responsibility for
their own health and payment for their own care. Several people stated
specifically that healthcare is a right and that all people should have
access regardless of their ability to pay, while others stated that
healthcare should not be free for anyone and that everyone should be
required to pay something. Other respondents specified that while
everyone should have access to a basic level of care, those who can pay
more should be able to purchase more or higher quality services. Some
students clarified that specific groups, such as those who are not
citizens or whose health problems are the result of unhealthy behaviors,
should not receive care funded by taxpayer dollars. Several respondents
also expressed concern that publicly funded care takes away personal
responsibility and that people would likely take advantage of the system.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0051827
Comment: As the nation implements the provisions of the Affordable Care
Act we can look forward to a future wherein, regardless of the structure
of financing and the delivery system in health care, the altruistic
students of today will demonstrate that we'll be in good hands. They
will make the system, regardless of how flawed, work for the benefit of
everyone. Or can we be so assured?
This study does have some limitations. Less than one-fourth of students
invited to participate actually responded. Because of the nature of the
survey, there may have been a self-selection bias toward more altruistic
students. A major feature of the study was to assess views before and
after viewing a two minute video montage of patients telling their
stories. Intuitively it seems unlikely that such a video could change
moral and ethical perceptions developed over a lifetime, though 83
percent who viewed the video, as opposed to 77 percent who did not,
expressed that they personally wanted to be involved in providing care
to those without access (a "statistically significant" insignificant
finding).
The key findings listed in the excerpts above superficially seem to be
reassuring in that fairly large percentages of these self-selected
students hold certain altruistic views. But what about the others? Do 4
percent of medical students really believe that not everyone should have
access to health care? Do 15 percent believe that care should not be
provided when there is no ability to pay? Do 33 percent believe that
they have no personal responsibility to volunteer time for underserved
patients? Are 34 percent unwilling to forgo a portion of income to
provide health care to the underserved? Do 28 percent believe that
publicly funded health care should not be available to all citizens?
You may be troubled as I was on reading the paragraph above titled
"Healthcare is a Right." It demonstrates that the opponents of
solidarity and egalitarianism have been very effective in delivering
their message that we are not all in this together, that we are each on
our own. Particularly prominent are the observations expressing the view
that everyone should be required to pay something, otherwise individuals
would abandon personal responsibility and take advantage of the system.
This, of course, represents the rhetoric of the advocates of
consumer-directed health care (CDHC).
So what is wrong with CDHC? Steffie Woolhandler and David Himmelstein
summarized it well in the following paragraph from their article,
"Consumer Directed Healthcare: Except for the Healthy and Wealthy It's
Unwise."
"Behind the rhetoric of consumer responsiveness and personal
responsibility, CDHC sets in motion huge resource transfers. The sick
and middle-aged pay more, whereas the young and healthy pay less. Women
spend more, whereas men spend less. Workers bear more of the burden,
whereas employers bear less. The poor skip vital care while the rich
enjoy tax-free tummy tucks. And, as in every health reform in memory,
bureaucrats and insurance firms walk off with an ever larger share of
health dollars."
http://www.pnhp.org/PDF_files/CDHC_Unwise.pdf
The question then, are these particular medical students merely
passively, naively and uncritically accepting the framing as presented
by the CDHC advocates, or do they really believe in a social order that
is defined by our individual efforts and rejects moral precepts of
social justice? Or is that even a valid dichotomy? The rhetoric of this
sector of the nation's medical students is not very reassuring.
Happy New Year anyway.
