Recently, several attending physicians sparked controversy on Twitter by implying that low-income medical students or trainees should not pursue careers in medicine. While these tweets have since been deleted, the systemic injustices that they echo still ring in the highest levels of modern medical education.
Even though most of our faculty and colleagues will not explicitly agree with these Twitter posts, their words and actions can certainly normalize these attitudes. While speaking to a hall full of diverse health care students, a prominent hospital chief medical officer once punctuated his lecture in a matter-of-fact manner with, “and of course, none of you have ever been on Medicaid or known anyone personally who used Medicaid.” When he was politely corrected by a student after class, he further defended his statement.
In another example, during our public health classes, our professors would talk at us about poverty as if it were a foreign culture. The social determinants of health and other issues commonly faced by indigent patients were repeatedly framed in a way that insinuated medical students could not possibly know these from personal experience or come from poor families. These microaggressions, far too frequent and often overlooked, led me to question whether some of my professors and seniors wanted students from poor backgrounds like myself to leave the medical community.
In a sense, their assumptions were correct. The vast majority of medical students hail from wealthy backgrounds, and only about five percent of matriculating students come from the bottom quintile in parental income.
As a medical trainee from an impoverished household, I have spent almost my entire post-secondary education and medical training as part of an invisible demographic. I grew up in a low-income immigrant family, but I studied hard and was accepted to college with a need-based scholarship. At my alma mater, I was part of the approximately three percent of students that came from the bottom quintile in parental income.
Like many low-income undergraduate students, I faced hurdles that my wealthier classmates could bypass with money. As a premed, when I was strongly encouraged to participate in research instead of a regular part-time job to strengthen my medical school application, I participated in a competitive summer research program. Grants were intended to supplement, not replace, parental support; they did not fully cover my basic costs of living. With dining halls closed for the summer, and unable to afford food, I lost 20 pounds in two weeks before I became savvy at locating events with free food. For people like me, preparing for medical school did not just mean choosing between application-strengthening activities and leisure, but choosing between those and basic necessities.
The systemic barriers for low-income students are only further amplified when attempting to access medical education and training. At the root of the matter is monetary cost: MCAT registration, test prep, medical school application fees, and (pre-COVID-19 pandemic) transportation and lodging to in-person interviews are all expensive. With limited financial resources, many medical students and trainees from similar backgrounds report restrictions in terms of how many applications we can submit or application cycles we can participate in, which then decreases our odds of ultimately getting accepted to medical school. Sadly, we cycle through a similarly expensive application process for residency. Without the family savings to pay for tuition and these extra expenses, even with a scholarship and federal loans, I resorted to borrowing additional private loans, which are difficult to qualify for without credit-worthy co-signers.
But once we are actually in residency and earning a full-time salary, the socioeconomic divide should start to shrink, right? Not exactly. As low-income individuals, we are more likely to have poverty-stricken family members, who we also support financially, along with mounting student loan debt. This means residency programs that underpay trainees compared to cost-of-living disproportionately hurt residents from low-income backgrounds, who are more likely to be first-generation and/or Black, Indigenous, and people of color. In turn, this may impede diversity at these types of programs and, aggregated over many programs, may widen the academic gap between our careers and those of our wealthier, equally-qualified peers because we must choose between training quality and financial reality.
Nonetheless, we exist, we belong and we persevere. Despite the extra challenges, we still meet or exceed the same high academic and professional standards as our more privileged peers in medicine. Five percent may be low, but that is 1 in 20, and you probably know more than 20 medical students or residents.
Like racial diversity, socioeconomic diversity in the profession is important because it brings new viewpoints and insights into medicine. We are not just aware of the obstacles faced by our most vulnerable patients — we may have lived through them ourselves.
Many of us have experienced homelessness, food insecurity and other forms of scarcity. My medical school’s administrative offices had a food pantry for students in need. We have had to navigate social safety nets, like Temporary Assistance for Needy Families (TANF) and Supplemental Nutritional Assistance Program (SNAP), on our own. We have made the same hard decisions that many of our patients make when deciding which basic need to skimp on in order to afford something else just as vital.
As medical students from poor backgrounds, we have had the special privilege of providing care for our patients while simultaneously being unable to afford adequate health care for ourselves or our families. During my first year of medical school, before the expansion of Medicaid, one of my parents needed a time-sensitive and relatively complex operation. However, it was inaccessible because my parents were uninsured and the procedure was technically considered an elective surgery. Locked out of the U.S. medical system, my parents traveled abroad to a low-income country to obtain the operation, where the procedure was more affordable but riskier. After the passage of the Affordable Care Act (ACA), we eventually crawled our way through bureaucratic messes, administrative loopholes, and games of telephone for weeks to months to obtain the expanded Medicaid coverage our families were legally promised.
Because of our shared hardships, clinicians from low-income backgrounds may find it easier to empathize with vulnerable patients, and patients may build more trust and rapport with doctors from similar backgrounds, leading to better patient care. In addition, we may be better poised to notice problems and reform the health care system from our lived experience.
The demeaning tweets and comments first described are only the tip of the iceberg of an entire system that structurally disadvantages low-income students in medicine at every turn. But the reality is that we need to increase socioeconomic diversity in medicine, address the fundamental problem of cost, and change the cultural narrative so that doctors from poor backgrounds are an accepted part of the medical community. Our experiences with socioeconomic hardship and adversity make us empathetic and resilient doctors. Doctors and doctors-in-training from low-income backgrounds are essential to the medical community. The question is not whether low-income trainees belong in medicine, but whether modern medicine is ready to embrace us.