Becoming a Doctor: Inequities in Medical Training

By Karen Sternheimer

The past year has taught us a lot about inequities within health care, from the disparities in COVID-19 infection and death rates to the impact of racial segregation on our health, and the disparities in receiving vaccinations during the early rollout phase.

Disparities also exist among health care workers, even between doctors.

We tend to think about medical professionals as having elite status, but as sociologist Tania M. Jenkins points out in her book Doctor’s Orders, there are status hierarchies most of us aren’t aware of within the medical profession. Who gets to be a highly-paid specialist? Who is on staff at a less-prestigious community hospital? Through ethnography and interviews of medical residents, Jenkins finds that status disparities are rooted in factors such as a doctor’s nationality and their family’s socio-economic status, not necessarily merit or skill as we often believe.

Jenkins’ respondents include graduates of allopathic medical schools in the U.S. who have earned MDs (Doctor of Medicine) and graduates of osteopathic medical schools who have DOs (Doctor of Osteopathy). Both degrees qualify graduates to take licensing exams, although Jenkins details how the MD degree often leads to a more prestigious residency, or post-graduate training program. Likewise, her study includes graduates of non-U.S. medical schools who also experience lower status, despite a shortage of doctors in the U.S. As Jenkins discusses, it is the limited supply of doctors that creates demand for foreign-trained doctors (pp. 11-12).

As Jenkins describes, “The game begins in early childhood, when ideally one becomes involved in projects and activities that are designed to open doors for the future and that offer early exposure to potential areas of interest” (p. 35). She found that the graduates of U.S. allopathic schools, which she calls USMDs, mostly “came from upper-middle-class, white families and had university-educated parents” (p. 38) and were raised in “resource-rich environments” (p. 39). These resources often continued into medical school, as she details how prep courses and extra mentoring are provided, even after a student failed an important exam in one example (p. 46).

The deck is often stacked against lower-income medical school applicants before they even begin college. Jenkins observes that “lack of information and support” impacts opportunities. One respondent who attended a foreign medical school played varsity sports. He describes how his heavy participation kept him from earning straight As, conducting research, or being involved in other extracurricular activities besides sports (p. 52).

Once in college, students who have to work or help with family responsibilities can’t afford to do unpaid summer programs and miss out on valuable resume-building experience. First-generation college students might not know that they are expected to earn more than good grades, but to also gather experience working in labs on campus, volunteering for health-related programs, and shadowing doctors. Test prep courses for the MCAT, the required medical school examination test, might also be out of reach, as they can cost nearly $1,000 (and some cost up to $7,000).

All of these factors might limit the type of medical school an applicant is admitted to, which then often translates to a less-rigorous residency program, and that reduces one’s chances of getting accepted to a specialty fellowship program (such as cardiology, neurology, or oncology, for example). This ultimately places limitations on a doctor’s career trajectory.

Jenkins describes the different trajectories of residents as “status separation,” which she defines “as the informal process by which residents get stratified by pedigree in internal medicine” (p.22). She goes on to detail how “structural advantages (often misidentified as merit) can help ensure elite reproduction” (p. 23).

In other words, this process unfolds in a complex and often hidden manner that makes it appear as though higher-status physicians are simply more deserving and worked harder to earn the prestige that goes along with their position. She notes, “candidates cannot easily distinguish themselves from the status afforded to them by their medical school—regardless of past performance or reputation,” and this means that residency applicants are regarded as “inferior simply by virtue of being affiliated with a lower-status medical school” (p. 116).

The training residents receive varies based on status as well. Jenkins concludes:

…non-USMDs not only had less help playing the game than USMDs but also faced harder rules of the game because of the stigma associated with their pedigree. The former therefore often had to go above and beyond what the latter had to do in order to reach lower-status positions, even after residency. By training in lower-resource environments, non-USMDs, in turn, received poorer training and less supervision than USMDs did. The result was a kind of self-fulfilling prophesy…. (p.258)

Aside from uncovering this mostly unknown process of status separation among doctors, one of the most interesting findings from this study is what residents do after their training. Those who have attended prestigious medical schools and residency training programs might find themselves seeking the most prestigious fellowship programs in exclusive specialties, not necessarily because of a passion for the specialty, but it is one more opportunity to strive for, and a mark of success for their residency program.

Regardless of personal fulfillment—and more importantly, societal need for primary care providers and other underrepresented and perhaps less “prestigious” specialties—Jenkins uncovers how doctor training is rooted in the reproduction of status. How might this reproduction of high status spill over into patient care and access to health care?

Comments

[Handehospital]

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[Auroraa]

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[Bharath orthopaedics]

Good content. thanks for the post.

[vs hospitals]

this article is great article.

[Auroraa Clinic]

this article is useful

[klathiresan]

this article is good

[Root Canal NY]

Health inequity causes preventable deaths. There are many examples of this, but one of the clearest examples is the difference between infant health and mortality among Black and white babies born in the U.S. Black people are more likely than white people to have babies with a low birth weight.

[Hodge]

It's pretty sad to see that there are such inequalities. I think this is one of the reasons why we are seeing a shortage in some countries as mentioned in the article I saw on https://www.mirrorreview.com/shortage-of-nurses-in-the-us/ . I hope that things will improve with time and there will be no more inequality in the field of medicine.

[Macleod Trail Dental]

The article highlights the inequities in medical training, particularly for underrepresented minorities, and the need for systemic change. Aspiring doctors from disadvantaged backgrounds often face significant hurdles, including financial barriers, inadequate mentorship, and biased selection processes. These challenges extend beyond medical school and into specialized fields, such as cosmetic dentistry, where access to training and opportunities may be further limited for minority groups. Addressing these inequities requires a commitment to diversity, equity, and inclusion across all aspects of medical education and practice.

[Brianna Ferreira]

This article is very useful and insightful while it highlights inequities in medical training especially for minority groups.

[Caroline Thurmond]

I found it really interesting to read about the inequities that exist among health care workers. It was enlightening to read about how people who hope to become doctors but are of a lower socioeconomic status are disadvantaged. The article highlights issues that exist in the U.S of a revolving cycle that makes it very difficult for those who are part of a minority group.
Without reading this article, I would not have thought of this inequity that exists.

[Lauren Gull]

I found it fascinating how this blog reveals the hidden hierarchy within the medical field. We often think doctors achieve success through hard work and talent, but this article shows that factors like family background, education, and financial resources play a significant role in shaping a doctor's career. Wealthier students have more opportunities. Those who attend lower-status medical schools often face more challenges and get less support in training. This shows how privilege shapes the medical profession in many ways.

[Summer Bauer]

Really informative article, its really important to bring attention to these types of inequalities because they are not something that everyone pays attention to.

[Marissa]

This was very interesting; it's not often that we think about the inequities health care workers face during their education and training. I love how you brought attention to this topic.

[Emma Mckeon]

I found this post really interesting! It’s surprising how much a doctor’s background and the status can affect their career. It was eye-opening to see how these challenges create a cycle that makes it harder for them to succeed. Not everyone thinks about these types of issues and can sometimes be overlooked. I believe it’s something more people should be aware of, and this blog does an amazing way of expressing these issues and making it clear to understand.

[Allie Sagat]

I found this very enlightening to hear that disparities can be shown amongst healthcare professionals with the same title. Typically, you don't think of disparities between the providers themselves, but rather the patients and community. Now that I think about it, I can see how these disparities can influence where you work and consequently dictate pay and prestige (based on the workplace). In a way, socioeconomic status plays a prominent role in health disparities amongst the providers and patients alike.

[Kate Ferreira]

I found this article to be eye opening in regards to the health care disparities, which were brought more to light after the covid-19 pandemic. I also appreciate the topic of status hierarchies in the medical profession; pointing out that there are minorities amongst doctors, explaining that a doctors career is typically shaped by their family background, and financial status; essentially saying that people with higher socioeconomic status have a better chance at becoming a successful doctor as opposed to someone with lower socioeconomic status.

[Adacelys Nichols]

I found this article to be very informative because I already knew health care disparities existed but not to the extent that the article highlighted. I never put it into perspective that I was able to access things like internships and tests with fees because my surroundings allow me to.

[Sunita Thongdee]

This article truly goes in-depth about the hierarchy and process of becoming a doctor. Being able to view all perspectives of an applicant's background is important since most are unable to access the same resources as others. I believe that having an open mind about the process of becoming a doctor from all economic backgrounds should be brought more into attention.

[Lily Mair]

I found this article interesting and appreciate that it challenges society's initial perception of the hierarchy that occurs within the medical field. At first glance, we often view doctors with a higher title as being more experienced, "smarter", and overall "better", which is why they have that position. However, this article challenges those initial thoughts stating that economic status, family background, financial resources, and education, all influence one's opportunities to advance in the field.

[Erin McLaughlin]

It was really interesting to learn about how there are different “tiers” or “statuses” within the medical field itself. I think it is also really important to recognize and understand that not everybody has access to the same resources, especially when it comes to education, internships, and other experiences that help individuals be successful in the medical field. This blog does a great job at shedding light on an important issue that should be talked about more often.