Study: Medical Students Not Satisfied With Training in Health Systems, Medical Economics

A University of Michigan study published recently in Academic Medicine says that although medical students are satisfied with their training in clinical decision-making and patient care, they are much less happy overall with their training in health care systems, especially the finer points of medical economics.

The findings come as no surprise to an AAFP medical education expert and other family medicine educators. They say that although most students are introduced to the economics of medical practice during their third-year clerkships or through required or elective courses, they learn the most about the topic during their residency training.

"Medical schools teach it in bits and pieces. Students learn much of it from the experiences they have during clinical clerkships as they seek resources for their patients," said Perry Pugno, M.D., M.P.H., director of the AAFP Division of Medical Education.

The study, "Medical Student Perceptions of Education in Health Care Systems," said that about 90 percent of the more than 58,000 medical graduates who completed the annual Association of American Medical Colleges, or AAMC, Medical School Graduation Questionnaire from 2003 to 2007 reported that they received "appropriate" training in clinical decision-making. About 80 percent said they felt the same way about their clinical care training.

But when it came to the practice of medicine -- including medical economics, health care systems, managed care and practice management -- only 40 percent to 50 percent of the students reported on their questionnaires that they thought they had received appropriate training.

To look specifically at students' satisfaction with their training in health care systems, the researchers compared questionnaire responses from students at two similar medical schools. The schools were chosen for their overall similar curricula but differing intensity in health care systems training.

Those in the medical school with a high-intensity curriculum -- 13 required lectures and 13 required small-group discussion sessions, plus student projects and a fourth-year clinical elective -- were three times more satisfied with their training in this area of medicine than those in the medical school with a low-intensity curriculum that consisted of three lectures, three discussion sessions and no additional projects.

"Nationally, students consistently reported that inadequate instructional time was devoted to the practice of medicine, specifically medical economics. A higher-intensity curriculum in health care systems may hold substantial potential to overcome these perceptions of inadequacy," the study said.

Pugno said many medical schools' curricula already are packed during both the preclinical and clinical years, so it's not surprising that the schools pay less attention to medical practice and medical economics. Some medical schools have dual degree programs that allow students to earn a master's of business administration or a master's of public health, and students can learn about medical economics in these secondary programs, he said.

Primarily, graduates learn about practice management in their residencies, especially family medicine residencies, said Pugno.

Joseph Scherger, M.D., M.P.H., of San Diego, is vice president for primary care at the Eisenhower Medical Center in Rancho Mirage, Calif., and clinical professor of family and preventive medicine at the University of California, San Diego, or UCSD. He agrees with Pugno that physicians-in-training get most of their education about the economic side of medicine while in residency.

"The economics of health care and delivery systems are not core to medical school education. Residency training is more appropriate for this, as it is closer to when doctors choose a practice setting and enter practice," Scherger told AAFP News Now.

That said, he added, second-year students at UCSD take a course on health systems led by a professor of health care economics. Scherger himself presents a lecture on quality of care, including outcomes measurement and improvement methods as part of the school's preclinical curriculum.

"I think this is good background learning for the first two years of medical school," he said.

Joshua Freeman, M.D., of Kansas City, Kan., professor and chair of the department of family medicine at the University of Kansas School of Medicine, said his university integrates teaching about these topics into the medical school curriculum.

Freeman said the curriculum for first- and second-year students was revised several years ago into multidisciplinary, systems-based modules. Issues such as health promotion and disease prevention, medical ethics and the social basis of medical practice are integrated into these modules. He himself lectures about the social determinants of health.

Many students, however, learn first-hand about the business and practice of medicine during an eight-week family medicine clerkship. "They fill out billing sheets; they work alongside the doctors and can observe if (the doctors) have an electronic medical record. They learn about coding," said Freeman.

Students also see how the health care system "doesn't work" when they volunteer at the JayDoc Free Clinic, located at Southwest Family Health Care in Kansas City, Kan., which serves the uninsured, underinsured and underserved, he said. Most students in each medical school class volunteer a few times during their preclinical years.

"Medical students have to understand where the health care system is now so they can make informed decisions about how it should change," Freeman said.