MANAGED CARE: Med Students Learn Dislike From Teachers
Most medical students don't like managed care, "primarily because their teachers don't like it," according to a survey in today's issue of the New England Journal of Medicine. The researchers found that "students and residents are getting their negative opinions about managed care from their teachers." The Boston Herald reports that 74% of those surveyed said primary care faculty gave them a negative opinion of managed care and 96% said specialty faculty "gave them a negative impression" (Lasalandra, 3/25). Of 2,162 students, residents and faculty members surveyed in 1997, including deans and department heads, most "reported negative attitudes toward managed care," with students and faculty rating fee-for-service superior to managed care, especially in areas of access (80.2%), ethical conflicts (74.8%) and doctor-patient relationships (70.6%). Managed care ranked the highest -- although it still fell far behind respondents' preference for fee-for-service -- in the areas of continuity of care, with 29.3% of respondents preferring managed care, and in care for the chronically ill, with 30.8% preferring managed care. On a 0 to 10 scale, with 0 being the most negative, respondents' opinions about managed care ranged from 3.9 for residents to a high of 5.0 for deans. Dr. Steven Simon and his colleagues at Harvard Medical School found that overall, 57.1% of all respondents said that "a single-payer system with universal coverage was the best health care system for the most people for a fixed amount of money." Simon concludes that the negative attitudes regarding managed care, the lack of medical education devoted to managed care -- 75.4% of deans reported their medical schools offered courses in managed care, but only 65.8% require students to take some courses -- and the effects of managed care cited by the respondents "may indicate a more fundamental concern about managed care itself." Indeed, Simon suggests that the deficiencies may reflect "even frank opposition to managed care among faculty members," and recommended that steps be taken to address the issues (Simon et al., New England Journal of Medicine, 3/25 issue).
Writing in an accompanying editorial, Dr. Robert Michels of Cornell University Medical College says that while Simon and his colleagues attribute the respondents' resistance to managed care "to the rigid conservatism of the medical culture, to nostalgia, to inertia and to simple venality," he proposes another explanation. "The alternative view is that medical education is working well and that it is doing so by underlining the urgent need to change managed care," he says. Faculty displeasure with managed care indicates to Michels that the faculty is teaching the "core values of the medical profession." Their concerns, he argues, reflect the belief that their core values are being threatened, and he says educators should defend the profession's values rather than "subordinat[e] them to the current socioeconomic fads of the health care delivery system" (Michels, New England Journal of Medicine, 3/25 issue). Speaking yesterday at the Medical College of Virginia, New England Journal of Medicine Editor-in-Chief Jerome Kassirer said the market pressures of managed care were threatening the "three covenants doctors hold." He said, "I see all of them in jeopardy and in urgent need of repair." However, he said that while managed care makes an easy target, "it has its benefits." He emphasized that physicians are now more aware of cost effectiveness, continuity of care and measuring patient satisfaction. However, he noted that physician "ethics were set some 2,000 years ago, long before a market-driven health care system," and that doctors "must adapt to ensure that patients still receive the attention and treatment they need," while being "vigilant in case ... market-driven forces go too far" (Hostetler, Richmond Times-Dispatch, 3/25).