September 20, 2021

Becoming a Doctor: Inequities in Medical Training

Author photoBy 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?

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