When considering the barriers to medical education for minorities and low-income groups, it is quickly apparent that there is great overlap between these social determinants and the social determinants of health. Indeed, much discussion has centered on the role of social and economic factors in the context of healthcare (Marmot & Allen, 2014). Similarly, the externally-derived barriers that limit access to medical education have been heavily explored from this perspective, and there is value to considering other categorical divisions for these issues, as new insights may be gained. There are some splitting of hairs necessary to discuss socioeconomic status as separate from social networks, but perhaps a different method of categorizing will minimize such entanglements.
From a broad perspective, where categories can be simplified, the following categories should be considered. The first is the availability of means, commonly thought of in terms of currency, as being the simplest way to assess the availability of means to pursue opportunities. The second category is social connections. This includes family members, friends, teachers, mentors, employers, etc. Of course, it cannot be forgotten that there is a relationship between the community that one belongs to and the availability of means, and this relationship can become exquisitely complicated in individual circumstances.
Availability of means
The cost of tuition for medical education in the United States is extraordinarily high. This high cost is even more notable when compared to other developed nations, where the cost of education is borne by the taxpayer base, rather than by the individual student. Here, in the United States, the cost of tuition for medical school ranges from approximately $16,000 per year to approximately $60,000 per year. This is the cost of the tuition alone, and does not include expenses for the cost of living. Cost of living expenses also vary widely, depending on the city where the medical school is located. For example, the estimated cost of living for medical students at the University of Arkansas for Medical Sciences is $20,780, whereas the estimated cost of living for medical students at the University of California at San Francisco is $31,656. Additional factors can also play a role, such as whether or not a student has in-state status at publically supported medical schools.
There have been some efforts to reduce the barrier imposed by the cost of attendance. The availability of federal student loans, for example, ensure that United States citizens who are accepted into medical school in the United States can generally have access to the funds to pay for it. However, these loans are administered at interest rates that are relatively high, although lower than the loan rates available through most consumer loan mechanisms. There is some controversy over the effectiveness of loan programs in improving minority access to education (Long & Riley, 2007). Beyond loans, many medical schools are part of larger, state-sponsored university systems. These medical schools typically offer residents of the state to attend the school at a significant reduction in tuition. For public medical schools, the difference in tuition for in-state students as compared to out-of-state students can be nearly two-fold. However, even with this subsidization of medical education, in-state tuition can cost tens of thousands of dollars per year.
However, looking only at the direct cost of medical school, one fails to capture the larger barriers imposed by the limited availability of means. Acceptance into medical school requires a number of academic and experiential qualifications to be met. Beginning with the academic requirements, it is worth keeping in mind that there are great disparities in the United States regarding high school graduation rates amongst minority and low-income groups (Heckman & Lafontaine, 2010). In general, families of similar financial means live in the same neighborhoods, and subsequently, their children attend the same schools. In many areas, school funds are related to property taxes. As a result, regions where the majority of the population is wealthier have more funding, compared to areas where the majority of the population is low-income. This creates a fundamental differential in what resources are considered standard. For example, at present, there are school districts that provide an iPad to every student, while there are also school districts struggling to maintain an adequate supply of classroom textbooks. Of course, education is about far more than the cost of the provided resources, and the value of an educator cannot be understated. However, teacher salaries also vary significantly across school districts. This, in turn, leads to a differential in educators as well. This is not to say that there are not many exemplary educators in low-income school districts, but it warrants acknowledgment that even a subtle differential can lead to significant consequences on a larger scale.
Therefore, before yet considering the impact of social connections, it is important to highlight that there are broad, system-level barriers affecting minority groups and those raised in low-income households.
The impact of social connections
It would be exceedingly difficult to overstate the importance of social connections, and the impact that they have on medical school matriculation rates. Children begin developing dreams and aspirations from a very young age. Indeed, it seems that perhaps the only limit to a child’s imagination is the breadth of their experience; therein lies the problem. Children that are exposed to professionals outside of a professional context (that is, a child that knows a doctor as a family friend, and not merely as the scary person with a white coat) have the concept that this profession is a real and viable option for them to pursue. This may not be the case for children who only meet the doctor in the doctor’s office.
There is also much to be said for the importance of family support. Familial networks that are fundamentally supportive in nature will encourage children to work towards dreams and aspirations, even if those aspirations are difficult to achieve. Alternatively, if the family environment is one in which such goals are scoffed at, a child will quickly become discouraged and choose to pursue more socially acceptable goals.
The process of pursuing post-secondary education can be overwhelming. The cost of applications alone can dissuade students. While there are fee waivers available, they require additional paperwork that is yet another barrier. Students who are surrounded by others going through this process have the benefit of peer support, which can also influence academic performance (Zimmerman, 2003). However, students who do not have peers or role models assisting them often drop out of the educational training pipeline at this juncture. Many schools employ counselors exclusively for the task of guiding students, but the utilization and quality of these resources vary greatly from school to school.
For students who overcome the aforementioned aspirational barriers, experiential barriers may still remain. Acceptance into college, and especially acceptance into medical school, require applicants to have pursued a certain set of baseline experiences, most often emphasizing community service. Students who have a rich social network are aware of this and can prepare accordingly. However, students lacking informal information resources may not realize that these non-curricular requirements exist, and may struggle to prepare a competitive application as a result.
Finally, the importance of developing social connections with mentors is essential. These mentors not only advise students but also endorse them through letters of recommendation. Depending on the social norms that a child is raised in, developing any type of personal rapport with an instructor may seem odd or even disrespectful. Yet this, once again, could serve as a barrier. A strong letter of recommendation can explain and even supersede a lack of experience or lapses in academic performance. But a recommendation letter of this sort would rely on there being a connection between the student and the mentor that exceeds the standard relationship.
The intersection of means and social connections
While the main focus here is on the consideration of broad categories of barriers with less overlap than those typically considered, it is important to still address the intersection of financial means and social connections. For this, two scenarios will be presented.
First, there are the students who overcome all aspirational and support barriers, yet social responsibilities are forced to take priority. For example, there are many students who must work full-time, even at the cost of ceasing their academic pursuits, in order to take care of their families. In this case, the financial resource systems designed to aid in the accessibility of medical education are insufficient. As discussed, the financial resources available involve loans and reducing the cost of tuition. However, neither of these mechanisms would help the student to fulfill their family obligations.
The second scenario is systemic in nature and related to the differential in opportunities provided by various school districts and education systems. As discussed above, there are a number of non-curricular, experiential requirements for post-secondary education as well as medical education. School districts with a greater availability of resources often organize opportunities for their students that meet these requirements. For example, volunteering opportunities around the community, and supplemental training that is outside of the formal coursework. Students from school districts with fewer resources likely need this assistance more to reduce barriers, but in the absence of sufficient resources, the point is simply unfeasible.
Using availability of means and social connections to reduce barriers to medical education
While it is clearly impossible to truly generate categories of barriers that are independent of one another, this perspective of the barriers to medical education is helpful from the perspective of implementation. To begin, a stronger education system nationwide is needed, but of equal importance are mechanisms needed to equalize the opportunities provided through education. Particularly when considering public education, resource re-allocation (though controversial) can significantly offset many of the opportunity barriers discussed here. There are many organizations and institutions that strive to help students through career and academic planning. Many of these resources are very good, however, they exist independently from one another. Some efforts have been made to aggregate these resources, but it is often still unintuitive and difficult to navigate without assistance. Improved promotion of and user interfaces for these resources would make them far more effective.
The fundamental cost of higher education, including medical education, must also be addressed. College tuition rates are ever increasing as the demand for non-curricular opportunities puts pressure on colleges and universities to spend increasing amounts of money on non-academic topics. Therefore, the cost of these additional programs must first be addressed. Additionally, the financial responsibilities of higher education should be considered separately from the perspective of social benefit. Increasing the educational level of a population also increases the quality of life in that population. While specific estimates on the ultimate size of the economic benefits from socially funding higher education are controversial, it is broadly accepted that this effect exists. In regards to medical education specifically, both the social value of a strong healthcare system and the economic benefits of a healthier population are great.
There is evidence that indicates that the diversity of healthcare providers has an effect on the extent to which patient populations pursue care (Komaromy et al., 1996). Therefore, as an increasing portion of the United States population is comprised of minority groups, the health of our overall population relies upon improving the diversity of our healthcare providers. Reducing barriers to medical education not only reduces barriers to education as a whole but also improves the health of the population. The need for these solutions are both social and economic in nature and therefore warrant broad support.
1. Heckman, J. J., & Lafontaine, P. A. (2010). The American high school graduation rate: trends and levels. Rev Econ Stat, 92(2), 244–262. http://doi.org/10.1162/rest.2010.12366.THE
2. Komaromy, M., Grumbach, K., Drake, M., Vranizan, K., Lurie, N., Keane, D., & Bindman, A. B. (1996). The role of black and Hispanic physicians in providing health care for underserved populations. The New England Journal of Medicine, 334(20), 1305–10. http://doi.org/10.1056/NEJM199605163342006
3. Long, B. T., & Riley, E. (2007). Financial Aid: A Broken Bridge to College Access? Harvard Educational Review, 77(1), 39–63. http://doi.org/10.17763/haer.77.1.765h8777686r7357
4. Marmot, M., & Allen, J. J. (2014). Social determinants of health equity. American Journal of Public Health, 104(SUPPL. 4), 517–519. http://doi.org/10.2105/AJPH.2014.302200
5. Zimmerman, D. J. (2003). Peer Effects in Academic Outcomes: Evidence from a Natural Experiment. Review of Economics and Statistics, 85(1), 9–23. http://doi.org/10.1162/003465303762687677
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