Abstract
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 maldistributed 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 of residents completing their training in eight specialties at 162 US academic 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 program. Among the valid sample of 4,019, the response rate was 65%.) The percentage of residents ranking public hospitals, rural areas, and poor inner-city areas as desirable employment locations and the percentage feeling prepared to provide specified services associated with indigent populations were ascertained. Logistic regressions were used to calculate adjusted percentages, controlling for sex, race/ethnicity, international medical graduate (IMG) status, plans to subspecialize, ownership of hospital, specialty, and exposure to underserved patients during residency. Only one third of residents rated public hospitals as desirable settings, although there were large variations by specialty. Desirability was not associated with having trained in a public hospital or having greater exposure to underserved populations. Only about one quarter of respondents ranked rural (26%) or poor inner-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 who were more likely to rate poor inner-city settings as desirable included women (28%, P =.03), noncitizen IMGs (35%, P =.01), and especially underrepresented 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 immunodeficiency syndrome (HIV/AIDS) or substance abuse patients (all 67%). Women were more likely than men to feel prepared to counsel patients about domestic violence (70% vs. 63%, P =.002) and depression (83% vs. 75%, P <.01). Underrepresented minority residents were more likely than other residents to feel prepared to counsel patients about domestic violence (P <.01) and compliance with care (P =.04). Residents with greater exposure to underserved groups were more prepared to counsel patients about domestic violence (P =.01), substance abuse (P =.01), and to treat patients with HIV/AIDS (P =.01) or with substance abuse problems (P <.01). This study demonstrates the need to expose graduate trainees to underserved populations and suggests a continuing role of minorities, women, and noncitizen physicians in caring for low-income populations.