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Kerfoot, Price B.; Conli,
Paul R.; McMahon, Graham T. Health systems knowledge and its determinants in medical
trainees. Medical Education November 2006; 40 (11) Reviewed
by Margaret Golden, SUNY Downstate What is the problem (issue)
and what is known about it so far?
The Accreditation Committee for Graduate
Medical Education (ACGME) requires residencies to teach six competencies to its
trainees, one of which is systems-based practice. Some U.S. medical schools are
beginning to adopt similar frameworks for curriculum design. Little is known about
the baseline knowledge of medical students and residents in systems-based practice
and how this knowledge changes with training. Why did the researchers
do this particular study?
The researchers wanted to examine the baseline knowledge
of health systems in residents and medical students and to examine the factors
that predicted a good knowledge base. Who was studied?
693 learners
were studied-two medical school classes and seven residency programs from three
hospital systems. How was the study done?
Curricular content was constructed
around knowledge of Medicaid, Medicare, the new prescription drug benefit and
women's health issues. After validating the content, learners were asked to complete
twelve questions to test their knowledge in these areas. They were also asked
to rate their own knowledge on the US health care system. What did the
researchers find?
92% of learners completed the test. Mean score on the test
was 46.7% (SD 14.0). There was no correlation between trainee level and test score.
There was some correlation between self-assessed knowledge and test score but
it accounted for a small level of the variance. Women scored higher than men by
a small margin. Residents who had trained at a primary care medical school scored
higher than those who did not, again by a small margin. Internal medicine residents
scored higher than OB-GYN residents. What were the limitations of the
study?
The study was done in only a few settings. No information is provided
about previous curriculum in systems-based practice at either the medical school
or residency programs. No information is provided about the birthplace or citizenship
of the trainees. The study looked only at knowledge rather than skills or attitudes.
No information is provided about the difficulty level of the questions. No information
is included about the type of residency programs included. What were the
implications of the study?
Knowledge of the U.S. health care system is not
extensive among U.S. medical students and residents. Knowledge does not increase
with level of training. Trainees have only a limited ability to assess their own
knowledge. Curricula to address this knowledge deficit are needed at all levels.
(Editorial comment: It is always striking that we train women and
men to practice medicine yet rarely do we teach them about the finances of medical
practice. There was a big push a few years back to incorporate more education
on this topic into medical school curricula but it is unclear how much impact
this has made. Although this is a small study with many methodological issues,
it seem pretty clear that unless more time (including assessment) is dedicated
to this issue during medical school or residency (and there will be arguments
about where this should take place) the first year of practice will continue to
be an unsupervised ambulatory fellowship in medical system financing. Bill Raszka)
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