Who Gets to Be a Doctor (and what that means for medicine)

I am just about coming to the end of the murky, potholed road that is the medical school application process, and as I limp through these final few steps I think it’s appropriate to look back and think about what kind of process this is, and what it says about medicine as a profession. There are many reasons why someone might find applying to medical school gruelling: it’s long, stressful, and frustratingly non-transparent, with little clear sense of what you’re being evaluated on. Perhaps most troubling though, both for applicants and for medicine, is how deeply inaccessible the entire process is. Leaving aside the fact that to even apply for medical school in the US you need to have completed a Bachelors degree, the application itself involves a number of both formal and informal costs and barriers that can make it extremely difficult for anyone without a host of support systems in place to apply. Those barriers in turn shape who ends up working in medicine, and I think can go a long way towards influencing how medicine and the healthcare system function.

The most obvious of obstacle for someone interested in applying to medical school is the financial cost. The American Association of Medical Colleges, the body that administers the medical school application process, breaks down the main costs of applying to med school into the following:

  • The cost for sitting the Medical College Admissions Test (the standardized test for entry into American, and most Canadian, medical schools): 300 USD
    The cost for submitting the primary application: 160 USD for the first school + 36 USD for each additional school
    The cost of secondary applications, which schools can choose to send applicants upon review of the primary application: 25-100 USD

AMCAS reports that each applicant applies to an average of 15 schools: assuming they get secondary applications from 7 of those, and we use the mean cost of each secondary application, that’s an estimated $1400 just for standard application fees. It’s true that AMCAS does provide financial assistance and some schools waive application fees for those who can prove need, but that is still a staggering amount (and the process of applying for that aid is a feat all its own). That number also doesn’t even begin to touch on informal costs: books, classes and study materials for the MCAT can add up to hundreds of dollars, and travel to and from interviews – which can include flights across the country – all also need to be funded by the applicant. Then there’s the fact that these interviews can take place any day of the week, an inconvenience to some that can be incredibly prohibitive to others with strict work schedules and other responsibilities.

The financial costs, while certainly not trivial, are far from the only barrier that prospective doctors need to face, nor is the one that tips the playing field most in the favour of those with existing advantages and privileges. As with any application process – and perhaps even more than most – applying to medical school is an obscure process of gathering documents, culling through past experiences and achievements, choosing what to emphasize, what to spin, wha to leave out. Even the process of deciding whether or not to apply, one that is laden with doubts about the time spent in school, the cost, and the lifestyle associated with medical careers was immensely supported by being able to talk to people who were at various stages on that path, from med students to residents and practicing physicians. Again, these are resources that not everyone has ready access to, this collection of little hints and conversations that all together go a long way towards getting you on the road to med school in the first place, and once there keep you from falling off it.

You can probably predict what all this means for the diversity of medical school applicants, and successful applicants in particular. A report released by AMCAS in 2008 showed that the percentage of applicants from the highest quintile of income (in 2005 this was families with incomes greater than $91 000) has never been less than 48% since 1987, and more troubling, the percentage has been growing since 2000. Additional reports released in 2010 supported these findings. Medical school applicants were shown to come from highly educated families (about a third of applicants’ mothers had a graduate degree, compared to about 10% of women in the US), and moreover that there were distinct differences by race when it came to applicants’ parental education. Black and Hispanic applicants were much more likely to have parents with no college degree than white or Asian applicants, and the percentage of White applicants with highly educated parents has actually increased in the past decade or so. Finally, SES was also found to be linked with attrition rates after two years in medical school, with lower SES students having higher attrition rates than middle and high SES students (2.1% compared to 1.4% and 1.3% respectively). So not only are fewer students from low-income backgrounds applying and getting into med school, more of those that make it in end up dropping out than their higher income peers.

This of course isn’t a problem specific to medicine: on the contrary, improving accessibility of higher education has probably dominated the inequality conversation in the US more than any other single issue (and indeed some, like Michelle Alexander, have argued that attention to this particular problem has sidelined discussion of other more deeply-rooted and farther-reaching inequalities ). Still, I think there’s particular value in thinking about what it means in the case of medical school, because who ends up being doctors not only has huge impacts for those individuals’ personal opportunities and life courses, but also for what medicine looks like as a field and how it meets the health needs of a population.

As I discussed in a previous post, there is a mountain (mountain ranges, really) of evidence showing that poor health is linked to poverty, and inequalities in health outcomes track with a host of social inequalities, including racial and economic. While it’s true that the fields of medicine and public health are becoming increasingly aware of the need to be attentive to the social determinants of health – larger, social factors (like poverty, housing and food access, employment) that impact health outcomes – and discussion of these issues are being included in more and more medical school curricula, my sense from visiting schools and talking to current students is that these are still seen as niche areas within medicine, specialities in the same way that surgery or cancer treatment might be. Medicine by and large is still very much driven by an individual level biological framework for approaching problems, and as a field hasn’t seemed to fully recognize that a given patient’s entire experience with the healthcare system and with medicine is shaped by these social, economic and cultural factors.

After looking through the data above and going through the medical school application process myself, I can’t help but wonder if this continued inability to recognize the importance of the social framing of medicine is due in some part to the fact that most practicing doctors, and most doctors-to-be, come from a segment of the population for which these concerns simply aren’t really an issue. When most doctors come from families that are on average much more highly educated than the general population, and much richer than the general population, it seems likely that their personal experiences of medicine and healthcare are going to be ones for which the dominant biomedical frameworks make sense. These are not on average going to be people who have had to think about whether they have enough food to take with their antibiotics, or whether their neighborhood is a safe place to go running in. This isn’t to say that people with social and economic privilege can’t be aware of how the healthcare system is unequal, but arriving at a critical mass of people who believe that and are willing to make changes to the field to address that I think involves bringing in voices and experiences that can speak to the myriad ways that medicine looks and is experienced across the country. Again, though, getting doctors who are able to draw on those experiences means getting more applicants from a variety of background through that initial application process. And that means reassessing the barriers that, intentionally or not, are preventing people who might be able to change the field from stepping onto it in the first place.

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