Study finds medical students disproportionately come from affluent backgrounds

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A new study conducted by medical school students and faculty at the University of Minnesota found that medical students of all racial backgrounds disproportionately come from affluent backgrounds. The study raises questions about the importance of socioeconomic diversity and the potential impact on health care.

Arman Shahriar, a fourth-year medical student and lead researcher for the study, said their findings could have implications for how patients relate to doctors, where doctors chose to practice based on income potential, and which topics doctors choose to research, among other issues. The study is the first of its kind to examine the interplay of race and income among medical school students.

Closing the gap for medical students of color from low-income households would lead to a more responsive health care system, Shahriar said. Four years of medical school costs an average of $250,000 at a public institution and $330,000 at a private institution, according to the Association of American Medical Colleges. The same organization lists median debt for medical students at $200,000. 

“That’s for a ton of different reasons, from individual patient experiences in being able to relate to a doctor all the way up to medical research agendas,” he said.

The study, which was published in the Journal of the American Medical Association Network Open earlier this month, may explain why medical schools have been slow to diversify their student bodies over the past several years, Shahriar added.

“There are only so many high-income underrepresented racial and ethnic students that can come into medical school,” he said. 

The study took three years’ of data from the Association of American Medical Colleges on medical students from across the country and compared it to general population data from the U.S. Census. It looked specifically at student’s parental household income levels in four major racial categories: Black, white, Latino, and Asian.

“High-income students who identify themselves as Black and Hispanic are overrepresented to the same degree, if not a little bit more, than their white and Asian colleagues,” Shahriar said. 

The study found that Black students were 5.3 times more likely to come from affluent backgrounds, defined by the study as annual household income at $270,000 or higher, compared to the general Black population. Latino students were 6.6 times more likely to come from affluence. For white students, that number was 4.8; and for Asian students, it was 2.3.

Across all racial groups, students from homes that ranked in the nation’s top 5 percent of annual household income — again, equaling $270,000 or higher — were disproportionately represented when compared to the overall households in that income bracket.  

The study found that 29 percent of white students came from a home in the nation’s top 5 percent of household income. By comparison, 5 percent of the country’s overall white population fall in that income bracket.

Similarly, 22 percent of Asian students came from the upper 5 percent, compared to 10 percent of the overall Asian population.

For Black students, 9 percent came from the top 5 percent, compared to 2 percent of the overall Black population.

Fifteen percent of Latino students came from those top-earning homes while 2 percent of overall Latino households fall into that income range.

Seven students and faculty members worked for six months to complete the study. The lead author, Shahriar, grew up in Minneapolis and Edina and is planning to become an internal medicine doctor. Sahan Journal recently spoke to Shahriar over the phone about the study’s implications, and where medical schools should go from here to increase socioeconomic diversity:

SJ: Why did you decide to undertake this project? 

I think most of the ideas just stem from conversations between myself and a number of my classmates who are also co-authors on this paper, just realizing that money, finance, and socioeconomics are generally things that aren’t talked about in med school. We found it pretty alarming that the socioeconomic composition of medical students hadn’t really been described in detail.

The Association of American Medical Colleges in the past put out aggregate reports showing that high-income students are overrepresented in medical schools, but didn’t look at it any further beyond that. We took it a step further. Most of the literature looking at workforce diversity and medical school diversity had been focused on visible forms of identity like race, ethnicity, and gender.

A lot of the papers and big name journals look at diversity of the workforce, diversity of medical students. But you have to really pry to find words related to money. Socioeconomics and finances are often mentioned in a paragraph in a discussion, but not as the primary focus.

Why is it important to include money and income as a factor?

To be clear, racial and ethnic diversity is extremely important and I’m not trying to downplay the work that’s been done to date. Diversity in general is important because patients generally prefer to be seen by physicians with whom they share some form of identity or lived experience. Patients also tend to do better when they’re seen by physicians that are like them in some way. 

Socioeconomic diversity is unique from racial and ethnic diversity. Lived experiences of folks who grow up without resources and poverty are markedly different from those who grow up in well-resourced settings. 

You found that affluent people make up a greater share of medical students than in the general population.

High-income students are overrepresented in medical school. The interesting thing we found: We looked at four major ethnic and racial groups, and it was true in each of those as well. Black and Hispanic students are underrepresented overall in medical schools, and that’s a big program. But high income students who identify themselves as Black and Hispanic are overrepresented to the same degree, if not a little bit more than their white and Asian colleagues.

Low-income students unsurprisingly are underrepresented across the board. 

How do you interpret these results?

In the last 20 years there’s been a lot of focus in medicine on increasing racial and ethnic diversity in the medical student body. But there’s been a lack of progress. The socioeconomic disparities could be one really reasonable explanation for this. There are only so many high-income underrepresented racial and ethnic students that can come into medical school.

Eventually, we need to start thinking about targeting low-income communities that are disproportionately Black and disproportionately Hispanic to increase racial and ethnic diversity in medical schools.

How do these socioeconomic gaps impact what gets taught at medical schools, what students learn, and ultimately what specialties doctors pursue?

Overall, we’d have a better health care system if our physicians mirrored our population. And that’s for a ton of different reasons: from individual patient experiences in being able to relate to a doctor all the way up to medical research agendas, the populations that physicians want to care for, [the number of] physicians willing to work at county hospitals and in areas where they might not make as much money. 

There’s a lot of ancillary purchases and costs associated with medical education that don’t necessarily get accounted for in the aggregate statistics when people are looking at the cost of attendance. Nowadays students do a lot of studying using third-party resources that are pretty expensive.

I’ll give you an example. We take a lot of exams, and exams are high stakes and everybody wants to do well. There’s a company called UWorld. They produce high-quality question banks for students to study. These are questions similar to the ones that are on board exams. They’re just really expensive. There’s no buying lifetime access; you get subscriptions. A 90-day subscription costs $400. It’s the little stuff like that.

Then it’s things like when you have clinical rotations, you need a car to get around. No one really talks about that until it happens. It’s just a different situation for a student who has access to money, whether it be from family or friends, versus a student who doesn’t.

So you offer recommendations as to how medical school admissions should think about socioeconomic status from applicants?

There are some standard metrics that medical schools can actually use through their application server to quantify socioeconomic status. We’re not sure if every school is using those.

For example, application servers can analyze an applicant’s parents’ education level and occupation. We’d recommend every school use these tools.

The University of Minnesota does a good job of allowing secondary essays where students can write about their lived experience. We recommend this, too, but fixing the admissions process is only a temporary solution.

What are some potential big-picture solutions to close this socioeconomic gap? 

Medical schools are going to need to get invested in communities, in low-income schools, get kids inspired and keep them inspired. This gets more at larger social problems, which are inherently tied to medicine. 

What was your socioeconomic background coming into medical school?

I come from an upper-middle class household, but that’s not true for a lot of my friends and especially some of the other co-authors of this project. But I’ve had some experiences in my life that taught me the importance of socioeconomic diversity. 

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