Understanding the relationship between market competition and students' ratings of the managed care content of their undergraduate medical education

Purpose. The increase in managed care has led to questions about the inadeq uacy of instruction undergraduate medical students receive in curricular ar eas related to managed care. This study examined (1) the percentages of gra duating medical students who felt they had received inadequate instruction in six curricular content areas (CCAs): primary care, care of ambulatory pa tients, health promotion and disease prevention, medical care cost control, teamwork with other health professionals, and cost-effective medical pract ice; and (2) whether the market competitiveness of these students' medical schools affected their reports of inadequacy of instruction in these CCAs. Method. Data from the Association of American Medical Colleges' Graduation Questionnaires (GQs) from 1994 to 1997 were analyzed. The GR asked graduati ng students to rate the adequacy of instruction they had received in the si x CCAs. Students' ratings were collapsed into the dichotomous variables "in adequate" and "not inadequate." The market competitiveness of medical schoo ls was determined using the four-stage Market Evolution Model developed by the University HealthSystem Consortium. Only responses from students gradua ting from medical schools that could be staged for all four years of the st udy were analyzed. Statistical analyses were performed to determine trends for each CCA by year, across the entire study period, by market stage, and by market stage across the entire study period. Results. A total of 39,136 respondents from 86 medical schools were used in the study. The percentages of graduating medical students who reported ina dequate instruction decreased over the study period for five of the six CCA s: primary care (27.6% in 1994 to 13.7% in 1997), ambulatory care (37.4% to 23.9%), medical care cost control (62.9% to 52.9%) cost-effectiveness of m edical practice (62.7% to 53.9%), and health promotion and disease preventi on (44.4% to 23.7%); all at P < .001. The responses for inadequacy of instr uction for teamwork with other health professionals remained steady from 19 94 to 1996 (10.2% to 10.6%), then increased 21.8% in 1997. Over the course of the study, students graduating from schools in more competitive markets (Stage 3 or Stage 4) were more likely to report inadequate instruction in t hree CCAs, primary care, ambulatory care, and health promotion and disease prevention, than were those graduating from schools in less competitive mar kets (Stage 1 and Stage 2). Conversely, students graduating from schools in the more competitive health care markets were less likely to report inadeq uate instruction in cost-effectiveness and cost control than were students from schools in less competitive markets. Conclusion. Graduating students' reports of inadequacy of instruction decre ased over the study period for five of the six CCAs, increasing only for te amwork with other professionals. Findings were mixed with regard to the rel ationship of medical schools' market competitiveness and graduating student s' reports of inadequacy of instruction, More research is needed to confirm graduating students' perceptions of the inadequacy of their instruction in CCAs related to managed care, particularly once they have gained experienc e treating patients in managed care environments.