Medical schools, affirmative action, and the neglected role of social class

The maintenance of classism in medical education: "time" as a form of social capital in first-generation and low-income medical students

As first generation (FG)/low income (LI) students enter the elite profession of medicine, schools make presumptions about how FGLI students allocate their time. However, their lives are markedly different compared to their peers. This study argues that while all forms of capital are necessary for success, time as a specific form keeps classism in place. Using constructivist grounded theory techniques, we interviewed 48 FGLI students to understand where, why and how they allocated their time, and the perceived impact it had on them. Using open coding and constant comparison, we developed an understanding of FGLI students' relationship to time and then contextualized it within larger conversations on how time is conceptualized in a capitalist system that demands time efficiency, and the activities where time is needed in medical school. When students discussed time, they invoked the concept of 'time famine;' having too much to do and not enough time. In attempting to meet medicine's expectations, they conceptualized time as something that was 'spent' or 'given/taken' as they traversed different marketplaces, using their time as a form of currency to make up for the social capital expected of them. This study shows that because medical education was designed around the social elite, a strata of individuals who have generational resources, time is a critical aspect separating FGLI students from their peers. This study undergirds the idea that time is a hidden organizational framework that helps to maintain classism, thus positioning FGLI students at a disadvantage.

A systematic review of barriers to pursuing careers in medicine among Black premedical students

Among the various etiologies of the exclusion of Black male physicians from the healthcare workforce, it is critical to identify and examine the barriers in their trajectory. Given that most medical school matriculants graduate and pursue residency training, medical school admission has been identified as the primary impediment to a career in medicine. Thus, this work aims to identify barriers in the journey of primarily Black, and secondarily underrepresented minority, premedical students. A systematic review of the medical literature was conducted for articles pertaining to the undergraduate/premedical period, Black experiences, and the medical school application process. The search yielded 5336 results, and 13 articles were included. Most papers corroborated common barriers, such as financial/socioeconomic burdens, lack of access to preparatory materials and academic enrichment programs, lack of exposure to the medical field, poor mentorship/advising experiences, systemic and interpersonal racism, and limited support systems. Common facilitators of interest and interventions included increasing academic enrichment programs, improving mentorship and career guidance quality and availability, and improving access to and availability of resources as well as exposure opportunities. No article explicitly discussed addressing racism. There is a dearth of studies exploring the premedical stage-the penultimate point of entry into medicine. Though interest in becoming a physician may be present, multiple and disparate impediments restrict Black men's participation in medicine. Addressing the barriers Black and underrepresented minority premedical students face requires an awareness of how multiple systems work together to discriminate and restrict access to careers in medicine beyond the traditional pipeline understanding.

Into the Unknown: Experiences of Social Newcomers Entering Medical Education

PURPOSE

Amid efforts to diversify the medical profession, research has yet to fully explore the role of early social ties to the field. This study examined diversity through the experiences of students without early ties to medicine through family members working in health care (i.e., "newcomers") in comparison with more-connected peers (i.e., "insiders"), examining how social newcomers to medicine negotiate challenges stemming from their outsider status.

METHOD

The author conducted an exploratory qualitative study from 2018 to 2021 using a constructivist grounded theory approach. Following a voluntary preliminary survey of 2 cohorts of first-year medical students about their social connections in health care, the author conducted interviews over the next 2 years with students who had indicated their willingness to participate. Interviews addressed how social context shaped-and continued to influence-their journeys into medicine. Eighty second- and third-year students participated in 94 interviews, including some follow-up interviews for longitudinal insight into outsider status. Interviews from the second year (58 new, 14 follow-up) provided the foundation of the qualitative results.

RESULTS

Students experienced outsider status primarily on the basis of being newcomers to medicine, often compounded by intersectional characteristics, including first-generation college status, rural or low-income background, race or ethnicity, and nontraditional status. For some, an early shortage of social capital became internalized, continuing to influence confidence and belonging well into training, in line with social reproduction theory. However, newcomers also experienced benefits associated with diverse backgrounds which helped them find a sense of belonging in medicine, as suggested by community cultural wealth and antideficit perspectives.

CONCLUSIONS

Newcomer status proved to be a central cause of outsiderness for students from all backgrounds and warrants greater attention from stakeholders, perhaps mirroring the undergraduate focus on first-generation college-goers. Findings suggest institutions that provide robust networking and community-building opportunities are best positioned to support newcomers.

Region of birth differences in healthcare navigation and optimisation: the interplay of racial discrimination and socioeconomic position

Background

While a large body of research has documented socioeconomic and migrant inequities in the effective use of healthcare services, the reasons underlying such inequities are yet to be fully understood. This study assesses the interplay between racial discrimination and socioeconomic position, as conceptualised by Bourdieu, and their contributions to healthcare navigation and optimisation.

Methods

Using a cross-sectional survey in Luxembourg we collected data from individuals with wide-ranging migration and socioeconomic profiles. We fitted sequential multiple linear and logistic regressions to investigate the relationships between healthcare service navigation and optimisation with perceived racial discrimination and socioeconomic position measured by economic, cultural and social capital. We also investigated whether the ownership of these capitals moderates the experience of racial discrimination in healthcare settings.

Results

We observed important disparities in healthcare navigation among different migrant communities. These differences were explained by accounting for the experience of racial discrimination. Racial discrimination was also negatively related with the extent of healthcare services optimisation. However, the impact of discrimination on both health service navigation and optimisation was reduced after accounting for social capital. Higher volumes of economic and social capital were associated with better healthcare experience, and with a lower probability of perceived racial discrimination.

Conclusions

Racial discrimination plays a substantial role in accounting for inequality in healthcare service navigation by different migrant groups. This study highlights the need to consider the complex interplay between different forms of economic, cultural and social capital and racial discrimination when examining migrant, and racial/ethnic differences in healthcare. Healthcare inequalities arising from socioeconomic position and racism need to be addressed via multilevel policies and interventions that simultaneously tackle structural, interpersonal, and institutional dimensions of racism.

Affirmative action programmes in postgraduate medical and surgical training-A narrative review

OBJECTIVE

This review aims to identify and summarise the literature pertaining to the implementation of affirmative action programmes (AAP) for selection of ethnic minorities and Indigenous peoples into selective specialist medical and surgical training programmes.

METHODS

A systematic literature search was conducted to identify relevant studies reporting on the background, implementation and results of AAP for ethnic minorities and Indigenous peoples into medical and surgical training. MEDLINE, EMBASE, PubMed, Scopus and Google Scholar databases were queried from inception through to 1 February 2020. All included studies were subjected to inductive thematic analysis in order to systematically collate study findings. Articles were read through several times in an iterative manner to allow the identification of themes across the included studies. The themes were cross-compared among the authors to establish their interconnectedness.

RESULTS

Forty-five articles described AAP pertaining to ethnic minorities in the United States of America (African-Americans and Hispanic Americans), women and ethnic minorities, Indigenous peoples (New Zealand Māori) and people with low socio-economic status. Four themes were identified. These included the need for social responsiveness in clinical training organisations, justification and criticism of AAP, how clinical training agencies should participate in AAP and what constitutes an effective AAP for specialist medical and surgical training.

CONCLUSIONS

Affirmative action programmes have been effective at increasing numbers of ethnic minority medical school graduates but have not been used for specialist medical or surgical training selection. AAP achieve the best results when they are associated with a comprehensive programme of candidate preparation, support and mentorship beginning prior to application, and support and mentorship extending through training and subsequently into the post-training period as an independent professional. The overall aim of any AAP in medical or surgical training must be graduation of significant numbers of minority and Indigenous trainees into successful practice with appointment to faculty member and leadership positions.

Medical conspiracy theories: cognitive science and implications for ethics

Although recent trends in politics and media make it appear that conspiracy theories are on the rise, in fact they have always been present, probably because they are sustained by natural dispositions of the human brain. This is also the case with medical conspiracy theories. This article reviews some of the most notorious health-related conspiracy theories. It then approaches the reasons why people believe these theories, using concepts from cognitive science. On the basis of that knowledge, the article makes normative proposals for public health officials and health workers as a whole, to deal with conspiracy theories, in order to preserve some of the fundamental principles of medical ethics.

Financial burden and financial aid for medical students in Singapore: a national survey across all three medical schools

INTRODUCTION

Singapore has had three medical schools since 2013. We undertook a cross-sectional quantitative national survey to determine the financial impact of medical education on medical students in Singapore.

METHODS

All 1,829 medical students in Singapore were invited to participate in this study. Information on demographics, financial aid utilisation and outside work was collected and analysed.

RESULTS

1,241 (67.9%) of 1,829 students participated in the survey. While the overall proportion of students from households with monthly incomes < SGD 3,000 was only 21.2% compared to the national figure of 31.4%, 85.4% of medical students expected to graduate with debts > SGD 75,000. There were significant differences in per capita incomes among the schools, with 54.5%, 23.3% and 7.8% of Duke-NUS Medical School (Duke-NUS), NUS Yong Loo Lin School of Medicine (NUS Medicine) and Lee Kong Chian School of Medicine (LKCMedicine) students, respectively, reporting a per capita income of < SGD 1,000 (p < 0.001). There were significant differences in financial support: 75.0%, 34.1% and 38.8% of Duke-NUS, NUS Medicine and LKCMedicine students received financial aid, respectively (p < 0.001). The top reasons for not applying for aid included a troublesome application process (21.4%) and the perception that it would be too difficult to obtain (21.0%).

CONCLUSION

Students in the three medical schools in Singapore differ in their financial needs and levels of financial support received. A national approach to funding medical education may be needed to ensure that financial burdens do not hamper the optimal training of doctors for Singapore's future.

An ethnography of chronic pain management in primary care: The social organization of physicians' work in the midst of the opioid crisis

BACKGROUND

This study reports on physicians' experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities.

METHODS

Our team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings.

FINDINGS

In their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse.

INTERPRETATION

Our findings show that care providers find the treatment of patients with chronic pain-especially those patients also experiencing poverty-to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients' social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision.

The History and Horizons of Microscale Neural Interfaces

Microscale neural technologies interface with the nervous system to record and stimulate brain tissue with high spatial and temporal resolution. These devices are being developed to understand the mechanisms that govern brain function, plasticity and cognitive learning, treat neurological diseases, or monitor and restore functions over the lifetime of the patient. Despite decades of use in basic research over days to months, and the growing prevalence of neuromodulation therapies, in many cases the lack of knowledge regarding the fundamental mechanisms driving activation has dramatically limited our ability to interpret data or fine-tune design parameters to improve long-term performance. While advances in materials, microfabrication techniques, packaging, and understanding of the nervous system has enabled tremendous innovation in the field of neural engineering, many challenges and opportunities remain at the frontiers of the neural interface in terms of both neurobiology and engineering. In this short-communication, we explore critical needs in the neural engineering field to overcome these challenges. Disentangling the complexities involved in the chronic neural interface problem requires simultaneous proficiency in multiple scientific and engineering disciplines. The critical component of advancing neural interface knowledge is to prepare the next wave of investigators who have simultaneous multi-disciplinary proficiencies with a diverse set of perspectives necessary to solve the chronic neural interface challenge.

Widening participation in medicine: what, why and how?

This article was migrated. The article was marked as recommended. Widening Participation (WP) is 'the process of encouraging underrepresented socioeconomic groups to apply for Higher Education'. This is particularly relevant to medicine, where representation of lower socioeconomic groups is generally poor. Reducing this divide is necessary as socioeconomic diversity enhances social mobility and is likely to improve patient outcomes. This review aims to explore the background to WP, including relevant political theory and also highlights the key methods currently used by medical schools to promote WP. These include pre-application measures (outreach and access to medicine courses), application interventions (contextual data, multiple-mini interviews and situational judgement tests) and post-application measures (foundation courses and ongoing support during medical school). The review also discusses the main criticisms of WP. Finally, it offers recommendations for medical schools regarding the implementation of WP initiatives.

How Medical School Applicant Race, Ethnicity, and Socioeconomic Status Relate to Multiple Mini-Interview-Based Admissions Outcomes: Findings From One Medical School

PURPOSE

To examine associations of medical school applicant underrepresented minority (URM) status and socioeconomic status (SES) with Multiple Mini-Interview (MMI) invitation and performance and acceptance recommendation.

METHOD

The authors conducted a correlational study of applicants submitting secondary applications to the University of California, Davis, School of Medicine, 2011-2013. URM applicants were black, Southeast Asian, Native American, Pacific Islander, and/or Hispanic. SES from eight application variables was modeled (0-1 score, higher score = lower SES). Regression analyses examined associations of URM status and SES with MMI invitation (yes/no), MMI score (mean of 10 station ratings, range 0-3), and admission committee recommendation (accept versus not), adjusting for age, sex, and academic performance.

RESULTS

Of 7,964 secondary-application applicants, 19.7% were URM and 15.1% self-designated disadvantaged; 1,420 (17.8%) participated in the MMI and were evaluated for acceptance. URM status was not associated with MMI invitation (OR 1.14; 95% CI 0.98 to 1.33), MMI score (0.00-point difference, CI -0.08 to 0.08), or acceptance recommendation (OR 1.08; CI 0.69 to 1.68). Lower SES applicants were more likely to be invited to an MMI (OR 5.95; CI 4.76 to 7.44) and recommended for acceptance (OR 3.28; CI 1.79 to 6.00), but had lower MMI scores (-0.12 points, CI -0.23 to -0.01).

CONCLUSIONS

MMI-based admissions did not disfavor URM applicants. Lower SES applicants had lower MMI scores but were more likely to be invited to an MMI and recommended for acceptance. Multischool collaborations should examine how MMI-based admissions affect URM and lower SES applicants.

Transition: health professionals as medical students

BACKGROUND

It has long been acknowledged that health professionals who retrain as doctors make a significant contribution to the medical profession. Having a background as a health professional sets this group apart from the other medical students, including mature students. It is therefore important to understand more about how health professionals adapt to their role as medical students.

METHODS

A qualitative approach was adopted, in which interviews were conducted with 12 of the possible 30 medical students who met the inclusion criterion: namely that they were or had been registered health professionals.

FINDINGS

The most common driver to retrain was a desire to seek a fresh challenge, and they described their previous roles as limited; however, returning to student status after life as an autonomous health professional was initially very uncomfortable. Once they loosened their grip on their previous role and embraced life as a medical student the students eventually realised that, irrespective of their previous health profession, they had a set of core professional abilities that they could bring to their role as a doctor.

DISCUSSION

There has been considerable focus on the support required for mature students, graduate students and students from disadvantaged backgrounds. Little attention has been afforded to the experience of health professionals as medical students. This category of individual already possesses a wealth of experience, knowledge and attitudes relevant to health care work. This experience should be built upon so that the transition from 'expert' to 'novice' is as comfortable as possible for all parties. Health professionals who retrain as doctors make a significant contribution to the medical profession.

Medical school admission test: advantages for students whose parents are medical doctors?

BACKGROUND

Admission candidates especially in medicine do not represent the socio-demographic proportions of the average population: children of parents with an academic background are highly overrepresented, and those with parents who are medical doctors represent quite a large and special group. At Göttingen University Medicine, a new admission procedure was established with the intention to broaden the base of applicants towards including candidates with previous medical training or lower final school grades. With a view to family background, we wished to know whether candidates differ in the test scores in our admission procedure.

METHODS

In February 2014 we asked all admission candidates of Göttingen University Medicine by questionnaire (nine closed, four open questions) about the academic background in their families, specifically, the medical background, school exam grades, and previous medical training as well as about how they prepared for the admission test. We also analysed data from admission scores of this group (semi-structured interview and four multiple mini-interviews). In addition to descriptive statistics, we used a Pearson correlation, means comparisons (t-test, analysis of variance), ANOVA, and a Scheffé test.

RESULTS

In February 2014 nearly half of the applicants (44%) at Göttingen University Medicine had a medical background, most frequently, their parents were physicians. This rate is much higher than reported in the literature. Other socio-demographic baseline data did not differ from the percentages given in the literature. Of all applicants, 20% had previous medical training. The group of applicants with parents who were medical doctors did not show any advantage in either test-scoring (MMI and interview), their individual preparation for the admission test, or in receiving or accepting a place at medical school. Candidates with parents who were medical doctors had scored slightly lower in school exam grades.

CONCLUSION

Our results suggest that there is a self-selection bias as well as a pre-selection for this particular group of applicants. This effect has to be observed during future admission procedures.

Understanding the inverse care law: a register and survey-based study of patient deprivation and burnout in general practice

INTRODUCTION

According to the inverse care law, there is a mismatch between patients' medical needs and medical care supply. As an example, the number of doctors is often lower in areas with high deprivation compared to areas with no deprivation, and doctors with a deprived patient population may experience a high work pressure, have insufficient time for comprehensive tasks and be at higher risk for developing burnout. The mechanisms responsible for the inverse care law might be mutually reinforcing, but we know very little about this process. In this study, the association between patient deprivation and burnout in the general practitioners (GPs) was examined.

METHODS

Active GPs in the Central Denmark Region were invited to participate in a survey on job satisfaction and burnout and 601 GPs returned the questionnaire (72%). The Danish Regions provided information about which persons were registered with each practice, and information concerning socioeconomic characteristics for each patient on the list was obtained from Statistics Denmark. A composite deprivation index was also used.

RESULTS

There was significantly more burnout among GPs in the highest quartile of the deprivation index compared to GPs in the lowest quartile (OR: 1.91; 95% CI: 1.06-3.44; p-value: 0.032). Among the eight variables included in the deprivation index, a high share of patients on social benefits was most strongly associated with burnout (OR: 2.62; 95% CI: 1.45-4.71; p-value: 0.001).

CONCLUSIONS

A higher propensity of GP burnout was found among GPs with a high share of deprived patients on their lists compared to GPs with a low share of deprived patients. This applied in particular to patients on social benefits. This indicates that beside lower supply of GPs in deprived areas, people in these areas may also be served by GPs who are in higher risk of burnout and not performing optimally.

Shorter adult stature increases the impact of risk factors for cognitive impairment: a comparison of two Nordic twin cohorts

We analyzed the association between mean height and old age cognition in two Nordic twin cohorts with different childhood living conditions. The cognitive performance of 4720 twin individuals from Denmark (mean age 81.6 years, SD = 4.59) and Finland (mean age 74.4 years, SD = 5.26) was measured using validated cognitive screens. Taller height was associated with better cognitive performance in Finland (beta-estimates 0.18 SD/10cm, p value < .001, for men and 0.13 SD, p = .008, for women), but this association was not significant in Denmark (beta-estimates 0.0093 SD, p value = .16, for men and 0.0075 SD, p value = .016, for women) when adjusted for age and education/social class. Among Finnish participants higher variability of cognitive performance within shorter height quintiles was observed. Analysis using gene-environment interaction models showed that environmental factors exerted a greater impact on cognitive performance in shorter participants, whereas in taller participants' it was explained mainly by genetic factors. Our results suggest that shorter participants with childhood adversity are more vulnerable to environmental risk factors for cognitive impairment.

Psychosocial determinants of socioeconomic inequalities in cancer screening participation: a conceptual framework

Cancer screening participation shows a strong, graded association with socioeconomic status (SES) not only in countries such as the United States, where insurance status can be a barrier for lower income groups, but also in the United Kingdom, where the National Health Service provides all health care to residents, including screening, for free. Traditionally, the literature on socioeconomic inequalities has focused on upstream factors, but more proximal (downstream) influences on screening participation also need to be examined, particularly those that address the graded nature of the association rather than focusing specifically on underserved groups. This review offers a framework that links some of the components and corollaries of SES (life stress, educational opportunities, illness experience) to known psychosocial determinants of screening uptake (beliefs about the value of early detection, fatalistic beliefs about cancer, self-efficacy). The aim is to explain why individuals from lower SES backgrounds perceive cancer screening tests as more threatening, more difficult to accomplish, and less beneficial. A better understanding of the mechanisms through which lower SES causes negative attitudes toward screening could facilitate the development of intervention strategies to reduce screening inequalities.

Socioeconomic origins of deans at America's elite medical schools: should these leading programs weigh deans' social class background information as a diversity criterion?

PURPOSE

American higher education is committed to diversity, saying it enhances the learning environment. Medical schools weigh applicants' socioeconomic origins when deciding admissions, fostering higher attendance by students from the working and poverty classes, historically underrepresented groups. When choosing deans, however, categories of diversity do not include lower socioeconomic origins. The author studied the socioeconomic backgrounds of medical school deans to test whether America's leading medical schools should be hiring more deans of working and poverty class origins for diversity purposes.

METHOD

During spring 2009, the author surveyed deans at America's 50 top-rated medical schools, asking them about their parents' highest levels of education and principal occupations during the respondents' youth. He then compared the results against the general population.

RESULTS

Based on the responses of 34 deans, deans of working and poverty class origins are appreciably underrepresented at America's elite medical programs. These results are particularly revealing given what reformers say about the importance of demographic diversity for enhancing the quality of higher education and the power these administrators exercise over their respective programs.

CONCLUSIONS

Socioeconomic origins should be included in the campaign to achieve greater diversity among medical school deans, as now happens with medical school students. If these leading programs expand their diversity efforts to hire more deans with working class backgrounds, perhaps other medical schools will follow their precedent.

Perspective: medical students' perceptions of the poor: what impact can medical education have?

There is currently little knowledge or understanding of medical students' knowledge and attitudes toward the poor. Teaching hospitals bring students face-to-face with poor and uninsured patients on a regular basis. However, an overview of the research available suggests that this contact does not result in students' greater understanding and empathy for the plight of the poor and may, in fact, lead to an erosion of positive attitudes toward the poor. A basic understanding of justice suggests that as the poor are disproportionately the subjects of medical training, this population should enjoy a proportionate benefit for this service. Furthermore, medicine's social contract with the public is often thought to include an ideal of service to the underserved and a duty to help educate the general public regarding the health needs of our nation. In their discussion, the authors situate medical students' attitudes toward the poor within larger cultural perspectives, including attitudes toward the poor and attributions for poverty. They provide three suggestions for improving trainees' knowledge of and attitudes toward the poor-namely, increasing the socioeconomic diversity of students, promoting empathy through curricular efforts, and focusing more directly on role modeling. The authors argue that service learning, especially efforts that include gaining detailed knowledge of a particular person or persons, coupled with critical reflection, presents a very promising direction toward achieving these goals. Finally, they posit an agenda for future educational research that might contribute to the increased efficacy of medical education in this important formative domain.

Changing geographies of access to medical education in London

This paper highlights the need for health geographers to consider the social and cultural geographies of who gets to train as a doctor. The paper presents a case study of a scheme intended to widen access to medical education for working class students from inner London. This work examines the role of local education markets and cultures of education in shaping the aspirations and achievements of potential future doctors. It employs ethnographic data to consider how 'non-traditional' learners acclimatise to medical school. Our findings indicate that the students who succeed best are those who can see themselves as belonging within the education system, regardless of their social and cultural background.

Medical School Performance, Alumni Membership, and Giving: How Do Scholarship Recipients and Non-Recipients Differ?

PURPOSE

This study examines student recipients of merit, need-based, service, or minority scholarships, their performance in medical school, and the relationship to future alumni association membership and financial giving.

METHOD

Retrospective data on grade-point average attained across the four-year curriculum and extracurricular activities reported at graduation were collected on students at the University of Kentucky College of Medicine from 1981-1991. Comparisons of academic performance and participation in institutional activities were made across scholarship recipients and non-recipients. These data were then linked to other data tracking alumni association membership and institutional giving.

RESULTS

Compared to other scholarship recipients and non-recipients, merit scholars were more likely to be ranked above their class medians and be involved in extracurricular activities, including membership in Alpha Omega Alpha. However, seven years post-graduation, there was no difference between scholarship recipients and non-recipients in alumni association membership or donations to the medical school. Instead, students graduating in the upper half of their class, as compared to graduates in the lower half, and UKCOM graduates who attended the University of Kentucky as undergraduates, rather than students who attended other in-state or out-of state institutions, were more likely to join the medical alumni association. Alumni association members were more likely than non-members to make donations to the institution.

CONCLUSIONS

More should be done to ensure that graduates who received scholarships are afforded meaningful ways to give back to the institution that supported them as students.

Insurgent multiculturalism: rethinking how and why we teach culture in medical education

The author proposes a theoretical orientation for cultural competency that reorganizes common curricular responses to the study of culture in medical education. What has come to be known in medical education as cultural competency is theoretically truncated and may actually work against what educators hope to achieve. Using Giroux's concept of insurgent multiculturalism, she suggests that the critical study of culture might be a bridge to certain aspects of professional development. Insurgent multiculturalism moves inquiry away from a focus on nondominant groups to a study of how unequal distributions of power allow some groups but not others to acquire and keep resources, including the rituals, policies, attitudes, and protocols of medical institutions. This approach includes not only the doctor-patient relationship but also the social causes of inequalities and dominance. Linked to professional development efforts, insurgent multiculturalism can provide students with more opportunities to look at their biases, challenge their assumptions, know people beyond labels, confront the effects of power and privilege, and develop a far greater capacity for compassion and respect.

Effects of rising tuition fees on medical school class composition and financial outlook

BACKGROUND

Since 1997, tuition has more than doubled at Ontario medical schools but has remained relatively stable in other Canadian provinces. We sought to determine whether the increasing tuition fees in Ontario affected the demographic characteristics and financial outlook of medical students in that province as compared with those of medical students in the rest of Canada.

METHODS

As part of a larger Internet survey of all students at Canadian medical schools outside Quebec, conducted in January and February 2001, we compared the respondents from Ontario schools with those from the other schools (control group). Respondents were asked about their age, sex, self-reported family income (as a direct indicator of socioeconomic status), the first 3 digits of their postal code at graduation from high school (as an indirect indicator of socioeconomic status), and importance of financial considerations in choosing a specialty and location of practice. We used logistic regression models to see if temporal changes (1997 v. 2000) among Ontario medical students differed from those among medical students elsewhere in Canada apart from Quebec.

RESULTS

Responses were obtained from 2994 (68.5%) of 4368 medical students. Across the medical schools, there was an increase in self-reported family income between 1997 and 2000 (p = 0.03). In Ontario, the proportion of respondents with a family income of less than $40,000 declined from 22.6% to 15.0%. However, compared with the control respondents, the overall rise in family income among Ontario students was not statistically significant. First-year Ontario students reported higher levels of expected debt at graduation than did graduating students (median $80,000 v. $57,000) (p < 0.001), and the proportion of students expecting to graduate with debt of at least $100,000 more than doubled. Neither of these differences was observed in the control group. First-year Ontario students were also more likely than fourth-year Ontario students to report that their financial situation was "very" or "extremely" stressful and to cite financial considerations as having a major influence on specialty choice or practice location. These differences were not observed in the control group.

INTERPRETATION

At Canadian medical schools, there are fewer students from low-income families in general. However, Ontario medical students report a large increase in expected debt on graduation, an increased consideration of finances in deciding what or where to practise, and increasing financial stress, factors that are not observed among students in other provinces.

Characteristics of first-year students in Canadian medical schools

BACKGROUND

The demographic and socioeconomic profile of medical school classes has implications for where people choose to practise and whether they choose to treat certain disadvantaged groups. We aimed to describe the demographic and socioeconomic characteristics of first-year Canadian medical students and compare them with those of the Canadian population to determine whether there are groups that are over- or underrepresented. Furthermore, we wished to test the hypothesis that medical students often come from privileged socioeconomic backgrounds.

METHODS

As part of a larger Internet survey of all students at Canadian medical schools outside Quebec, conducted in January and February 2001, first-year students were asked to give their age, sex, self-described ethnic background using Statistics Canada census descriptions and educational background. Postal code at the time of high school graduation served as a proxy for socioeconomic status. Respondents were also asked for estimates of parental income and education. Responses were compared when possible with Canadian age-group-matched data from the 1996 census.

RESULTS

Responses were obtained from 981 (80.2%) of 1223 first-year medical students. There were similar numbers of male and female students (51.1% female), with 65% aged 20 to 24 years. Although there were more people from visible minorities in medical school than in the Canadian population (32.4% v. 20.0%) (p < 0.001), certain minority groups (black and Aboriginal) were underrepresented, and others (Chinese, South Asian) were overrepresented. Medical students were less likely than the Canadian population to come from rural areas (10.8% v. 22.4%) (p< 0.001) and were more likely to have higher socioeconomic status, as measured by parents' education (39.0% of fathers and 19.4% of mothers had a master's or doctoral degree, as compared with 6.6% and 3.0% respectively of the Canadian population aged 45 to 64), parents' occupation (69.3% of fathers and 48.7% of mothers were professionals or high-level managers, as compared with 12.0% of Canadians) and household income (15.4% of parents had annual household incomes less than $40,000, as compared with 39.7% of Canadian households; 17.0% of parents had household incomes greater than $160,000, as compared with 2.7% of Canadian households with an income greater than $150,000). Almost half (43.5%) of the medical students came from neighbourhoods with median family incomes in the top quintile (p < 0.001). A total of 57.7% of the respondents had completed 4 years or less of postsecondary studies before medical school, and 29.3% had completed 6 or more years. The parents of the medical students tended to have occupations with higher social standing than did working adult Canadians; a total of 15.6% of the respondents had a physician parent.

INTERPRETATION

Canadian medical students differ significantly from the general population, particularly with regard to ethnic background and socioeconomic status.