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
PLOS ONE, December 12, 2012

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.

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.”

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.