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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


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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