Access to medical care for black and white Americans. A matter of continuing concern

A 1986 national survey of use of health services shows a significant deficit in access to health care among black compared with white Americans. This gap was experienced by all income levels of black Americans. In addition, the study points to significant underuse by blacks of needed medical care. Moreover, blacks compared with whites are less likely to be satisfied with the qualitative ways their physicians treat them when they are ill, more dissatisfied with the care they receive when hospitalized, and more likely to believe that the duration of their hospitalizations is too short.     

Mississippi's physician labor force: current status and future challenges

The literature review indicates that changes in Medicaid/Medicare reimbursement, large numbers of uninsured patients, the legal climate, and largely rural and chronically ill populations create a challenging environment for physicians practicing in Mississippi. As a largely rural state, many Mississippians find medical care to be physically distant, with most care being concentrated in a couple areas of the state. Given these factors, the legal climate in Mississippi and the top relocation decision factors, Mississippi will be further challenged in recruiting and retaining the numbers of general practitioners and specialists necessary to provide care to the state's population. The challenges that physicians are facing have led to challenges for health policy makers, in that physicians are difficult to recruit to Mississippi and, once here, difficult to retain as practitioners throughout their career. Four datasets were used in conjunction to analyze the demographic characteristics of Mississippi's physicians, including the age structure disaggregated by several other variables. Ultimately, the results were extended to impacts of recruitment, relocations, and retirement decisions of physicians who participated in the MSMDS. Briefly, demographic results indicate that Mississippi has a largely white physician population serving a nearly 40% minority population in Mississippi. The under representation of women within the medical profession in Mississippi means that women in the state might find it unusually challenging to find a female physician, particularly in rural areas where access to physicians is more limited in the first place. Mississippi has a high concentration of African-American patients with a low African-American physician presence. The proportion of physicians who are female is on the rise nationwide and within Mississippi, largely due to increasing enrollments of women in medical schools. Though variations exist within the groups of physicians identified as generalists, Mississippi is only slightly more likely than the nation to have specialists, rather than generalists (see Table Seven). Age structure analysis indicates that Delta physicians are older than physicians elsewhere in the state, that urban physicians are younger than rural physicians, and that our physician labor force is more highly concentrated between the ages of 35 and 54 than in the nation as a whole. Analyses concerning the future of the physician labor force indicate that a near majority of Mississippi's practicing physicians received their MD degree at UMC, but younger physicians are more likely to have been educated out-of-state than older physicians. Those who received their degrees elsewhere and chose to practice in Mississippi are more likely to be specialists (60%) than generalists (40%). Those physicians practicing in the state who were educated in-state are nearly equally as likely to be generalists (47%) as they are to be specialists (53%). Additionally, those approaching retirement are more likely to be generalists, yet the state is recruiting more generalists from recent medical school classes than in the past. Variations in intentions to recruit, relocate, and retire exist. However, most of the substantively important variation is across age groups and time in practice. There is little relevance of specialty or location within the state when examining variation in recruitment, relocation or retirement plans. Given the findings, policy research recommendations focus on improving the retention of UMC's graduates for practice in the state, improving retention of active physicians, increasing the recruitment of physicians from out of state, and easing difficulties associated with working part-time as a step toward retirement. With these changes in policy, it is possible that Mississippi can thwart a physician workforce shortage; however, without changes, with more physicians relocating, retiring early, or opting out of practicing in the state, the extant physician shortage will become more severe. Furthermore, without the data collection efforts mentioned here, there will be no means to assess whether policy changes are actually impacting the physician labor force.     

Career choice of 'fifth pathway' graduates from New York state medical schools

Graduates of "fifth pathway" programs at medical schools in New York state between 1976 and 1978 were studied to determine their professional careers and choice of medical specialties. Of the 545 physicians participating in the program, 510 were able to be located. Of this latter cohort, 177 (34.7 percent) had entered primary care fields as of 1981. Of the physicians no longer in residency training, 19.1 percent had full-time salaried positions in academic institutions, and the remaining physicians were engaged in various clinical medical activities. Of the 545 fifth pathway graduates, 74 (13.6 percent) had not been able to pass the licensing examinations as of 1981, and an additional 54 (9.9 percent) had not taken those examinations. Comparisons with regular students graduating from a medical school in New York state showed that fifth pathway graduates were more likely to select nonprimary care specialties than primary care specialties (p less than 0.001). These data suggest that although a majority of graduates of fifth pathway programs in New York state are involved in the provision of health care, a small number are still unable to engage in the practice of medicine.     

Career changes among Saskatchewan physicians.

OBJECTIVE: To determine how often Saskatchewan physicians changed career paths during medical training and practice. DESIGN: Population survey (mailed questionnaire). SETTING: Saskatchewan. PARTICIPANTS: All 1077 active members of the Saskatchewan Medical Association were sent a questionnaire; 493 (45.8%) responded. OUTCOME MEASURES: Long-term career goal or plan in next-to-last year of undergraduate medical school, probable choice of career if forced to choose at that time, and number of physicians who changed their field of training or practice at any time since graduation. RESULTS: In all, 57.8% (237/410) of the respondents were currently practising in a field different from that planned in their next-to-last year of medical school, 63.5% (275/436) were not practising in the field they would have chosen if forced to at that time, and 42.9% (211/492) had changed their field of training or practice at some time since graduation. Older physicians, those who graduated outside of Canada and specialists were the most likely to have changed career paths, family physicians, and those who graduated in Saskatchewan were the least likely to have changed. CONCLUSION: The current system of postgraduate training in Canada does not permit career changes of the sort made by most of the practising Saskatchewan physicians in the survey sample. The implications of this new system are as yet unknown but require careful monitoring.     

Do female general practitioners have a distinctive type of medical practice?

Using data collected in 1983-84 for a representative sample of 736 general practitioners practising in Quebec, we compared the practice characteristics of the 296 female physicians and the 320 male physicians who agreed to participate. The female doctors were more likely than the male doctors to favour salaried practice in local community health centres, to practise in an urban setting and to have an office-based practice. The female physicians had a less diversified type of practice, being less involved in hospital care, emergency care, home care and administrative work. Sex differences were more marked for physicians in fee-for-service practice than for salaried physicians. Given the increasing numbers of women in the medical profession, these findings are of special interest since they indicate distinctive differences in medical practice between women and men.     

The relation between personal characteristics of physicians and practice location in Manitoba.

A questionnaire survey of 562 physicians in Manitoba who had graduated from the University of Manitoba was carried out to assess the effect of personal characteristics on choosing a practice location. The results closely resemble those of studies performed in the United States: the choice of a nonurban practice location is significantly more likely if the physicians and their spouses have nonurban backgrounds and if the physicians have had a nonurban preceptorship during undergraduate medical education. In this study practitioners who were male and whose fathers were farmers or health care professionals were also more likely to practise in nonurban areas. These findings will help in making physician distribution more equitable.     

A survey of postgraduate training for family practice

The results of a survey of Canadian primary care physicians for the Canadian Medical Association (CMA's) Task Force on Education for the Provision of Primary Care Services are reported. Recent Canadian medical school graduates in primary care practice reported that the three major training routes (rotating and mixed internships and family medicine residencies) each prepared them differently for practice. The graduates of 2-year family medicine residencies were more satisfied with their preparation than were the graduates of the other major training routes. A 2- or 3-year family medicine residency was preferred by 50% of the respondents, although only 33% of them had actually taken one of these routes. There was considerable agreement in the respondents' assessments of the types of postgraduate education needed for primary care practice. The results of this survey were consistent with the recommendations in the final report of the CMA's task force.     

A gender-based study of attitudes and practice characteristics of rural physicians in West Virginia

Physician gender can affect the numbers of future rural health care providers since female physicians are less likely to enter rural practice, but the proportion of female U.S. medical students is increasing. This survey study of rural West Virginia physicians who were trained in the U.S. obtained information on demographics and prior practice intent, working time, practice characteristics, and satisfaction with practice and community for female vs. male physicians. Female physicians were more likely to report pre-existing intent to work in underserved areas and having higher proportions of Medicaid and uninsured patients, but fewer work hours and on-call services and less likelihood of providing hospital services. Initiatives to help address the shortage of rural providers could include residency program and community initiatives to address work flexibility and personal and spouse concerns for female physicians.     

Effects of residency training in family medicine v. internship training on professional attitudes and practice patterns.

OBJECTIVES: To determine whether the professional attitudes and practice patterns of physicians with residency training in family medicine differ from those of generalists with internship training. DESIGN: Mail survey conducted in 1985-86. SETTING: Province of Quebec. PARTICIPANTS: A stratified random sample of French-speaking family and general practitioners who graduated after 1972 (325 physicians with residency training and 304 with internship training) (response rate 82%). MAIN RESULTS: Physicians with residency training were 3 years younger on average than those with internship training, were more likely to be female (38% v. 18%, p less than 0.001) and were more likely to work on a salaried basis in CLSCs (public community health centres) (36% v. 14%, p less than 0.001). Even after these confounding factors were controlled for, physicians with residency training seemed to be more sensitive to the psychosocial aspects of patient care and tended to attach more importance to informing patients about useful materials and resources concerning their health problems. They were not, however, more likely to value health counselling or integrate it in medical practice. CONCLUSION: Our findings provide some evidence that the new requirement that physicians complete a residency in family medicine to obtain medical licensure in general practice in Quebec may foster a more patient-centred approach to health care.     

Which medical schools produce rural physicians?

OBJECTIVE--To examine the hypothesis that medical schools vary systematically and predictably in the proportion of their graduates who enter rural practice. DESIGN--The December 1991 version of the American Medical Association Physician Masterfile was used to examine the rural and urban practice locations of physicians who graduated from American medical schools between 1976 and 1985. Selected characteristics of the medical schools--including location, ownership, and funding--were linked to the Physician Masterfile. MAIN OUTCOME MEASURES--The percentage of the graduates from each medical school who were practicing in rural areas in December 1991, disaggregated by physician specialty. RESULTS--Of the practicing graduates from our study, 12.6% were located in rural counties; family physicians were much more likely than members of other specialties to select rural practice, particularly in the smallest and most isolated rural counties. Women were much less likely than men to enter rural practice. Medical schools varied greatly in the percentage of their graduates who entered rural practice, ranging from 41.2% to 2.3% of the graduating classes studied. Twelve medical schools accounted for over one quarter of the physicians entering rural practice in this time period. Four variables were strongly associated with a tendency to produce rural graduates: location in a rural state, public ownership, production of family physicians, and smaller amounts of funding from the National Institutes of Health. DISCUSSION--The organization, location, and mission of medical schools is closely related to the propensity of their graduates to select rural practice. Increasing policy coordination among medical schools and state and federal governmental entities would most effectively address residual problems of rural physician shortages.     

Public vs physician views of liability for artificial intelligence in health care

The growing use of artificial intelligence (AI) in health care has raised questions about who should be held liable for medical errors that result from care delivered jointly by physicians and algorithms. In this survey study comparing views of physicians and the U.S. public, we find that the public is significantly more likely to believe that physicians should be held responsible when an error occurs during care delivered with medical AI, though the majority of both physicians and the public hold this view (66.0% vs 57.3%; P = .020). Physicians are more likely than the public to believe that vendors (43.8% vs 32.9%; P = .004) and healthcare organizations should be liable for AI-related medical errors (29.2% vs 22.6%; P = .05). Views of medical liability did not differ by clinical specialty. Among the general public, younger people are more likely to hold nearly all parties liable.     

Prenatal care in northwestern Wisconsin

The purposes of this study were to identify the components of prenatal care given by family practice physicians and obstetricians in a rural area and determine whether they were in agreement with standards of care advanced by the American College of Obstetricians and Gynecologists (ACOG). We surveyed 76 physicians (family physicians with and without residency training and obstetricians) and identified 40 components of regular prenatal care; they were consistent with 94% of the ACOG recommendations. Few differences were found in prenatal care practices by type of family practice training. Although the number of obstetricians was small, these specialists appeared more likely to agree with ACOG guidelines. Risk assessment instruments were not routinely used by most physicians, and the services of public health nurses were not generally recommended as part of prenatal care. The findings have implications for continuing medical education programs.     

Medical education in People's Republic of China

The three types of physicians being educated in the People's Republic of China--practitioners in traditional Chinese medicine, traditional Mongolian medicine, and western-type medicine--and the nation's medical schools are discussed. The country officially recognizes 117 health professions educational institutions--23 colleges of traditional Chinese medicine, 91 western-type medical schools, two schools of pharmacy, and one institution that trains pharmacy, medical, and hygienic inspectors. Eight of the 91 western-type schools, in addition to providing training in western-type medicine, also offer education in traditional Chinese medicine. Training in Mongolian medicine is offered by one of these eight western schools and by one other western school. No schools offer only Mongolian medicine education.     

Virtual microscopes in podiatric medical education

In many medical schools, microscopes are being replaced as teaching tools by computers with software that emulates the use of a light microscope. This article chronicles the adoption of "virtual microscopes" by a podiatric medical school and presents the results of educational research on the effectiveness of this adoption in a histology course. If the trend toward virtual microscopy in education continues, many 21st-century physicians will not be trained to operate a light microscope. The replacement of old technologies by new is discussed. The fundamental question is whether all podiatric physicians should be trained in the use of a particular tool or only those who are likely to use it in their own practice.     

Cutting medical care costs. Primum non nocere

A serious slowdown in the nation's economy has led to widespread agreement that the rate of escalation of medical care costs must be slowed. In responding to the pressures to cut costs, physicians need to be guided by the basic tenet of medicine: first do no harm. In recent years, this nation has made extraordinary progress in improving health and longevity. A recent study suggestively links reductions in mortality to increased expenditures for health. Thus, physicians should watch closely how the nation reduces medical care expenses. We suggest a series of yardsticks that might track the effects of the nation's cost-cutting efforts on personal health. Keeping a careful eye on where people receive care, how frequently they see a physician, trends in mortality, and the adequacy or timeliness of care could help us keep our sights set on the continuing improvement of the health of Americans.     

Private physicians in ambulatory care training in U.S. medical schools

The contribution of private physicians to medical student education in ambulatory care was determined by a questionnaire directed to departments of family practice, internal medicine, and pediatrics in 124 U.S. medical schools and their branch campuses. The response rate was 84 percent. Of the responding departments, 82 percent offered an ambulatory care course in curricular years three and/or four, and 56 percent utilized private physicians in their courses. Departments of internal medicine were least likely to offer such a course, and their courses less frequently included teaching by private physicians (p less than 0.0001). When offered, internal medicine courses in ambulatory care were least likely to be required for graduation and involved the fewer students. Departments of family practice were most likely to offer ambulatory care courses and were most likely to utilize private physicians in their courses.     

American women physicians in 2000: a history in progress

This article surveys major trends in the history of women physicians in American medicine during the 20th century, noting especially factors that have elicited renewed and increasingly public attention during the past two decades. These include the challenges of achieving greater professional visibility while also balancing family and career, of sustaining women physicians' legacy of commitment to women's health and primary care medicine without reinforcing the traditional stereotype that these are the specialties "best suited" to women doctors, and of addressing the need for more ethnic and racial diversity in the medical profession. Other recent developments include the leveling off of the number of women entering medical school and the increasing tendency of both men and women physicians to practice as employees.     

Recruitment and progress of minority medical school entrants 1970-1972.

This is a report on a national study of minority group applicants and entrants to the 1970, 1971, and 1972 entering classes of U.S. medical colleges. The aim of the investigation was to further understanding of the factors involved in attempting to increase minority representation in education for the practice of medicine. Data from the Association of American Medical Colleges are used to examine characteristics of successful and unsuccessful minority applicants to medical school. Socieconomic, personal, institutiona, and geographical factors that relate to the recruitment and progress of minority students in medicine are analyzed and evaluated. Differences between Caucasian and minority group students affecting admissions, retention, and promotion are documented. The investigators also compare the projections of a 1970 AAMC task force report with actual occurrences in the national effort to expand educational opportunities in medicine for blacks and other underrepresented minority students (that is, American Indians, Mexican Americans, and mainland Puerto Ricans). This comparison shows substantial progress toward the projected figures but a need for renewed commitment if they are to be reached. Suggestions are offered for improving the recruitment and progress of minority medical school entrants by such means as the AAMC Simulated Minority Admissions Exercises and by ongoing programs at individual medical schools. The study also yielded such pertinent findings as the following: 1. Confirmation that the racial characterizations self-reported by medical school applicants have a high degree of accuracy and an increasing degree of completeness. 2. An encouraging increase in the number of black premedical students who will potentially apply for the medical school classes entering in 1976 and 1977. 3. Growth in the enrollment of low-income medical students, most of it explained by the increase in the numbers of minority group members who have been admitted in recent years. 4. More mobility among blacks than Caucasians with regard to attending medical schools in other than their region of legal residence. 5. A higher proportion of women, of older, and of married students among minority medical school matriculants than among Caucasian matriculants. 6. A slightly higher medical school retention rate for Caucasians than for students from underrepresented minority groups, possibly explained in part by the greater diversity in the socioeconomic and educational backgrounds of the latter. 7. A positive relationship for blacks between the size of undergraduate college attended and successful completion of the first year of medical school.     

US graduate medical education, 1999-2000

This report examines data collected through the American Medical Association Annual Survey of Graduate Medical Education Programs for 1999-2000 and compares these data with similar data collected during the past several years. The number of resident physicians enrolled during 1999-2000 was 606 more than during the previous year; graduates of US osteopathic medical schools (USDOs) had the greatest proportional increase (5.2%). The number of physicians entering graduate medical education (GME) for the first time in 1999-2000 (n = 22,320) also increased, with the number of USDOs increasing the most, by 14.5%, followed by international medical graduates (IMGs) at 6.5%. Between academic years 1998-1999 and 1999-2000, the number of physicians with prior US GME occupying first-year positions for which prior GME was not required (GY1 positions) increased by more than 300 (12%). Compared with graduates of US allopathic and osteopathic medical schools (USMGs), IMGs were more likely to seek additional training after graduating from a program. However, this was not true of IMGs who were US citizens or who had been naturalized or had permanent residency status. For the second year in a row, the number of white graduates of US allopathic medical schools (USMDs) entering GME has declined (2.0%), while the number of Hispanic GY1 USMDs has increased by 10.5%. The number of Asian GY1 USMDs increased steadily (11.0%) but the number of blacks decreased by 7.1% from 1998-1999. Growth continues, both in numbers and in heterogeneity of physicians in training, and must be considered in the future development of policy to guide US GME. JAMA. 2000;284:1121-1126     

Racial differences in mortality among men hospitalized in the Veterans Affairs health care system

CONTEXT: Racial disparities in health care delivery and outcomes may be due to differences in health care access and, therefore, may be mitigated in an equal-access health care system. Few studies have examined racial differences in health outcomes in such a system. OBJECTIVE: To study racial differences in mortality among patients admitted to hospitals in the Veterans Affairs (VA) system, a health care system that potentially offers equal access to care. DESIGN, SETTING, AND PARTICIPANTS: Cohort study of 28 934 white and 7575 black men admitted to 147 VA hospitals for 1 of 6 common medical diagnoses (pneumonia, angina, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and chronic renal failure) between October 1, 1995, and September 30, 1996. MAIN OUTCOME MEASURES: The primary outcome measure was 30-day mortality among black compared with white patients. Secondary outcome measures were in-hospital mortality and 6-month mortality. RESULTS: Overall mortality at 30 days was 4.5% in black patients and 5.8% in white patients (relative risk [RR], 0.77; 95% confidence interval [CI], 0.69-0.87; P =.001). Mortality was lower among blacks for each of the 6 medical diagnoses. Multivariate adjustment for patient and hospital characteristics had a small effect (RR, 0.75; 95% CI, 0.66-0.85; P<.001). Black patients also had lower adjusted in-hospital and 6-month mortality. These findings were consistent among all subgroups evaluated. CONCLUSIONS: Black patients admitted to VA hospitals with common medical diagnoses have lower mortality rates than white patients. The survival advantage of black patients is not readily explained; however, the absence of a survival disadvantage for blacks may reflect the benefits of equal access to health care and the quality of inpatient treatment at VA medical centers.