Attitudes and knowledge regarding health care policy and systems: a survey of medical students in Ontario and California

By Sherif Emil, MDCM, Justine M. Nagurney, MD, Elise Mok, PhD, Michael D. Prislin, MD
CMAJ OPEN, November 11, 2014

Abstract

Background

Canada and the United States have similar medical education systems, but different health care systems. We surveyed medical students in Ontario and California to assess their knowledge and views about health care policy and systems, with an emphasis on attitudes toward universal care.

Methods

A web-based survey was administered during the 2010–2011 academic year to students in 5 medical schools in Ontario and 4 in California. The survey collected demographic data and evaluated attitudes and knowledge regarding broad health care policy issues and health care systems. An index of support for universal health care was created, and logistic regression models were used to examine potential determinants of such support.

Results

Responses were received from 2241 students: 1354 from Ontario and 887 from California, representing 42.9% of eligible respondents. Support for universal health care coverage was higher in Ontario (86.8%) than in California (51.1%), p < 0.001. In California, females, self-described nonconservatives, students with the intent to be involved in health care policy as physicians and students with a primary care orientation were associated with support for universal coverage. In Ontario, self-described liberals and accurate knowledge of the Canadian system were associated with support. A single-payer system for practice was preferred by 35.6% and 67.4% of students in California and Ontario, respectively. The quantity of instruction on health care policy in the curriculum was judged too little by 73.1% and 57.5% of students in California and Ontario, respectively.

Interpretation

Medical students in Ontario are substantially more supportive of universal access to health care than their California counterparts. A majority of students in both regions identified substantial curricular deficiencies in health care policy instruction.

From the Interpretation

Whether the culture of many American medical schools promotes or discourages support for universal health care can be debated. However, most would agree that health policy education in North American medical schools is poor. In our study, only one-third of all respondents demonstrated accurate knowledge of the basics of their own health care system, and fewer than 1 in 10 respondents understood the basics of the neighbouring country’s health care system. For example, less than 60% of California respondents correctly answered the question regarding the Patient Protection and Affordable Care Act of 2010, despite a recent survey showing that 80% of students are supportive of the law. A large majority of respondents in both locations rated the quantity of instruction on health care policy as too little, and a minority rated the quality as good or excellent. The medical curriculum ranked low as a source of information. These deficits have been consistently reported in previous medical student surveys. If students graduate without adequate knowledge of health care policy or alternative health care systems, they are unlikely to acquire that knowledge as physicians. Studies have shown that American physicians, both primary practitioners and specialists, have inaccurate impressions of the Canadian system. On the other hand, there is evidence that integration of instruction on health care policy into resident and student curricula results in increased knowledge, participation and action.

Conclusion

The differences in health care systems between the US and Canada are deep-rooted and embedded in the history, politics and cultural traditions of both countries. These differences were reflected in our comparison of Ontario and California medical students. The differences in the level of physician support for universal access to health care between Ontario and California start in medical school. Many of these views, which are embedded early in a physician’s formative experience, are based on inadequate knowledge of health care systems. Like many, we believe that medical schools and academic medicine in general have a responsibility to train socially responsible physicians who will advocate for universal health care access of appropriate quality and cost. This can only be achieved if high-quality and sufficient quantity instruction on health care policy and health care systems is integrated into medical school curricula in the US and Canada, a challenge yet to be met.

http://www.cmajopen.ca/content/2/4/E288.full

Two-thirds of medical students in Ontario and in California do not have accurate knowledge of the policy basics of their own health care systems and nine-tenths fail to understand the basics of the neighboring country’s health care systems.

However, Ontario students do show greater support for universal health care coverage than do California students (86.8% versus 51.1%). Also, support for a single payer health care system, which of course the Canadians have and we do not, was greater amongst Ontario students than it was amongst California students (67.4% versus 35.6%).

What might account for these differences? The authors state, “In California, females, self-described nonconservatives, students with the intent to be involved in health care policy as physicians and students with a primary care orientation were associated with support for universal coverage. In Ontario, self-described liberals and accurate knowledge of the Canadian system were associated with support.”

We can only speculate that if these students were better informed on health policy that their views of their own country’s system and especially of the neighboring country’s system might change. It may be that ideology is a greater driving force of opinion, especially when unencumbered with facts of which they are unaware. If so, it seems that Canadian medical students have more egalitarian views than those in the United States.

Can a better understanding of the facts change ideological stances? The Ontario students with more accurate knowledge of the Canadian system were more supportive of universal health care coverage. There is hope that PNHP’s mission of educating our colleagues and the public could help.