Barriers to Entry and Success in Medical Education

Annalese Duprey, PhD

Despite monumental and ongoing demographic shifts, inequality still marks post-graduate education, including medical education. Female college students have outnumbered males in the United States since the 1980s, but it wasn’t until 2019 that women represented the majority of incoming medical students. And while this first majority class of women wends their way through the rigors of medical training, the current reality is that among practicing doctors, males still outnumber females in the United States by just about two to one. Likewise, white students are vastly overrepresented at all stages of higher education but the shares of Black and Hispanic students have been increasing over the past decade. Yet non-white students are still underrepresented in medical training, a lack of diversity that extends to medical practice.

While non-white students make up 53% of medical school applicants and 50% of acceptees, they only represent about 45% of graduates. Bodies like the AAMC and ACGME are working to provide resources that will recruit and train a more diverse and inclusive body of future physicians. However, decades of accumulated experience at LAS indicate that merely casting a wider net will not yield more diversity. The attrition rates for non-white medical students speak starkly to this reality. Undergraduate medical education has its own culture; real inclusion requires providing resources, education, and professionalization for students who are entering as first- or early-generation medical students.

Many first- and early-generation medical students are unaware of the hidden curriculum, the “unwritten, unofficial, and often unintended lessons, values, and perspectives” imposed by institutional or curricular culture. First-generation, non-white, and lower socioeconomic status students often struggle to navigate largely invisible structures that are are intuitive to their more privileged peers. In medical schools, the hidden curriculum can make assumptions about the privilege, background, education, and study skills of students; failure to understand this system can result in students being exposed to increased instances of both overt bias and microaggressions, underachievement, and increased risks to their mental health. Furthermore, studies have shown that stereotypical, biased assumptions about gender, race/ethnicity, and socioeconomic status abound in the cases presented in medical education. In particular, vignettes often center white, heterosexual, and male patients as the “norm” against which all other groups are “othered.” Attention to the socio-political aspects and implicit structural hierarchies of medical education is necessary to resist implicit biases and outright racism.

Another threat to the achievement of less privileged students is stereotype threat, where fear of fulfilling a negative stereotype based on one’s group affiliations undermines performance on a variety of tasks. Recent studies have demonstrated the detrimental effects of stereotype threat on female and non-white medical students. Both individual and institutional remedies are necessary to reduce stereotype threat, including increasing the visibility of people from underrepresented groups, making sure that diversity is both implicitly and explicitly valued within an institution, recruiting and presenting role models from a variety of groups, and creating a climate that truly validates and supports students’ individuality.