COMMENTARY

Med Ed Racism Discussions Must Include Classism

Abdikarin Abdullahi

Disclosures

April 20, 2021

I honestly thought the hardest part about med school was going to be getting in. While applying, I was constantly thinking about the debt my credit card was accumulating. I booked red-eye flights to save on costs while visiting campuses. The MCAT course I asked my parents to buy cost about one eighth of our family's annual salary. If this wasn't the hardest part of the process, what could possibly lay ahead?

When I committed to attending University of California, San Francisco (UCSF) for my medical education, I was convinced that the worst obstacles were behind me. Then I hit a pothole before med school even began. I was connected with some soon-to-be classmates who had similar interests, and we settled on an apartment close to campus. I could almost feel that white coat draped around my shoulders. Then came the rent bill.

I knew that San Francisco is among the most expensive cities to live in the United States, but the requirement to pay first and last month's rent — in addition to a security deposit — stunned me. I was counting on a very generous need-based financial aid package to survive. That money would not be disbursed until the academic quarter actually started. Other classmates mentioned dipping into "gap-year savings" or borrowing money from their families. Those weren't realistic options for me.

Before I attended a single day of medical school, the thought You don't belong here started to make its way into my mind. Lucky for me, I called the director of admissions at UCSF and was able to sort out my situation. Still, the feeling that this system isn't made for "people like me" has lingered.

Abdikarin Abdullahi

My experience is not unique. It reflects a medical education process that systematically excludes low-income students, many of whom also happen to be students of color. The Association of American Medical Colleges (AAMC) reports that 75% of medical students come from families in the top two quintiles of family income, with 24%-33% coming from the top 5%. Notably, only 5% of students are from the lowest household-income quintile. These percentages have been stagnant for more than three decades.

These statistics show that economic privilege remains a serious gatekeeper at the entry point of medical education. Many low-income students decide not to apply altogether, based on both the costs of application and the lack of opportunities that accompany low socioeconomic status. Because students of color are much more likely to be from low-income communities, we cannot have conversations about structural racism, diversity, and inclusion within medicine while ignoring the classism that continues to dictate who is allowed to become a doctor.

Conversations in medicine have been changing. As a Black medical student, I feel encouraged by discussions about systemic racism that were previously taboo. We are finally beginning to acknowledge that practicing clinical medicine walled off from the reality of our patients' lived experiences borders on malpractice.

Still, all of this will continue to ring hollow if we cannot address the issues within our own halls. Multiple Black women, including Aysha Khoury, MD, and Princess Dennar, MD, have been removed from faculty positions for what they suspect are discriminatory reasons. A recent JAMA podcast and tweet declared that no physician is racist, and that because racism is illegal, we should shift away from focusing on discussing it.

Clearly, the way our own institutions contribute to and perpetuate structural inequality must be part of the ongoing conversation. Because racism and classism go together hand in glove, medical schools must implement strategies that seek to address the exclusion of low-income students. Here are some first steps that can be taken.

Minimizing Application-Related Expenses

The AAMC fee-assistance program provides low-income students with financial support during their application process, but this support is clearly not enough. Institutions should adopt practices that seek to minimize application-related expenses for students across the board. This includes sending secondary applications only to students who are seriously being considered for an acceptance, providing financial support to cover the cost of interview travel, and continuing to offer the option for virtual interviews, even after the pandemic.

Reconsidering 'Objective' Measures of Academic Success

Calls advocating for de-emphasizing standardized exams are often met by a reluctance to remove "objective" measures used to compare applicants. If we have any intention of making the medical profession accessible for all, we must finally widely acknowledge that the MCAT is not truly a standardized measure. Literature has thoroughly explained how significantly socioeconomic status influences performance on standardized exams. Although medical schools cannot directly change the circumstances under which students take the MCAT, a true commitment to holistic admissions is necessary.

Moving forward, MCAT averages should not serve as a proxy for a medical school's prestige. Rankings such as US News & World Report's encourage institutions to reduce applicants to a three-digit number. This does not create a culture in which holistic admissions is attainable. We need "holistic" to be more than an ambiguous term. We need to see actions that fall in line with that policy, and that starts with de-emphasizing the MCAT.

Alternative Routes to Matriculation

Post-baccalaureate linkage programs provide students with an opportunity to garner an acceptance to medical school without an unblemished academic record. These programs can serve as effective ways to diversify medical school cohorts. This will allow students who decided on a career in medicine later than others a second opportunity to become physicians. It would also help students who have faced academic difficulties in their transition to college.

Investing in Communities

Medical institutions cannot single-handedly fix income inequality. The advantages of wealthy medical school applicants are mirrored in many other domains, including undergraduate education. However, this does not mean that we cannot play a role in increasing the representation of low-income students and students of color.

Underrepresented minority (URM) students, residents, and faculty often engage in pipeline work that seeks to provide mentorship and support to students who otherwise would be excluded from our profession. This work is often undervalued and unpaid. My organization, Bridging Admissions, is a free mentorship program that has launched the Hope Fellowship. This is intended to help URM and first-generation students with the cost of applying to medical school. Although we're excited to provide this support, true accessibility requires larger systemic changes and an investment on the part of medical schools.

If medical schools want to tackle the issues of racial and economic diversity in medicine, they will have to allocate considerable institutional resources toward this cause. That includes supporting URM students and faculty in the work they are already doing and directing institutional efforts toward engaging high-school and undergraduate students.

The medical profession has taken important recent steps toward disavowing racism and proclaiming an investment in the health of marginalized communities, but we cannot simultaneously declare our support for these communities while systematically excluding them by ignoring aspects related to income. We can no longer exist inside an ivory tower; if we are charged with healing these communities, we need to be a part of them and allow them to be a part of us too.

Abdi Abdullahi is a third-year medical student at the University of California, San Francisco, who will be taking a gap year to pursue a master of public health degree. He is interested in the intersection between health inequities and health policy, medical education, and social justice. He is looking forward to dedicating his future career to mentorship and working with underserved communities.

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