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John A. Dodson; Allen S. Keller, MD
New York University School of Medicine, New York, NY

JAMA. 2004;291:121.

Medical education has long been related to care of the poor, especially in public hospitals, where medical education programs have traditionally provided treatment for indigent patients.¹ While medical education now covers a range of clinical environments, poor patients still represent a significant number of those cared for in educational settings. For example, public teaching hospitals currently provide 3 times the amount of indigent care relative to their share of the overall hospital market.² Students are also involved in a substantial number of community service programs, such as free clinics, that provide care for a growing population of uninsured patients.³

Poor patients have a greater number of negative outcomes than patients of higher socioeconomic status.⁴ Indigent patients have shorter hospital stays than patients with private insurance, and they are less likely to undergo high-cost procedures when hospitalized.⁵ Circumstances such as unemployment, homelessness, or lack of means to pay for basic needs may lead clinicians to form negative judgments about patients' social worth and may also reduce patients' chances of benefiting from certain kinds of treatment.⁶

It is unclear whether indigent patients' frequent exposure to trainees poses an additional risk to their health outcomes. Studies on outcomes of student care in the general population are rare as well; for example, 1 review noted that there are few empirical data about the risks of student-performed procedures.⁷ Although outcomes data are scarce, it is well documented that medical students face ethical dilemmas during their education, as they mediate between their relative inexperience and the need to practice their clinical skills with patients.⁸ It remains unstudied whether such ethical conflicts occur more frequently with indigent patients, although this issue should be a topic of further evaluation.

While the actual risks of medical students caring for indigent populations are largely unknown, there is some evidence suggesting that student involvement in indigent care potentially benefits both patients and students. Patients have reported that talking to medical students is helpful and that students often give more time than other members of the health care team.⁹ For students, involvement with the underserved in community clinics teaches them to give freely and also encourages activism as they become aware of the barriers to care that disadvantaged populations face.¹⁰ One study reported that a structured volunteer program in a homeless clinic during the first year of residency resulted in a significant increase in volunteer activities later in residency.¹¹ Although another study reported that residents with a high level of prior exposure to underserved populations did not find public hospitals more desirable practice settings than other residents, this group reported feeling more prepared to treat substance abuse problems and human immunodeficiency virus infection, both of which are more prevalent among the indigent.¹²

These results suggest that students working with underserved patients can develop an increased awareness of the issues facing this population and feel more prepared to treat their specific health needs. It is important to note that regardless of prior exposure, women, underrepresented minorities, and international medical graduates have reported a greater preference for practicing in poor inner-city settings than other trainees.¹² Thus, in addition to prior experience, other factors may guide students' future motivations in caring for the poor.

It is likely that medical students will continue to care for indigent populations through both public teaching hospitals and community clinics. Further study can assess whether poor patients disproportionately serve as subjects of medical student procedures and whether their results are adverse as a result of medical student care. While medical students working with the poor appear to have greater understanding of issues within this population, future research should also focus on the degree to which these students care for such patients in their subsequent careers. Ultimately, this research can help determine whether student involvement with indigent patients can increase the future number of physicians dedicated to caring for this vulnerable population.

REFERENCES
1. Fishman LE, Bentley JD. The evolution of support for safety-net hospitals. Health Aff (Millwood). 1997;16:30-47. ABSTRACT 2. Mann JM, Melnick GA, Bamezai A, Zwanziger J. A profile of uncompensated hospital care, 1983-1995. Health Aff (Millwood). 1997;16:223-232. ABSTRACT 3. Medical Student-Run Clinics of America. Available at: http://www.student-clinics.org. Accessed December 4, 2003. 4. Council on Ethical and Judicial Affairs, American Medical Association. Caring for the poor. JAMA. 1993;269:2533-2537. FREE FULL TEXT 5. Hadley J, Steinberg EP, Feder J. Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. JAMA. 1991;265:374-379. FREE FULL TEXT 6. Jecker NS. Caring for "socially undesirable" patients. Camb Q Healthc Ethics. 1996;5:500-510. ISI | PUBMED 7. Marracino RK, Orr RD. Entitling the student doctor: defining the student's role in patient care. J Gen Intern Med. 1998;13:266-270. FULL TEXT | ISI | PUBMED 8. Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study. BMJ. 2001;322:709-710. FREE FULL TEXT 9. Richardson PH, Curzen P, Fonagy P. Patients' attitudes to student doctors. Med Educ. 1986;20:314-317. ISI | PUBMED 10. Eckenfels EJ. Contemporary medical students' quest for self-fulfillment through community service. Acad Med. 1997;72:1043-1050. ISI | PUBMED 11. O'toole TP, Hanusa BH, Gibbon JL, Boyles SH. Experiences and attitudes of residents and students influence voluntary service with homeless populations. J Gen Intern Med. 1999;14:211-216. FULL TEXT | ISI | PUBMED 12. Weissman JS, Campbell EG, Gokhale M, Blumenthal D. Residents' preferences and preparation for caring for underserved populations. J Urban Health. 2001;78:535-549. ISI | PUBMED

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