"Any doctors here who really 'started from the bottom?'" a medical student asked on Reddit. The poster explained that they hadn't encountered many medical students or doctors who actually come from less-privileged backgrounds, leading them to believe medicine is "an exclusive club for those who have the money and support." At every step along the way of my seven years of medical training, I have been struck by the economic homogeneity of my classmates and colleagues. The vast majority of medical trainees I have encountered come from families with six-figure incomes. Many actually come from two-physician households. Personally, I may not have made it this far, had my family not removed various financial obstacles in my path. The circumstances of one's birth have no bearing on qualities that a quality physician should possess, things like diligence, compassion, and curiosity. However, because the American medical system includes high financial barriers to entry, the wealth of a student's family can exclude her from a career in medicine. Now that I am a member of this community, I am concerned that medicine's gatekeepers are not doing enough. Too few opportunities are provided to students from less wealthy backgrounds. Privilege, it seems, has become a prerequisite for a medical career in America. Medicine and the Aristocracy A quick glance at the evidence shows the scope of the problem. The median combined annual income of an incoming American medical student's parents was $130,000 last year, up from $125,000 the year prior. This places those families squarely in the top 20% of earners nationwide. Only 5% of incoming medical students came from families in the lowest quintile of America's income distribution. This is not a new phenomenon. Over the last decade, those from the third quintile or below have never accounted for more than a quarter of first-year medical students. Part of the reason why American medical schools preferentially attract the rich may have to do with the increasing difficulty of actually getting into medical school. In the 2018 application cycle, only 41% of students who applied actually ended up matriculating. With such slim odds, students have been engaging in an escalating arms race, creating ever more sophisticated applications to improve their odds. This process requires years of stellar grades, high scores on the Medical College Admission Test (MCAT), and participation in a plethora of extracurricular activities. This often necessitates substantial financial investments that students from less wealthy families are often unable to afford. The process of simply applying to an American medical school is enormously expensive, costing as much as $5000-$10,000. Having applied to a number of medical schools, I can attest to this. Not only are applications expensive, most schools require an in-person interview for admission. All of this is before students agree to spend enormous sums on tuition and forego four years of pay in order to become a physician. Combined, these conditions strongly favor students from privileged backgrounds. The Perils of Privilege-based Opportunity Not only does this system seem inherently unjust, it threatens to undermine the American healthcare system. Modern medicine is built around the sanctity of the relationship between patients and their doctors. This patient-provider relationship is imbalanced. During my medical training, I have found that patients are reliant on the judgement and expertise of their treating physicians to navigate an unfamiliar system. The relationship between patient and doctor is marked by an asymmetric distribution of knowledge and power. Overcoming this requires a high degree of sustained trust. The wide gulf between the economic backgrounds of physicians and their patients increases the odds of a disconnect between the parties. Wealthy physicians may struggle to fully grasp the hardships experienced by patients with low incomes; they may then fail to understand the factors that play into "compliance" with their instructions. They may be unable to relate to patients who struggle with costly drug regimens or miss appointments because they cannot take time off from work. I have already seen this many times during my training. What's dangerous is that this lack of understanding can become disdain. Studies have shown that physicians are already less likely to view patients of lower socioeconomic status as intelligent, responsible, and compliant with medical care. Perhaps as a result, physicians minimize communication with such patients, refer them to specialty providers less frequently, and provide them with lower quality care. This dynamic threatens to erode the confidence patients place in their doctors. Patients with low levels of trust in their providers are less likely to be satisfied with their care and follow their providers' advice. Without a crop of physicians that are more economically representative of the country at-large, these problems are likely to persist. In fact, they may very well get worse. Medicine at a Crossroads Given the fundamental structural factors that are driving wealthy students to become physicians, restoring variety in the economic backgrounds of incoming medical students will be challenging. However, American medical schools can do some things to help. An increasing number of schools have begun offering free tuition in an attempt to help students from lower income backgrounds to attend. Medical schools should also strongly consider expanding the use of application fee waivers and video interviews to reduce the overall costs of applications. In the longer term, American medical schools need to do a far better job recruiting students from less privileged backgrounds. Many promising low-income students who initially consider a career in medicine do not go on to apply to medical school years later. Getting more of these students to apply would expand the applicant pool, thus giving institutions more opportunity to economically diversify their classes. Increasing the number of medical school seats in tandem would augment these efforts. American medicine is at a crossroads. If we, as a profession, are to retain the trust of the public in an era of increasing suspicion of establishment and institutional power, we must more closely reflect the patient populations we treat. Basically, future physicians must be more socioeconomically diverse. Source
