Journal of Urban Health

, Volume 78, Issue 3, pp 535–549 | Cite as

Residents' preferences and preparation for caring for underserved populations

  • Joel S. Weissman
  • Eric G. Campbell
  • Manjusha Gokhale
  • David Blumenthal
General Topics


Access to care by low-income persons and residents of rural and poor innercity areas is a persistent problem, yet physicians tend to be maldistributed relative to need. The objectives were to describe prefernces of resident physicians to locate in underserved areas and to assess their preparedness to provide service to low-income populations. A national survey was made of residents completing their training in eight specialties at 162 USacademic health center hospitals in 1998, with 2,626 residents responding. (Of 4,832 sampled, 813 had invalid addresses or were no longer in the residency program. Among the valid sample of 4,019, the response rate was 65%). The percentage of residents ranking public hospitals, rural areas, and poor inner-city areas as desirable employment locations and the percentage feeling prepared to provide specified services associated with indigent populations were ascertained. Logistic regressions were used to calculate adjusted percentages, controlling for sex, race/ethnicity, international medical graduate (IMG) status, plans to subspecialize, ownership of hospital, specialty, and exposure to underserved patients during residency. Only one third of residents rated public hospitals as desirable settings, although there were large variations by specialty. Desirability was not associated with having trained in a public hospital or having greater exposure to underserved populations. Only about one quarter of respondents ranked rural (26%) or poor inner-city (25%) areas as desirable. Men (29%. P<.01) and noncitizen IMGs (43%, P<.01) were more likely than others to prefer rural settings. Residents who were more likely to rate poor innercity settings as desirable included women (28%, P=.03), noncitizen IMGs (35%, P=.01), and especially underrepresented minorities (52%, P<.01). Whereas about 90% or more of residents felt prepared to treat common clinical conditions, only 67% of residents in four primary care specialties felt prepared to counsel patients about domestic violence or to care for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) or substance abuse patients (all 67%). Women were more likely than men to feel prepared to counsel patients about domestic violence (70% vs. 63%, P=.002) and depression (83% vs. 75%, P<.01). Underrepresented minority residents were more likely than other residents to feel prepared to counsel patients about domestic violence (P<.01) and compliance with care (P=.04). Residents with greater exposure to underserved groups were more prepared to counsel patients about domestic violence (P=.01), substance abuse (P=.01), and to treat patients with HIV/AIDS (P=.01) or with substance abuse problems (P<.01). This study demonstrates the need to expose graduate trainees to underserved populations and suggests a contininuing role of minorities, women, and noncitizen physicians in caring for low-income populations.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Rivo ML, Satcher D. Improving access to health care through physician workforce reform. Directions for the 21st century. JAMA, 1993;270:1074–1078.CrossRefPubMedGoogle Scholar
  2. 2.
    Council on Graduate Medical Education. Tenth Report: Physician Distribution and Health Care Challenges in Rural and Inner-city Areas. Rockville, MD: US Department of Health and Human Services; February 1998.Google Scholar
  3. 3.
    Li LB, Williams SD, Scammon DL. Practicing with the urban underserved. A qualitative analysis of motivations, incentives, and disincentives. Arch Fam Med. 1995;4:124–33; discussion 134.CrossRefPubMedGoogle Scholar
  4. 4.
    Calman NS. A piece of my mind. No shattered vision. JAMA. 1993;269:638.CrossRefPubMedGoogle Scholar
  5. 5.
    Pathman DE, Konrad TR, Ricketts TC III. The National Health Service Corps experience for rural physicians in the late 1980s. JAMA. 1994;272:1341–1348.CrossRefPubMedGoogle Scholar
  6. 6.
    Komaromy M, Lurie N, Bindman AB. California physicians' willingness to care for the poor. West J Med. 1995;162:127–132.PubMedGoogle Scholar
  7. 7.
    Politzer RM, Cultice JM, Meltzer AJ. The geographic distribution of physicians in the US and the contribution of internatonal medical graduates. Med Care Res Rev. 1998; 55:116–130.CrossRefPubMedGoogle Scholar
  8. 8.
    Baer LD, Ricketts TC, Konrad TR, Mick SS. Do international medical graduates reduce rural physician shortages. Med Care. 1998; 36:1534–1544.CrossRefPubMedGoogle Scholar
  9. 9.
    Mick SS, Lee SY. The safety-net role of international medical graduates. Health Aff (Millwood). 1997;16:141–150.CrossRefGoogle Scholar
  10. 10.
    Mick SS, Lee SY. International and US medical graduates in US cities. J Urban Health. 1999;76:481–496.CrossRefPubMedGoogle Scholar
  11. 11.
    Mick SS, Lee SY, Wodchis WP. Variations in geographical distribution of foreign and domestically trained physicians in the United States: “safety nets” or “surplus exacrebation”? Soc Sci Med. 2000;50:185–202.CrossRefPubMedGoogle Scholar
  12. 12.
    Mullan F. The case for more US medical students. N Engl J Med. 2000; 343:213–217.CrossRefPubMedGoogle Scholar
  13. 13.
    Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. JAMA. 1995;273:1515–1520.CrossRefPubMedGoogle Scholar
  14. 14.
    Cantor JC, Miles EL, Baker LC, Barker DC. Physician service to the underserved: implications for affirmative action in medical education. Inquiry. 1996;33:167–180.PubMedGoogle Scholar
  15. 15.
    Cohen AB, Cantor JC, Barker DC, Hughes RG. Young physicians and the future of the medical profession. Health Aff (Millwood). 1990;9:138–148.CrossRefGoogle Scholar
  16. 16.
    American Medical Association. Graduate Medical Education Directory 1997–1998. Chicago, IL: American Medical Association; 1997:1244.Google Scholar
  17. 17.
    University Health System Consortium. 1996 Market Classifications and Revisions of the Market Classification Tool. Oak Brook, IL: University Health System Consortium; May 1997. UHC Managed Care White Papers, Volume 4, Number 2.Google Scholar
  18. 18.
    Centerwall BS. Race, socioeconomic status, and domestic homicide. JAMA. 1995;273:1755–1758.CrossRefPubMedGoogle Scholar
  19. 19.
    Gin NE, Rucker L, Frayne S, Cygan R, Hubbell FA. Prevalence of domestic violence among patients in three ambulatory care internal medicine clinics. J Gen Intern Med. 1991;6:317–322.CrossRefPubMedGoogle Scholar
  20. 20.
    Gordillo V, del Amo J, Soriano V, Gonzalez-Lahoz J. Sociodemographic and psychological variables influencing adherence to antiretroviral therapy. AIDS. 1999;13:1763–1769.CrossRefPubMedGoogle Scholar
  21. 21.
    Frazier PA, Davis-Ali SH, Dahl KE. Correlates of noncompliance among renal transplant recipients. Clin Transplant. 1994;8:550–557.PubMedGoogle Scholar
  22. 22.
    Miles-Doan R, Kelly S. Geographic concentration of violence between intimate partners. Public Health Rep. 1997;112:135–141.PubMedGoogle Scholar
  23. 23.
    US Department of Health and Human Services. Healthy People 2010. Washington, DC: US Dept of Health and Human Services; 2000.Google Scholar
  24. 24.
    Johnson EM, Belfer ML. Substance abuse and violence: cause and consequence. J Health Care Poor Underserved. 1995;6:113–121; discussion 121–123.PubMedGoogle Scholar
  25. 25.
    Grisso JA, Schwarz DF, Hirschinger N, et al. Violent injuries among women in an urban area. N Engl J Med. 1999;341:1899–1905.CrossRefPubMedGoogle Scholar
  26. 26.
    Weissman JS, Campbell EG, Blumenthal D. How does market competition affect resident physicians' views toward managed care? Am J Med. 2000;109:5):437–442.CrossRefPubMedGoogle Scholar
  27. 27.
    Campbell EG, Weissman JS, Blumenthal D. Relationship between market competition and the activities and attitudes of medical school faculty. JAMA. 1997;278:222–226.CrossRefPubMedGoogle Scholar
  28. 28.
    Weissman JS, Saglam D, Campbell EG, Causino N, Blumenthal D. Merket forces and unsponsored research in academic health centers. JAMA. 1999; 281:1093–1098.CrossRefPubMedGoogle Scholar
  29. 29.
    Shah BV, Barnwell BG, Bieler GS. SUDAAN User's Mannual. Release 7.0 ed. Research Triangle Park, NC: Research Triangle Institute; 1996.Google Scholar
  30. 30.
    Hosmer DW, Lemeshow S, Applied Logistic Regression. New York; Wiley; 1989.Google Scholar
  31. 31.
    Donelan K, Blendon RJ, Lundberg GD, et al. The new medical marketplace: physicians' views. Health Affairs. 1997;16(5):139–148.CrossRefPubMedGoogle Scholar
  32. 32.
    Tambor ES, Chase GA, Faden RR, Geller G, Hofman KJ, Holtzman NA. Improving response rates through incentive and follow-up: the effect on a survey of physicians' knowledge of genetics. Am J Public Health. 1993;83:1599–1603.CrossRefPubMedGoogle Scholar
  33. 33.
    Miller RS, Dunn MR, Richter TH, Whitcomb ME. Employment-seeking experiences of resident physicians completing training during 1996. JAMA. 1998;280:777–783.CrossRefPubMedGoogle Scholar
  34. 34.
    Dunn MR, Miller RS, Richter TH. Graduate medical education, 1997–1998. JAMA. 1998;280:809–812, 836–845.CrossRefPubMedGoogle Scholar
  35. 35.
    Association of American Medical Colleges. AAMC DATA BOOK:Statistical Information Related to Medical Schools and Teaching Hospitals, Washington, DC: Association of American Medical Colleges; 2000.Google Scholar
  36. 36.
    Council on Graduate Medical Education. First Report of the Council. Vol 1. Rockville, MD: Bureau of Health Professions, Division of Medicine; No. HRP-0907210.Google Scholar
  37. 37.
    Institute of Medicine. The Nation's Physician Workforce: Options for Balancing Supply and Requirements. Washington, DC: National Academy Press; 1996.Google Scholar
  38. 38.
    Pew Health Professions Commission. Critical Challenges: Revitalizing the Health Professions for the 21st Century. San Francisco, CA: University of California at San Francisco Center for the Health Professions; December 1995.Google Scholar
  39. 39.
    Talley RC. Graduate medical education and rural health care. Acad Med. 1990;65:S22-S25.CrossRefPubMedGoogle Scholar
  40. 40.
    Hawkins RE, Sumption KF, Gaglione MM, Holmboe ES. The in-training examination in internal medicine: Resident perceptions and lack of correlation between resident scores and faculty predictions of resident performance. Am J Med. 1999;106:206–210.CrossRefPubMedGoogle Scholar
  41. 41.
    Politzer RM, Harris DL, Gaston MH, Mullan F. Primary care physician supply and the medically underserved. A status report and recommendations [see comments]. JAMA. 1991;266:104–109.CrossRefPubMedGoogle Scholar

Copyright information

© The New York Academy of Medicine 2001

Authors and Affiliations

  • Joel S. Weissman
    • 1
    • 2
    • 3
  • Eric G. Campbell
    • 1
    • 2
  • Manjusha Gokhale
    • 1
    • 2
  • David Blumenthal
    • 1
    • 2
  1. 1.Department of Medicine, Harvard Medical SchoolMassachusetts General Hospital and Partners HealthCare SystemBostonUSA
  2. 2.Institute for Health PolicyMassachusetts General Hospital and Partners HealthCare SystemBostonUSA
  3. 3.Department of Health Care PolicyHarvard Medical SchoolUSA

Personalised recommendations