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PubMed1988

Career plans and debt levels of graduating U.S. medical students, 1981-1986.

Trends in students' responses to the annual graduation questionnaire of the Association of American Medical Colleges from 1981 to 1986 were examined. Since 1981 the percentage of students choosing primary care specialties dropped from 43.6 percent to 36.6 percent. The decline of interest in primary care specialties occurred mainly in general internal medicine. Changes in career activity since 1981 reflected increasing interest by the students in full-time academic appointments and decreasing interest in solo, private practices. Changes in the size of a city in which students planned to practice reflected an increasing interest in large cities or suburbs. The students' preferences for certain geographic regions of the country for practice locations changed very little. Finally, total postsecondary educational debt increased from an average of +19,697 in 1981 to an average of +33,499 in 1986. This difference represents a 70 percent increase as measured by 1987 dollars and a 37 percent increase in constant dollars.

Career Choice↗
PubMed1996

Effect of debt on U.S. medical school graduates' preferences for family medicine, general internal medicine, and general pediatrics.

The authors assess the importance of educational debt in graduates' primary care specialty choices, and the variety of mechanisms through which debt may influence career decisions. Logistic regression models were used to identify significant predictors of the primary care specialty choices made by the 1991 and 1992 graduates of U.S. medical schools. These predictors were debt itself; other financial indicators; certain medical school characteristics; certain practice location plans; certain demographic factors; aspects of academic performance; and students' predisposition to a primary care specialty. Data for this study were gathered from a variety of sources at the Association of American Medical Colleges and from the Health Education Assistance Loans program. Both direct and indirect effects of debt were identified under specific conditions. The study revealed complex relationships between debt and the other predictors identified. For example, debt operated in relation to the levels of the graduates' expected incomes; debt from subsidized loan sources was significant for women who chose general internal medicine; debt was important in choices of family practice; and debt by itself was significant for those planning to practice in the West and who chose general internal medicine. Also, seemingly opposing effects of debt occurred. For example, in the family practice model used in this study, the threshold effect of debt was positive, while the linear effect of debt above the threshold was negative. Such vriations help explain the conflicting findings of some past research. These and other findings prompt the authors to state that when investigating the effects of debt, it is not fruitful to ask what the effect of the debt is on all three primary care fields as a group. It is more appropriate to ask several questions, such as: under what conditions does debt influence specialty plans? Among which groups of students does debt have an impact on specialty plans? Are all of the primary care specialties similarly affected by the issues surrounding debt? Does the effect of debt change over time? The authors conclude by indicating possible policy implications of their findings.

Career Choice↗
PubMed2005

The impact of U.S. medical students' debt on their choice of primary care careers: an analysis of data from the 2002 medical school graduation questionnaire.

PURPOSE: To examine the hypothesis that medical students' rising total educational debt is one of the factors that explains the recent decline in students' interest in family medicine and primary care. METHOD: The authors used results from questions on the Association of American Medical Colleges' 2002 Medical School Graduation Questionnaire that focused on students' debt and career choices. Logistic regression was used to determine the independent association of students' debt with career choices, while controlling for students' demographic characteristics. RESULTS: In 2002, 83.5% of graduating students were in debt, and the average student owed US $86,870. Minority students had higher levels of debt. Students reported that higher levels of debt influenced their future career choices, and there was an inverse relationship between the level of total educational debt and the intention to enter primary care, with the most marked effect noted for students owing more than $150,000 at graduation. Total debt was associated with a lower likelihood of choosing a primary care career, but factors such as gender and race appeared to have more explanatory power. Female students were much more interested in primary care-and especially pediatrics-than were male students; African American students were more interested in inner-city practice than was any other identified racial or ethnic group. CONCLUSION: In 2002, students' debt levels were high and increasing. Although students with higher debt levels were less likely than were their counterparts to pursue a career in primary care, the effect was modest when demographic characteristics were taken into consideration.

Adult↗
PubMed2006

An evaluation of four proposals to reduce the financial burden of medical education.

PURPOSE: To determine the financial impact of four potential solutions to reduce the financial burden of medical education: reducing medical school tuition, decreasing medical school duration, increasing residency compensation, and decreasing residency duration. METHOD: The four proposed remedies were compared to the current medical education system using net present value, a standard financial metric, which calculates financial impact in today's dollars. Medical school tuition and duration, residency stipends and duration, and physician salaries for general internists and internal medicine subspecialists were modeled based on historical data and current requirements. RESULTS: Decreasing medical school duration by one year had the greatest financial benefit for future physicians and ranged from 160,000 US dollars to 230,000 US dollars in today's dollars. Reducing residency duration for medicine subspecialists by one year generated a financial benefit of 170,000 US dollars. Increasing residency compensation to that of a first-year physician assistant resulted in a financial benefit of between 60,000 US dollars and 100,000 US dollars. Reducing medical school tuition by 25% had the smallest financial impact, 30,000 US dollars in today's dollars. CONCLUSIONS: Decreasing the duration of medical education offers the greatest potential for reducing the financial burden of medical education. In many cases, the benefit in current dollars to a prospective physician exceeds 100,000 US dollars. This solution warrants further investigation.

Cost Control↗
PubMedDate not supplied

Prevalence, correlates, and costs of patients with poor adjustment to mixed cancers.

Approximately 2% to 3% of the Canadian society has experienced cancer. Literature indicates that there is poor adjustment to chronic illness. Individuals with poor adjustment to chronic illness have been found to disproportionately use more health services. The purpose of this study was to determine the prevalence, correlates, and costs associated with poor adjustment to mixed cancer. A consecutive sample (n = 171) of breast, lung, and prostate cancer patients at the Nova Scotia Regional Cancer Center were surveyed. Twenty-eight percent of the cancer group showed fair to poor adjustment to illness using the Psychological Adjustment to Illness Self-report Scale Psychological Adjustment to Illness Self-Report Scale raw score. Poor adjustment was moderately correlated with depression (r = 0.50, P < .0001) and evasive coping (r = 0.38, P < .0001) and unrelated to demographic variables. Depression explained 25% of the variance in poor adjustment to illness in regression analysis. Cancer patients with fair to poor adjustment to illness had statistically significantly higher annual healthcare expenditures (P < .002) than those with good adjustment to illness. Expenditure findings agree with previous literature on chronic illnesses. The prevalence of fair to poor adjustment in this cancer population using the Psychological Adjustment to Illness Self-Report Scale measure is similar to that reported for chronic illness to date, suggesting that only those with better adjustment consented to this study.

Adaptation, Psychological↗
PubMed2002

How patients feel about prolonged mechanical ventilation 1 year later.

OBJECTIVES: To elicit mechanical ventilation preferences among patients who previously received prolonged (>/=48 hrs) mechanical ventilation, to identify patient characteristics associated with mechanical ventilation preferences, and to assess the association between the intensive care experience and mechanical ventilation preferences. DESIGN: Prospective cohort study conducted between June of 1997 and July of 2000. SETTING: Four intensive care units at a tertiary care institution. PATIENTS: Former critically ill patients (n = 133; mean age +/- sd, 51.8 +/- 17.1 yrs; 49% women) who survived for 12 months after prolonged mechanical ventilation. MEASUREMENTS: Patients' preferences toward their actual mechanical ventilation experiences, by asking patients to reflect on the decision to apply mechanical ventilation made 1 yr earlier. Preferences for hypothetical situations, by asking patients to evaluate mechanical ventilation choices, assuming that their experiences had been different in terms of pain or discomfort, familial financial burden and stress, and health status after mechanical ventilation. RESULTS: Of the 133 patients, 115 (86.5%) would have chosen mechanical ventilation, with younger and healthier patients having higher odds of choosing mechanical ventilation than older and sicker patients, respectively. One fourth of patients who initially would have chosen mechanical ventilation would have refused this therapy had their families' financial burdens been beyond certain thresholds. A similar proportion would have refused mechanical ventilation with greater mechanical ventilation pain or discomfort. CONCLUSION: Although most subjects would have made the same decision to receive mechanical ventilation, younger and healthier subjects were most likely to favor mechanical ventilation. Many patients indicated that factors such as the amount of pain or discomfort from mechanical ventilation and their families' financial burden would cause them to refuse this potentially life-saving intervention.

Adolescent↗
PubMed2001

The impact of health insurance plan type on satisfaction with health care.

Because many previous studies of satisfaction with health care used unreliable measures, failed to consider all major health care plan choices, or did not include a broad population, this study used a reliability-tested multi-item instrument on individuals in HMO, PPO, and fee-for-service insurance plans who were randomly drawn from a national population. The findings regarding satisfaction were that differences existed among the plan members' satisfaction on the dimensions of access to care, availability of resources, and financial aspects of care.

Analysis of Variance↗
PubMed2002

Professional association membership by nursing facility administrators and quality of care.

This article compares 4,220 nursing homes whose administrators belonged to a long-term-care professional association to 12,322 nursing homes whose administrators did not belong to a long-term-care professional association. The research results show that professional membership is associated with higher quality of care on several measures and with a higher private-pay proportion. The study suggests that these facilities do not do better because they have more resources or because they care for less-challenging residents-they do better because they have a professional association as a resource.

Bed Occupancy↗
PubMed1993

Patient choice and nonionic contrast media.

RATIONALE AND OBJECTIVES: Because of the greatly increased cost of nonionic, low-osmolar contrast material, some practitioners reserve its use for patients at high risk for an adverse contrast reaction. The authors attempt to evaluate the proportion of low-risk outpatients--when offered a choice between the more expensive but lower-risk nonionic and the cheaper but higher-risk conventional ionic contrast material--that would choose the nonionic media. METHODS: Two hundred and fifty consecutive outpatients awaiting contrast-enhanced computed tomography were included in this study. Patients at increased risk for a contrast reaction were excluded. The remaining 162 patients were informed of the risks and told of the availability of nonionic contrast media with its up to six-fold decrease in serious complications. They were also informed that if they chose the lower-risk nonionic agent, they would likely have to pay the additional $100 to $150 in cost. RESULTS: Of the 162 low-risk patients surveyed, 48% selected nonionic contrast media, and 63% believed that all patients should be informed of the risks of contrast material and of the availability of nonionic contrast. CONCLUSIONS: The data support providing patients at low risk for an adverse reaction informed consent about the relative risks of ionic and nonionic contrast material.

Contrast Media↗
PubMed2000

The cost value of medical versus surgical hormonal therapy for metastatic prostate cancer.

PURPOSE: The cost of luteinizing hormone releasing hormone analogue and antiandrogen for prostate cancer is being scrutinized by the Health Care Finance Administration and other insurers. We compared the discounted present value cost of medical hormonal therapy to that of orchiectomy as well as the value created by these treatments from the insurer and patient perspectives. MATERIALS AND METHODS: We performed a telephone survey of 42 patients receiving hormonal therapy to estimate the value created by medical versus surgical castration from the patient perspective. The cost of medical hormonal therapy was discounted back to the present value and compared with the cost of bilateral orchiectomy. RESULTS: The total cost of bilateral orchiectomy was $2,022, while the discounted present value cost using the average wholesale price for 30 months of medical hormonal therapy was $13,620. Therefore, medical hormonal therapy costs $11,598 more than orchiectomy ($13,620 - $2,022). A discounted payment of $386 per month for 30 months is necessary to recoup the $11,598 difference. All surveyed patients on medical hormonal therapy stated that avoiding orchiectomy was worth $386 per month and it was an appropriate insurer expense. If patients paid $386 per month out-of-pocket, 22 of the 42 (52%) would pay the additional monthly expense, while 20 (48%) indicated that they could not afford the additional expense. CONCLUSIONS: These results indicate that medical hormonal therapy costs significantly more than bilateral orchiectomy but creates positive value for men with prostate cancer by enabling them to avoid orchiectomy.

Algorithms↗