Associate Professor and IHSS Fellow
Getting a place to study medicine is tough, especially if you come from a less privileged background. New research shows how disadvantages persist, even once you make it to medical school. Understanding this issue is key to creating a fairer system for doctors in training and building a health service that reflects the community it serves.
“There’s increasing statistical evidence that there is this thing called ‘social stratification’ in the medical profession,” says Dr Louise Ashley, an Associate Professor at the School of Business and Management. “We’re starting to see that doctors from less advantaged backgrounds are more likely to train in areas that are potentially less competitive and possibly less prestigious as well.”
Dr Ashley is a sociologist who studies access to elite professions for people from less advantaged backgrounds. She has been working with the Social Mobility Foundation and NHS England to examine this issue in medicine.
She continues: “Although there's support available for non-traditional applicants in terms of getting into medical school, this doesn’t always extend throughout medical school, or as new entrants progress in their careers as doctors.”
Dr Ashley says the hierarchy in medicine is complicated, but generally, hospital work can be seen as more prestigious than general practice, and surgery more prestigious than medical specialisms. Clinical academics – doctors who also conduct research – are also perceived as relatively high status.
To understand the issue of social stratification better, Dr Ashley interviewed 30 medical students across several UK medical schools, who were all the first in their family to attend university and came from homes with low income. She spoke to 16 of them again four years later, by which time many were working as trainee doctors.
She asked them about their experiences of medical school, what barriers they encountered, and what support might help. Her findings have now been published in a paper in Social Science & Medicine called ‘When the Penny Drops: Understanding how social class influences speciality careers in the UK medical profession’.
Dr Ashley explains what the students told her: “One of the attractive features of medicine is they think it's largely meritocratic; that’s what they've been told by teachers or by people in the profession. They think if they do well in exams, then their background, gender or ethnicity will become unimportant. So, they focus on academic performance and not so much on what you might think of as extracurricular activities.”
“But what they realise over time is that getting on in medicine requires much more than just academic performance. Around the third year, when they're involved in clinical placements, they discover what we call the ‘hidden curriculum’. That can be things like doing research, getting additional qualifications and being involved in internships that differentiate you from your peers.”
Students from less advantaged backgrounds often realise this later than some of their more privileged peers, at which point they are already behind. They may struggle to catch up since they do not have family and friends in the profession who can help them access these extra learning opportunities.
“Doctors from less advantaged backgrounds may start a little bit further behind, and those disadvantages can accumulate, so it just becomes more and more difficult to catch up with their peers.”
Dr Ashley goes on: “Some of the students said that initially, they had aspirations towards extremely competitive specialisms. But as they moved through education, they gradually adjusted those aspirations to meet the barriers and obstacles they faced.” These barriers included difficulty finding internships and research placements without a network, but they often came down to money.
“Money is so important because medical training is long and often doctors from less advantaged backgrounds need to do part-time work. This can undermine academic performance, but it also leaves less of the emotional bandwidth that you need to compete for those prestigious specialties.”
Dr Ashley believes that addressing this inequality will ultimately benefits patients because it could improve diversity throughout the health service. “Matching diversity of doctors to patients has been shown to improve patient care,” she explains.
Her new research provides medical schools with some steps towards a fairer system for trainees from less privileged backgrounds, starting by uncovering the hidden curriculum.
“All this tacit information and knowledge that is more available to others, particularly those who've got medical parents and family, needs to be much more transparent at an early stage. Universities must also address the issue of ‘social capital’ because who you know is absolutely critical for internships and research opportunities. These opportunities should be formally advertised, and internships should be paid, which is standard in many other industries.”
In the longer term, Dr Ashley says that medicine needs to cease being a “gentlemanly profession” that “assumes you have the finances to support yourself through a very long training programme”.
She adds: “I think we need to consider very carefully how medical students are supported and funded to train for what is a really important and difficult job.”