Shut out: the medical profession’s intractable class problem
BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6433 (Published 14 November 2019) Cite this as: BMJ 2019;367:l6433Head to head
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I read this article with great interest, but feel it is important to ensure buy in from all major stakeholders by emphasising the benefits to the profession and the health service of improving social mobility in medicine. I also feel it necessary to address the gap in applications, not just attendance, to medical schools between students of the highest and lowest income backgrounds.
Evidence suggests that medical students from a lower socio-economic background are more likely to practice in deprived areas (1), and that they are more likely to become GPs (2). Given the current ‘crisis’ in General Practice, and the focus of the government on recruiting more GPs over the next 5-10 years, it would seem in the interests of the government and NHS England to focus on recruitment of students from lower socio-economic groups.
Applications to medical schools from disadvantaged students are significantly lower than from their peers who attended private or grammar schools (3). The reasons for this are likely multi-factorial, but advice from schools, parental expectation and perceived chances of success are believed to be involved. These students need to know that there are options available to them, even if they are not achieving the A* grades usually assumed necessary to attend medical school.
One option could be for universities to organise outreach programmes to schools in their vicinity to show students that attending medical school is attainable for students of any background. As students from disadvantaged backgrounds tend to attend universities near to where their parents live (4), those universities who do this effectively would be likely to see an impact on their own applicants, not just applications nationally. In the long-term, disadvantaged students could be offered bursaries contingent on their involvement in these programmes, as students would be more likely to have hope if they see students from similar backgrounds coming back to talk to them about their experiences. ‘If you can’t see it, you won’t be it!’.
1. Dowell, J et al. “Widening access to medicine may improve general practitioner recruitment in deprived and rural communities: survey of GP origins and current place of work.” BMC Med Educ vol. 15 165. 1 Oct. 2015, doi:10.1186/s12909-015-0445-8
2. Centre for Health Economics. The socioeconomic and demographic characteristics of United Kingdom junior doctors in training across specialties. Dec 2015. www.york.ac.uk/media/che/documents/papers/researchpapers/CHERP_119_junio....
3. Steven, K., Dowell, J., Jackson, C. et al. Fair access to medicine? Retrospective analysis of UK medical schools application data 2009-2012 using three measures of socioeconomic status. BMC Med Educ 16, 11 (2016) doi:10.1186/s12909-016-0536-1
4. The Sutton Trust. Home and Away. Feb 2018. https://www.suttontrust.com/research-paper/home-and-away-student-mobility/
Competing interests: No competing interests
I welcome this feature highlighting the need to tackle the barriers that are preventing individuals from socioeconomically disadvantaged backgrounds entering and flourishing in the medical profession.
Another issue that is not frequently discussed is the opportunity cost of undertaking an intercalated degree during medical school. A previous study [1] indicated that over 50% of medical students who chose not to intercalate identified that increased student debt was a factor. The costs incurred from an additional year at university include tuition fees, living expenses and delayed employment. Naturally, the trade-off between these costs and the benefits of an intercalated degree may disproportionately discourage those from more disadvantaged backgrounds.
The possible consequences of this are two-fold. The first is that those from disadvantaged backgrounds may have reduced exposure to academic research at an early stage in their careers. The second, and more subtle issue, arises from the points-based system for shortlisting and ranking in foundation and specialty training applications which rewards candidates who have an intercalated degree. As such, the aforementioned trade-off could feasibly reduce diversity in academic research and introduce class differences in career progression in highly competitive specialties.
A way to address this may be through centrally funded scholarships that encourage and incentivise enthusiastic medical students from all socioeconomic and demographic backgrounds who wish to pursue a career in research.
References:
[1] Nicholson, J.A., Cleland, J., Lemon, J. et al. Why medical students choose not to carry out an intercalated BSc: a questionnaire study. BMC Med Educ 10, 25 (2010) doi:10.1186/1472-6920-10-25
Competing interests: No competing interests
Dear BMJ,
I really appreciated seeing this piece on the site. I am a third year medical student and am from a working class background, I went into medicine when I was 25. I've thought a lot about these issues raised in the article since starting medical school, being surrounded by peers who have a lot of financial support, or who have certain beliefs that are a result of their privileged position in society. As you say, there is not much diversity in medicine.
Within my first week at medical school, I became very conscious of the differences between my background and the backgrounds of the majority of my colleagues. One of many comments I received was that "those from private schools generally just are more clever than those from state schools" and my accent has often been imitated. At this point where diversity is still lacking and progress in widening access to medicine is slow, I think that it's important to consider the culture that people from lower income backgrounds are faced with once they reach medical school. My personal experience is that this culture is often based upon elitist and cliquey traditions that many doctors and medical students seem very keen to hold onto. The air of superiority is palpable. Traditions include the exclusive medical school parties and societies that receive large amounts of funding compared to other courses, and the lack of accommodation mixing with other university course students. It took me around 7 years to gain work experience and a place at medical school, but the biggest challenge has been acclimatising to a new environment once I got there, where entitlement seems to be one of the most common characteristics of people surrounding me. Key to making people from lower income backgrounds feel welcome is the awareness of the presence of entitlement in medicine and providing support networks and groups for these people to navigate a very foreign class culture. These could also provide space for people to take ownership over their life experiences which often result in important qualities like empathy and resilience.
I hope you might consider this in another BMJ article in the future.
Thanks,
Abi
Competing interests: No competing interests
Re: Shut out: the medical profession’s intractable class problem. How to enable more students to fulfil their potential in medicine.
I was a working-class medical student in the early 1960s. There were several interventions that enabled me to achieve a successful medical career.
In the first place my parents, who had themselves been unable to access further education, were determined that their children were going to benefit from the newly available educational opportunities. They made sacrifices to enable us to do this. My career would have been impossible had it not been for the excellent free education I received and completely free university tuition, including a maintenance grant.
The headmaster at my Secondary Technical School in Lancashire was far-sighted and dedicated. He recognised my potential and encouraged me. He made sure the school timetable could provide for the necessary four science A levels in the sixth form. He suggested that I apply to the Royal Free Hospital School of Medicine. This establishment was of course set up expressly to enable women to enter the medical profession.
My GP encouraged me. He told me that I would encounter prejudice against women, but not to let that deter me. He gave me some textbooks.
When I applied to the Royal Free there was a recent directive for sexual equality so that what had previously been exclusively a women’s college had a quota of 10% men. This was the reverse of the situation in most other colleges. I do not know whether there were any other specific entry criteria at that time for diversity. There were certainly many among my peers who were from non fee paying schools and who had parents who were not in the medical profession. There were also several students from other countries and other ethnic backgrounds. There was a nun. There were some mature students. We were all allocated a personal tutor who did take an interest in our welfare.
Later in my career I benefitted from mentors who gave me sound advice. One consultant in particular supported me to apply for the so-called married women’s retainer scheme. This enabled me to take maternity leave and return to a part time role to continue my postgraduate training. In my turn I have also tried to be a role model and a mentor to my colleagues.
In today’s world free tuition is not available and I am sure this is a major disincentive to many students. Providing bursaries, or removing tuition fees would make it possible for many more students to fulfil their potential in medicine. The importance of encouragement and advice from experienced mentors at every stage cannot be stressed enough. All members of the profession can contribute to this. Diversity legislation is also important, as without this it is easy for good intentions to fall by the wayside.
It is up to all of us to remember how we got to where we are and to help others to follow on.
Janet Thomas
Competing interests: No competing interests