What Does a Medical Student Look Like? Social Determinants of Medical Education
Adina Kalet, MD, MPH
In this week’s Director’s Corner, Dr. Kalet muses on what it means that not all, but most, medical students come from high-income households and how this may be the cause of unnecessary struggle and suffering ...
*While this is a true story as I experienced it, I have changed my friend’s name and some of the details to respect her privacy.
It was late on a wintery night when the car’s brakes failed. As we rolled down the steep Upper Manhattan hill the driver, my classmate, Laura, pumped the hand break until we came to a stop by gently bumping the rear of the vintage Mercedes Benz paused at the traffic light. “Shit,” she muttered.
Following Laura’s lead, I got out of the car and gingerly approached the older tuxedoed man who had emerged from the driver’s seat and was now carefully inspecting the rear bumper. No harm done. A moment later, a woman emerging from the passenger seat, wrapping her fur coat tightly around her shoulders as she strode over. She looked us up and down, no doubt taking in our matching server uniforms, poorly fitting black skirts, and polyester white button downs, bow ties askew. She then eyed the rusted 10-year-old baby blue Buick from which we had emerged and screeched, “How can you have this piece of junk on the road? You could have killed us...and my husband is a surgeon!?”
It was chilling. To his credit, the man looked chagrined. Using my best communication skills, intending to diffuse the tension, I said softly, “Ma’am, we are sorry for frightening you. We hope no one is hurt. We are medical students on our way home from a catering job.”
The woman’s tirade revved up. She accused me of lying about being medical students and us of being dangerous menaces, among other things. She was rattled and had cell phones been available in the 1980s, no doubt, she would have called the police. The man coaxed his wife back to the car and waved us on.
Luckily, no one asked for Laura’s insurance information because she didn’t have any.
Clearly, we did not fit this wife-of-a-surgeon’s image of medical students. She could not imagine medical students driving run-down jalopies or being employed in the “service industry.” I was perplexed, aggravated, and embarrassed. But Laura was nonplussed. She was used to this sort of dismissive treatment. After all, she was regular catering waitstaff at NYC gala fundraisers. She was used to being invisible to people like this couple.
Laura’s story
In retrospect, I realize Laura grew up poor. Compared to most of us who had taken loans to pay our tuition and were otherwise fully supported by our parents (I lived with my family in a two- bedroom apartment and commuted to school by subway), she needed the car to get to school and her service jobs from her working-class neighborhood on Staten Island. Public transportation was not an affordable nor easily available option. Both Laura and her mom, who had a serious chronic disease, needed to work to pay the family’s basic expenses. Her car was a mess, clearly in need of repairs, and probably dangerous, but it was all she could afford. While a handful of us occasionally joined her on a catering job to make some extra cash, she had no choice but to work nearly full time. To be clear, medical school is a more than full time endeavor and most medical students do not need to hold down jobs.
Laura’s family likely went hungry or were marginally-housed during the time we were in school together. Maybe they were on public assistance. She might have told me if I had asked. But I didn’t. I hope she asked for—and received—help from the office of financial aid. But I am not certain, knowing her, that she would have.
Even in our highly competitive city university program, dedicated to recruiting a diverse class of local students able and committed to becoming inner city primary care physicians, Laura’s level of financial need was rare. Laura had a few friends and was an excellent school project partner, but she rarely showed up for social outings or joined us when we went out for meals. She couldn’t afford the time or money. I never quite figured out when she studied, but she survived academically, repeating a year of school along the way.
I lost touch with her after we graduated. I know she trained as a surgeon, worked in the community from which she came, and had a child. A few years ago, I learned that Laura died young of cancer.
When we all went off to traditional medical schools to finish our training I was, for the first time in my life, introduced to the fact that most medical students came from relatively wealthy families. Naive as it sounds, I was stunned when a new medical school classmate picked me up in his vintage Aston Martin to drive out to his family’s suburban home, replete with private
swimming pool and tennis court for a weekend barbeque, bringing his laundry along to be done by the maid. I felt like Dorothy in Oz, “Toto, we are not in Kansas anymore.”
The COVID-19 pandemic reveals the Social Determinants of Education
Much has already been written about how the pandemic revealed the stark health and economic disparities in our society. It should not surprise anyone that medical schools were also challenged to recognize and be responsive to the needs of students with fewer resources. It became crystal clear that like Social Determinants of Health that create negative consequences for patients, Social Determinants of Education (SDOE) create disparities among learners. There is a myriad of ways that some student’s lives have been shaped by factors such as socioeconomic stress; bias and oppression; food and housing insecurity; poor access to health care; and unsafe neighborhoods. These challenges put otherwise highly motivated ambitious, capable students at a significant educational disadvantage compared with their peers in terms of access to and success in the health professions.
Because society desperately needs a robustly diverse and excellently prepared pool of future health professionals, the 2022 Josiah Macy Jr. Foundation Consensus Conference on COVID-19 and the Impact on Medical and Nursing Education recommended (among many other things) that, “Health Professions Education (HPE) leaders, educators, and learners—together—must examine and eliminate the detrimental effects of the SDOEs on HPE learners and build equitable learning environments for everyone.” But this is often difficult to do because it is traditionally a hidden problem.
Medical students disproportionately come from high-income households
In 2022, data from an AAMC-Medical Student Questionnaire revealed that 50.5% of all Allopathic medical students come from the top quintile of household income, with 24.0% from the top 5% and less than 6% come from the bottom quintile. This overrepresentation of higher income and underrepresentation of low-income groups—consistent across race and ethnicity— is a manifestation of the fact that access to the profession has been persistently out of reach for those from the lowest socioeconomic strata. This is being addressed in many ways. Long-term upstream targeted investments in the student pipeline through community partnerships can get more students like Laura to feel prepared to apply to health professions programs. Medical schools can, and do, assess socioeconomic disadvantage during the admissions process using essays and the parental education and occupation indicator. And grade point average and Medical College Admission Test scores, can be adjusted for socioeconomic disadvantage.
But more needs to be done. To reduce the unequitable circumstances while in medical school, students from low-income households could be monitored for the accumulation of unexpected expenses and provided with what they need to thrive (e.g., food, clothing, computers and internet access, emergency housing) given that they do not have nearly the same level of family support as most of their peers.
The pandemic worsened every social determinant of education and negatively impacted current and future students. Students from poorer families are much more likely than their peers to have experienced the devastating impact of the pandemic, the death of family members and loss of livelihoods, the serious economic deprivation while having fewer resources to recover from these challenges. In addition to providing concrete support and wellness and financial counseling, schools should monitor policies that inadvertently disadvantage some students like required travel and housing for training and fees not included in financial aid packages (aka “hidden tuition”). Medical schools like ours have restructured large classes into smaller learning communities to build better communal resilience both academically and socially and to enhance our opportunity to look out for each other.
For those of us working for transformation of a medical education that is built around a core of character and caring, the pandemic has “catalyzed a strategic inflection point” (Lucey, 2022) where we now have an opportunity to better address the health care needs of both our patients and students. While Laura’s “journey traveled” from poor kid to surgeon is inspiring, her almost invisible struggles to persevere in the face of hardship makes me wish we had been more compassionate and kinder. We could have done better.
For more reading:
Lucey CR, Davis JA, Green MM. We have no choice but to transform: The future of medical education after the COVID-19 pandemic. Acad Med. 2022(suppl 3);97:S71–S81.
Muller D, Hurtado A, Cunningham T, Soriano RP, Palermo AS, Hess L, Willis MS, Linkowski L, Forsyth B, Parkas V. Social Determinants, Risk Factors, and Needs: A New Paradigm for Medical Education. Acad Med. 2022 Mar 1;97(3S):S12-S18. doi: 10.1097/ACM.0000000000004539. PMID: 34817406; PMCID: PMC8855756
Shahriar AA, Puram VV, Miller JM, et al. Socioeconomic Diversity of the Matriculating US Medical Student Body by Race, Ethnicity, and Sex, 2017-2019. JAMA Netw Open. 2022;5(3):e222621. doi:10.1001/jamanetworkopen.2022.2621
Josiah Macy Jr. Foundation Conference on COVID-19 and the Impact on Medical and Nursing Education: Conference Recommendations Report. Acad Med. 2022 Mar 1;97(3S):S3-S11. doi: 10.1097/ACM.0000000000004506. PMID: 34736279.
Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.
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