PEDIATRICS Vol. 106 No. 5 November 2000, pp. 1022-1027

Care to Underserved Children: Residents' Attitudes and Experiences

Carol Cohen Weitzman, MD^*, Kimberly Freudigman, PhD, David J. Schonfeld, MD^*, and John M. Leventhal, MD^*

From the ^* Department of Pediatrics and the Child Study Center, Yale University School of Medicine; and  Yale University School of Medicine, New Haven, Connecticut.

	ABSTRACT

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Objectives.  To examine: 1) the relationship between residents' responses toward caring for underserved children and families during residency and their perceptions of their continuity clinic experience; and 2) which characteristics are related to continuing to care for the underserved after completion of training.

Design.  Cross-sectional descriptive study.

Methods.  A 49-item questionnaire was mailed to 210 third-year pediatric residents at 12 urban training programs in the Northeast in May 1995. Information was collected about residents' emotional responses toward caring for underserved families, their assessments of clinic operations, their sense of effectiveness in caring for underserved patients in continuity clinic, preresidency experiences with the underserved, and their intent to care for the underserved after training.

Results.  Of 210 surveys mailed, 71% were returned. Thirty-six percent of residents planned to pursue a career in primary care, 53% did not, and 11% did not answer or were planning a year as chief resident. Fifty-seven percent of all residents planned to devote a portion of their practice toward caring for the underserved after training.Residents whose emotional responses toward caring for the underserved included: 1) not worrying that they had become numb to children's psychosocial difficulties, 2) not feeling angry with how families cared for their children, and 3) feeling more empathy with the underserved had significantly higher mean scores on both their assessment of clinic operations and their sense of effectiveness. The only demographic characteristic associated with a greater sense of effectiveness was being black. To better characterize which residents planned to care for the underserved after training, we examined a subsample of 46 residents who recalled an interest in caring for the underserved during residency training and who were pursuing a career in primary care. Residents that did not recall an interest in caring for the underserved at the onset of residency training were unlikely to have plans to care for the underserved after the completion of training. Within this group residents who planned to care for the underserved after training differed significantly from residents who did not plan to continue this work by feeling a greater sense of effectiveness in clinic, feeling less worried about becoming numb, and having greater empathy for underserved families.

Conclusions.  There are a number of identifiable emotional responses residents develop toward caring for the underserved that relate to their perceptions of continuity clinic and whether a resident chooses to continue to care for the underserved after training.  Key words:  underserved, resident training.

Nearly 21% of American children in the United States live below the federal poverty level at any given time, and 5% of all children live in poverty for 10 years or longer.¹ These children have particular health care needs related to a variety of reasons, such as race, geography, and lack of access to care. Children living in poverty suffer from increased morbidity and mortality, including higher rates of infant mortality, prematurity, and traumatic death.² In addition, these children and their families often confront complex psychosocial issues, such as violence, substance abuse, and family instability.^1-4

Clearly, such children require a stable medical home to address these complex needs. Despite a prediction by the Council on Graduate Medical Education of an overall physician surplus in the future, there has not been a significant movement of physicians into medically underserved areas. In fact, of all physicians, approximately one quarter to one third do not provide service to the poor.⁵ A number of strategies have been implemented to direct a greater number of physicians into both rural and urban medically underserved areas with varying degrees of success.⁶ These strategies have included interventions to shape medical student admissions and curriculum to develop primary care track training programs within internal medicine and pediatrics and to encourage residents to care for the underserved through incentive programs, such as the National Health Service Corps, which uses both scholarship and loan repayment programs.^6-8

Few efforts, however, have focused on modifying the training of residents in traditional track programs so that these residents would seek careers in providing care to the underserved. A recent survey of pediatric program directors revealed that although 61% of programs cared for the underserved, these programs had no current curriculum for caring for this population, but all program directors endorsed the establishment of such a curriculum.⁹

Academic pediatric groups have recognized the importance of improving care for the underserved, and in 1990, the Ambulatory Pediatric Association sponsored a conference to focus attention on the education of pediatric residents providing health care to underserved children.^3,10 Subsequent to this conference, a curriculum to educate pediatric residents on the many facets of caring for the underserved has been developed.⁹

Despite the interest in caring for underserved children, little information is available about residents' attitudes toward or experiences in caring for underserved children. The purpose of this study, therefore, was twofold. First, we aimed to understand how residents who cared for underserved children and families in primary care settings assessed this experience. We hypothesized that residents who had positive responses toward caring for the underserved would feel more effective in their work in clinic and would perceive their continuity clinic experience more positively. Second, we were interested in understanding which residents planned to continue to care for the underserved after training and which factors may be associated with this decision.

	METHODS

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Sample

The sample for the study consisted of third-year pediatric residents from 14 academic medical centers in the Northeast. Because this study focused on residents' experiences with urban underserved children and families, programs with at least 10 residents per training year in the Northeast, situated in areas with a population >100 000, were invited to participate. One program declined to participate, while another program, despite initial interest in participating, returned no questionnaires. The final sample consisted of 210 residents from 12 pediatric training programs in New York, Pennsylvania, Connecticut, and Massachusetts. This study did not ascertain why residents chose these particular programs and how this may have related to a resident's inclination to care for the underserved. The size of the programs ranged from 11 to 31 residents in their third year of training. Residents were guaranteed confidentiality, and thus no results will be presented for individual programs or subjects. This study was approved by the institutional review board of Yale University School of Medicine.

Procedures

This study was a cross-sectional, descriptive one that used a survey questionnaire administered anonymously to pediatric residents. In May 1995, pediatric chief residents at the above-described programs distributed questionnaires to third-year residents. A cover letter to residents explained that the purpose of the study was to learn about their primary care training experiences and their work with underserved children and families. Residents were ensured confidentiality by not recording individual names, and they were instructed to place their completed surveys in a provided envelope and seal it before returning it to their chief resident. Confidentiality was deemed a priority in this study because some questions were judged to be sensitive in content. A second mailing was performed 1 month after the first to residents who had not responded to the initial survey.

Survey

Based on information obtained during pilot interviews with a previous cohort of third-year residents at Yale-New Haven Hospital, we developed a questionnaire that contained 49 items and focused on the following 5 domains: 1) Baseline Characteristics of the residents, including, age, gender, and ethnicity; 2) Assessment of Continuity Clinic Operations (Operations), including questions about patient diversity, time allotted to patient care, number of patients seen per session, and feelings of frustration about how the clinic operates; 3) Sense of Personal Effectiveness (Effectiveness) in caring for patients within primary care settings. Questions were asked about their sense of futility in clinic, how well they knew their patients and were able to establish realistic goals, whether they believed that patients followed their advice, and comfort in managing complex psychosocial problems; 4) Responses Toward Caring for Underserved Families (Responses), including feelings of anger, numbness to psychosocial difficulties of families, empathy toward underserved families, and overinvolvement; and 5) Preresidency Experiences With the Underserved, such as whether a resident had clinical or nonclinical experiences with the underserved before or during medical school.

The majority of questions consisted of pairs of counterbalanced statements, with negatively worded statements on the left and positively worded statements on the right. Residents were instructed to select a response that represented their usual point of view from a 4-point Likert scale. We chose a 4-point scale so residents would not be able to select a neutral response. A sample of this question type is shown in Fig 1. A copy of the questionnaire is available from the first author.

View larger version (11K): [in this window] [in a new window]   Fig. 1.   Sample questions.

Analysis

Three domains on the questionnaire (Operations, Effectiveness, and Preresidency Experiences) were scored by summing the results of multiple individual questions into a single domain. Questions were grouped by likely domains, and internal consistency was tested by Cronbach's . We accepted an -coefficient of at least .70, indicating a high level of internal consistency, to group questions into a single domain. Other questions within the various topics that had a low level of internal consistency or single questions on the survey that measured a particular concept were analyzed individually. For questions that were analyzed individually, scores were dichotomized in the following way: if a resident answered with a 1 or a 2 response, this was considered a negative response, whereas a 3 or a 4 was considered a positive response.

Statistical analyses were performed using commercial software (SAS Institute, Cary, NC and SPSS, Chicago, IL). Bivariate analyses were performed using ² for dichotomous variables, and McNemar's test was used for paired variables, such as those examining a change in attitudes over time. Student's t tests and analysis of variance (ANOVA) were used for continuous variables. To determine which variables were significantly different from each other when performing ANOVA, posthoc multiple comparison analyses with Tukey's correction were performed.

	RESULTS

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Of the 210 surveys mailed, 141 (71%) were returned, with a range of 33% to 100% for individual programs. The mean age of residents was 30 years (range: 26-49); 34% of respondents were female. In terms of the ethnicity of respondents, 67% identified themselves as white, 18% Asian or Asian-American, 7% black, 3% Hispanic, and 5% as other or no identification of ethnicity.

The primary site of residents' continuity clinics was identified as a traditional hospital-based clinic for 90% of residents, a community health center for 7%, and a private practice or other for 3%. Chief residents had been asked to estimate the patient characteristics of the hospital-based continuity clinic by insurance status. Although it is recognized that this is not necessarily an accurate depiction of payer status, all programs identified primary care training sites that consisted of a majority of underserved patients.

When asked about their intent to pursue a career in primary care, 36% indicated that they were going into primary care, and 53% were not; 11% of residents did not respond to this question or indicated that they were pursuing chief residency after completion of training.

Residents' Assessment of Operations and Effectiveness

To determine how residents assessed their experiences in the outpatient clinic, we examined 2 domains (Operations and Effectiveness). Both of these domains are the sum scores of 7 questions (Tables 1 and 2). As noted in Table 1, although 72% of residents reported a positive primary care experience, at least 60% also reported that their outpatient experience detracted from their overall experience of residency training and that the clinic was more frustrating than other sites and was poorly run. When reporting about their effectiveness (Table 2), residents reported that 82% of their patients follow their advice, and 77% of residents believe that they know their patients well. More than 40% of residents, however, reported feeling ineffective, not feeling comfortable with helping families with psychosocial difficulties, an inability to be helpful to families because of their psychosocial difficulties, and a sense of futility in the work that they performed in clinic. Residents had a mean score (± standard deviation) of 17 (± 4.7) for Operations (range: 8-27) and a mean score of 19 (± 3.8) for Effectiveness (range: 8-25). The higher the score, the more positive the response.

In addition, although 75% of residents believed that they were well-trained to work with the underserved, 70% of residents expressed a desire to have greater opportunity to discuss personally upsetting or overwhelming cases.

Residents' Responses Toward Working With Underserved Families

Table 3 lists residents' emotional responses toward caring for the underserved. Most residents felt more empathic with underserved families since beginning training but also felt angry with the care families provided to their children. Nearly one half worried about becoming numb to psychosocial circumstances of children and were personally upset when families did not follow their advice.

Residents' Experiences With the Underserved Before Residency

This domain is the sum score to the responses of 4 questions. Most residents had experience with caring for the underserved in medical school (84%), expressed an interest in caring for the underserved in medical school (84%), and had formed opinions about the underserved before beginning medical school (64%). Most residents (84%) recalled having an interest as a medical student in caring for the underserved during residency training.

Relationships Between Residents' Responses Toward the Underserved and Effectiveness and Operations

To examine the first hypothesis that was concerned with the relationship between residents' responses toward caring for the underserved and their overall assessment of continuity clinic, we compared positive or negative responses to responses toward working with underserved families with mean scores for effectiveness and operations.

We found (Table 4) that those residents who did not worry that they had become numb to children's psychosocial difficulties, did not feel angry with how families cared for their children, and did not feel less empathic with the underserved had significantly higher mean scores on both effectiveness and operations. Higher mean scores indicate a more positive response.

When we examined residents' demographic characteristics, there were significantly different mean scores on effectiveness and operations by ethnicity but not by gender or age (Table 5). Posthoc analysis of 1-way ANOVA revealed a significant difference in mean scores in effectiveness and operations, with blacks having significantly higher mean scores than whites in both domains.

Residents' Intent to Care for the Underserved After Completion of Training

To test our second hypothesis, we examined which residents planned to continue to care for the underserved after completion of residency training. Fifty-seven percent of residents planned to devote a portion of their practice toward caring for the underserved after residency. We examined the relationship between past interest in and current plans for caring for the underserved. Of the 118 residents who recalled an interest in working with the underserved during their residency training, 39 (33%) no longer expressed current plans. Of the 22 residents who did not recall having this interest, only 2 (9%) now expressed current plans to care for the underserved after training (McNemar's test, P < .001.) These results indicates a strong relationship between recalled positive or negative interest in caring for the underserved as a resident and a current intent to care for the underserved after training.

To understand better those factors that may influence the practice decisions of those entering primary care, we narrowed the initial group of 118 residents who recalled an interest in caring for the underserved as a resident to include only those who stated that they were pursuing a career in primary care after the completion of residency training. Of this remaining group (n = 46), there were significant differences between those who planned to continue to care for the underserved (n = 32) and those who did not (n = 14). Those residents who planned to continue to care for the underserved had higher mean scores on their sense of effectiveness in continuity clinic ( = 20.9 vs 97; P = .000), less worry about becoming numb to children's psychosocial difficulties, and greater empathy with underserved families since beginning residency. There was no relationship with residents' assessment of clinic operations.

	DISCUSSION

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With the enormous number of children and families living in poverty in this country, it is critical to develop residency training sites that promote physicians' continued interest in caring for this population at the completion of their training. It is also crucial that current training sites develop models of primary care for the underserved that empower residents to value and excel at this type of general pediatric care. Such an emphasis is of particular importance, because 75% of all academic health centers care for sizable proportions of underserved families.¹¹ The task, however, of asking novice residents to grasp the unique and difficult aspects of caring for an at-risk population while they struggle to master the basics of primary care and manage many responsibilities elsewhere in the hospital is a difficult one.

Residents' Responses

We found that residents who did not report feeling numb to psychosocial difficulties, anger toward families care of their children, and less empathy for underserved families also felt more effective in their work in continuity clinic and greater satisfaction in the way the clinic functioned. It is hard to interpret the complexities of feelings that a resident may experience in response to patient encounters because many factors shape how a resident forms various attitudes and responses. In our study it was striking to note how many residents expressed negative responses toward caring for underserved families. One cannot assume that having negative feelings, such as anger or feeling personally upset, implies a dislike of the work or even a desire not to engage in it. Because 70% of residents, however, desired a greater opportunity to discuss personally upsetting or overwhelming cases, one can guess that these feelings may be confusing and difficult for residents themselves to understand. We do not know from our questionnaire why residents do not currently perceive that they have adequate opportunity to discuss these types of cases. This would be worth exploring in future work to learn what factors, such as time, learning climate, attending interest, etc, may be important.

There was a significant relationship between feeling numb to children's psychosocial circumstances, feeling anger with the care families provide to their children, and less empathy toward underserved families and a resident having a more negative perception of both the operations of the clinic and their own sense of effectiveness. These findings suggest that while some residents can integrate negative feelings into a useful and adaptive perspective, for many residents these overwhelming feelings may influence how they ultimately perceive their own performance and the climate of their learning environment. Although this study cannot ascribe causal relationships, residents who seemed dissatisfied with their outpatient experience may also have strong negative feelings toward working with underserved families and feel ineffective in the job that they are doing. Such feelings may need to be explored more closely with a preceptor who is knowledgeable about caring for underserved families. Our results provide an important reminder that trainees need to be taught general pediatrics in the cultural context of the population that they serve and with an awareness and sensitivity to the unique needs of that population.

The ethnicity of residents affected their views of the operations of the clinic and their sense of personal effectiveness. Compared with whites, blacks were more positive about both. These results in our study examining ethnic differences are limited because of small sample size and should be interpreted with caution. Similar findings, however, have been reported in other studies examining medical students. For example, Tippets and Westpheling¹² recently administered a survey to fourth-year medical students examining attitudes toward practice in medically underserved areas and intent to serve this population. Of all medical students, women, minority students, and students with a preference for primary care specialties were significantly more likely to plan to work with the underserved. In studies that have examined the relationship between practicing physicians' race or ethnic group and the characteristics of the patients who they served, blacks and Hispanics cared for significantly more patients of their own ethnic groups than did other physicians. Minority physicians also cared for a higher proportion of impoverished patients or established practices in urban underserved areas.^5,13,14 Our findings and those of others demonstrate the importance of recruiting and training minority physicians who are more likely to go on to continue caring for the underserved after training. Unlike Tippets and Westpheling,¹² we did not demonstrate a significant gender difference.

Caring for the Underserved After Training

It was encouraging that >50% of residents planned to devote a portion of their practice toward caring for the underserved after the completion of residency training. A significant limitation of this study was that it did not explore the multitude of reasons that may have influenced a resident's decision to care for the underserved, such as financial obligations.

We found, however, a strong relationship between residents' recalled interests on entering residency and their current plans. If residents did not recall an interest in the underserved at the onset of training, it was very unlikely that they developed this interest during their residency. Of the residents who had expressed this interest, however, 33% no longer did at the completion of training. This finding implies that training does not often motivate physicians to care for the underserved, and, if anything, training may act as a deterrent. We recognize the potential for recall bias that may distort residents' recollections of their past feelings and the accuracy of these recollections. It is interesting to note, however, that an insignificant number of residents indicated that residency training kindled their desire to care for the underserved.

This finding also indicates that many attitudes are shaped long before residency training begins. Crandall et al¹⁵ have found that senior male medical students are less favorably inclined toward caring for the underserved than first-year male students. For these reasons any significant interventions and curriculum about caring for the underserved must begin early during medical school.

Three additional characteristics were identified that distinguished those who continued to express interest in caring for the underserved at the end of residency from those who did not: feeling effective in caring for the underserved in outpatient clinical settings, not feeling worried about being numb to children's psychosocial circumstances, and having greater empathy for the underserved since the beginning of training. Again, although our study cannot ascribe causation to these relationships, these findings may help to identify those residents who are at risk of losing interest in caring for the underserved because they feel ineffective or disillusioned, and these findings may be informative in developing targeted strategies to prevent this from happening. Over the course of training, as residents make the transition from student to physician, many transformations take place. An important task of attending physicians is to guide residents not only by educating them about medical practice, but also by supporting their shift from idealism to the more realistic and pragmatic practice of medicine.

Limitations

There are several limitations to this study, some of which have been discussed throughout the discussion. We do not know the characteristics of residents who did not respond to the questionnaire; therefore, we cannot conclude that there is not a selection bias in the returned questionnaires. The motivation and cooperation of the chief resident seemed to be the single most important factor in whether the questionnaires were returned. However, with such a high return rate, presumably a range of views is represented. The views of large programs, especially those with higher return rates, may be overrepresented.

It is important to note that residents' future plans reported in this study in terms of the percentage of residents planning to pursue careers in primary care do not reflect current national practice patterns. We did not verify the accuracy of residents' responses. It is unclear whether these results might be different if this study had been conducted with a sample of residents in which a higher percentage of students were pursuing primary care. Because this study was a cross-sectional survey of third-year residents near the end of training, only a limited view of their experiences was examined. Only through a prospective, longitudinal study will it become clearer how residents form and modify attitudes toward the underserved over time.

	CONCLUSION

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There are relationships between residents' responses toward caring for the underserved and their perceptions of their own performance, assessment of their work environment, and their decisions to care for this population after training is completed. Increased attention needs to be focused on understanding these responses, how and when they develop, and how they truly influence career decisions or practice habits. Only through such efforts can improved models of training be developed that specifically address the challenges and rewards of providing health care to underserved children.

	ACKNOWLEDGMENTS

This work was supported in part by Training Grant MCJ-00987 in behavioral pediatrics from the Bureau of Maternal and Child Health.

We gratefully acknowledge all the residents who took the time to answer this questionnaire.

We also thank Ann Gottwals for her help in the preparation of this manuscript.

	FOOTNOTES

Received for publication Jan 29, 1999; accepted Mar 17, 2000.

Reprint requests to (C.C.W.) Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06520-8064. E-mail: carol.weitzman{at}yale.edu

	ABBREVIATIONS

ANOVA, analysis of variance.

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