COMMENTARY

Is Privilege the Real Prerequisite for Med School?

Kunal Sindhu, MD

Disclosures

October 23, 2019

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.

Kunal Sindhu, MD is a resident physician in New York City and frequently writes about medical education. The opinions expressed in this perspective are his own.

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