Residents' preferences and preparation for caring for underserved populations

Access to care by low-income persons and residents of rural and poor inner- city areas is a persistent Problem, yet Physicians tend to be maldistribute d relative to need. The objectives were to describe preferences 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 o f residents completing their training in eight specialties at 162 US academ ic 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 p rogram. Among the valid sample of 4,019, the response rate was 65%.) The pe rcentage of residents ranking public hospitals, rural areas, and poor inner -city areas as desirable employment locations and the Percentage feeling pr epared to provide specified services associated with indigent populations w ere ascertained. Logistic regressions were used to calculate adjusted perce ntages, controlling for sex, race/ethnicity, international medical graduate (IMG) status, plans to subspecialize, ownership of hospital, specialty, an d exposure to underserved patients during residency. Only, one third of res idents rated public hospitals as desirable settings, although there were la rge variations by specialty. Desirability was not associated with having tr ained in a public hospital or having greater exposure to underserved popula tions. Only about one quarter of respondents ranked rural (26%) or poor inn er-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 wh o were more likely to rate poor inner-city settings as desirable included w omen (28%, P=.03), noncitizen IMGS (35%, P=.01), and especially underrepres ented 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 immunodeficie ncy syndrome (HIV/AIDS) or substance abuse patients (all 67%). Women were m ore likely than men to feel prepared to counsel patients about domestic vio lence (70% vs. 63%, P=.002) and depression (83% vs. 75%, P<.01). Underrepre sented minority residents were more likely than other residents to feel pre pared to counsel patients about domestic violence (P<.01) and compliance wi th care (P=.04). Residents with greater exposure to underserved groups were more prepared to counsel patients about domestic violence (P=.01), substan ce abuse (P=.01), and to treat patients with HIV/AIDS (P=.01) or with subst ance abuse problems (P<.01). This study demonstrates the need to expose gra duate trainees to underserved populations and suggests a continuing role of minorities, women, and noncitizen physicians in caring for low-income popu lations.