News and Commentary The Social Determinants of Medical Education: A Call to Action

In this edition of Macy Notes, I had the opportunity to reconnect with Christopher DaSilva, MD, to discuss a topic of great importance to both of us—the social determinants of medical education. Dr. DaSilva was a medical student at the University of Chicago Pritzker School of Medicine during my tenure as dean for medical education. He is now a first-year resident in pediatrics at the University of California, San Francisco Benioff Children’s Hospital Oakland.

Dr. Holly J. Humphrey (HH): Chris, let me begin by thanking you for taking the time to talk with me, and perhaps even more so for your willingness to share some of your personal experiences and to “speak truth to power.” You and I knew one another during my time as dean for medical education at the University of Chicago when you were a medical student, and you impressed me during that time with your thoughtful feedback for the administration regarding topics about which you felt strongly. Over the years, I know you have thought carefully about the social determinants of medical education, by which I refer to structural inequalities at both a social and an individual level, which can adversely affect learners’ ability to be successful. I know our readers will learn from what you have to say. I have already learned so much from you through our earlier conversations.

Dr. Christopher DaSilva (CD): Thanks for inviting me to talk with you on this topic, Dr. Humphrey. Before I begin speaking, I want to acknowledge that while my words and perspective are my own, I’m not the first to voice these concerns, and this would not be possible without the input and shared voice of so many who’ve had the courage to share their stories and experiences with me. Even with the barriers I’ve overcome, there are many privileges I’ve been able to benefit from given my identities. With that being said, I felt the need to speak out on this subject because I feel these issues are not limited to just me. While I cannot speak for every student or learner, I do feel that what we are about to discuss resonates with more students than medical education would like to acknowledge. The need to act is urgent and long overdue.

HH: The social determinants of health have been widely discussed within health care and health professions education over the past many years, especially during the COVID-19 pandemic, and rightly so. The availability of resources to pay for housing, access to affordable health care, food insecurity—these types of social determinants play a significant role in health outcomes. What has also come into very clear view over the course of the COVID-19 pandemic is the impact of social determinants on the educational experiences of health professions learners. My colleague, David Muller, recently shared with me his belief—a belief that is the crux of a forthcoming paper in Academic Medicine—that social determinants are the most important variables determining how our students perform during medical school. They are foundational to success.

Over the course of my time leading undergraduate and graduate medical education programs and now in leading a foundation dedicated to health professions education, I have witnessed the impact when learners—beginning well before medical school and continuing throughout the journey to becoming physicians—navigate the stress of medical education together with the compounding stress of financial insecurity. Not all students arrive at medical school with equitable resources, and the pressure students face when confronted by these inequities on a daily basis combined with  the hidden costs of medical education has a deleterious impact on experiences during medical school and on outcomes in the classroom and clinical environments.

Chris, your experience is such that you have lived with some of the stress caused by financial inequities. Can you describe the points in the medical education process that were particularly stressful for you and for others whom you know?

CD: I would like to start off with some facts. The 2020 Matriculating Student Questionnaire demonstrated that the median household income of matriculating students was $140,000. This is more than double the median household income of the United States, which was $67,521 based on 2020 Census Bureau data. The most recent Physician Education Debt and Cost to Attend Medical School report, released by the AAMC, demonstrated that of the graduating medical students in 2019, 79% of medical school graduates come from families in the top two quintiles of U.S. family income.  Furthermore, Black, Hispanic, and American Indian/Alaskan Native students were more likely to report an increased likelihood to take out debt, report higher debt burdens, and have less familial support in financing their medical education when compared to their White peers. Despite this great disparity in wealth, the debt of medical school graduates across all income quintiles has remained uniform at approximately $200,000. Thus, students who matriculate into medical school from lower socioeconomic backgrounds are less likely to be equipped to effectively navigate the high debt burden they must pay to cover the increasing cost of medical education when compared to their peers from higher socioeconomic backgrounds.

Without having that knowledge, I had already begun to have serious doubts about the financial feasibility of matriculating into medical school, even though I successfully gained acceptance. My family qualified as low-income; we had barely enough to cover the everyday expenses of our home, and our income was certainly nowhere close to what was needed to pay for my application fees, much less the cost of medical education itself. I pursued the journey towards becoming a physician knowing that I would have to take on the financial responsibility of all costs that should arise.

The ways in which social determinants impede learners is not a new concept. It is an open secret that has long been actively ignored. Even when these inequities are brought to the attention of leadership, nothing has changed in these systems. While I can appreciate the numerous demands that are placed on medical school administration at any given time, I found it frustrating that financial inequity within medical school was not more urgently prioritized and addressed. Sweeping changes are needed to create a level playing field so that all students are positioned for success.

These hidden costs and barriers arise long before students matriculate into medical school, but accelerate as students progress through their medical training. Students must navigate the expensive process of registering for and taking the MCAT exam, along with the costs of sending their applications to each medical school they apply to. This process repeats again in medical school, in an environment where one’s future competitiveness and eligibility to enter a medical specialty hinge on their initial performance on USMLE Step 1—thankfully now pass/fail. Regardless of how the examination is scored, one’s performance on standardized exams is a crucial barrier for students hoping to go into specific specialties/professions, even though there is poor evidence correlating test scores and future clinical performance. Students who can afford test preparation materials and tutors are better prepared to outperform those students who cannot afford them. As learners prepare to apply to residency, those who are financially equipped to apply to more residency programs increase the likelihood that they can be interviewed, and their chances of success into matching into a specialty also increase. Clearly, those who have the financial means to increase their odds of success are rewarded, while those who do not are left to manage the ramifications of compounding disadvantages they cannot control.

The transition from medical school to residency is even less forgiving. While a tremendous amount of money was saved during interview season due to virtual interviews and not having to pay for flights and hotels while interviewing for residency (another financial inequity in retrospect), I still faced tremendous, looming moving costs as I prepared to move from Chicago to California. According to the American Moving and Storage Association, the average cost of a local household move is $2,300 and the average cost of a long-distance move is $4,300. Furthermore, from the time of students’ last loan disbursement (typically received several months before graduation) to their first paycheck of residency (typically near the middle of July) students are expected to come up with the financial means to pay for moving and relocation fees, a security deposit or down payment for housing, and sometimes even the first month of rent. None of this has been included as part of their fourth-year medical school budget, and if it were, that would only likely increase the debt burden that we would have at the time of graduation.

HH: I am hearing you talk about the ways in which the cost of applying to and attending medical school directly led to stress and uncertainty about your future. Can you tell us about the ways these financial inequities impact one’s overall experience as a medical student?

CD: Wealth gaps that are exacerbated throughout the process of medical education result in disparate experiences felt among learners. Some students can engage, plan, and participate in expensive service trips during breaks that serve as valuable experiences while simultaneously enhancing their future competitiveness. Other students struggle between having enough money for food and paying their utility bills quarter to quarter. These concerns regarding food insecurity have been voiced before, but little action has been taken to meaningfully address these issues. While I could only contemplate whether it was financially feasible for me to fly home during a school break or for a holiday, classmates were debating which country they would be visiting for their annual family vacation. This is not meant to shame those who come from more fortunate circumstances, but it does highlight the vast disparities that exist among students, and the struggle to feel as though you belong in that space.

What results is that learners, consciously or unconsciously, find themselves consigned into a system that was inherently designed for them to struggle and to encounter disproportionate barriers. The daily accumulation of financial stressors and microaggressions surrounding financial inequity compound and take their toll. An intangible consequence from this experience is the alienation we feel from our medical school, our peers, and perhaps the profession itself. I question if my decision to enter this profession was the right one, especially when it seems the current systemic structures in place were not made with students from low-income backgrounds in mind. I question what it means to persistently bring up these issues, have them acknowledged, and yet see no action taken to rectify these disparities. I question if the amount of debt that I took out to finance my medical education when I first embarked on this journey is worth the return on investment.

HH: Chris, thank you for sharing such personal and powerful experiences.

From my perspective, I believe the issues at hand are threefold:  First, medical students who come from low-income families do not have a family “safety net” to rely upon in the event of an emergency. Second, medical schools often underestimate the cost to attend medical school to be competitive with their peer institutions. By underestimating the cost, students are limited in how much access they have to favorable loans. Although schools may try to help students keep their borrowing in check and do not wish to signal that more borrowing is a good idea, striking the right balance is hard. For the student without a financial cushion, it can be a source of continual stress. Finally, neither medical schools nor residency programs are structured to provide resources and support to students during the transition to residency—a time of high financial need. This means that students who are relocating for residency need money for moving, for the first month of rent, and usually for a security deposit for their new apartment. None of this has been included as part of their fourth-year medical school budget.

Do you think these points accurately represent the issues that students, such as you, are facing or faced during medical school? If so, do you have ideas or suggestions for ways for medical schools and residency programs to resolve these problems?

CD: I have seen that the medical profession is starting to recognize its own history of inaccessibility to identities that have been historically neglected by this profession. From my perspective, leadership first and foremost needs to understand that a firm commitment to rectifying financial inequity among its students extends past the moment they matriculate. If we hope to effectively address these disparities, it will require both medical schools and residency programs working together to ensure that students are supported throughout the medical education curriculum.

As for how to resolve the problems, I have three recommendations:

  1. We need an intensive overhaul of the financial aid system. Financial advising services are necessary to educate students and provide them with a financial literacy foundation that will help prepare them for future success; however, that education should not be included as an afterthought. When educating potential candidates about the cost of attending medical school, leadership must make a more conscious effort to better understand the financial situations of the candidates they are aiming to recruit, while also taking the time to examine the hidden costs that serve as financial barriers for their students. Financial literacy education should be a requirement for every medical school, with such education starting at matriculation and taught as an extended curriculum. Lessons regarding debt management, financial planning, and healthy attitudes towards money should be taught as an extended curriculum instead of relying on students to learn it on their own.
  2. Schools should each have an emergency fund ready for students to draw upon, with the amount allocated based on the financial need of the student. This will require institutions to redefine their definition of need-based eligibility by taking a critical look at their true cost of attendance and carefully allocating and redistributing resources appropriately to cover each student’s financial needs should they arise. For example, a $4000 alumni donation could be better utilized as an emergency fund for a deserving student rather than be given at a 0% interest loan.
  3. At minimum, residency programs should offer a relocation bonus for the transition to residency. Many other professions and programs provide hiring bonuses and moving costs to those they successfully recruit. Current and future trainees are owed the same after they’ve worked to match successfully into the program. While the amount offered will vary from institution to institution, it should take into account the trainee’s security deposit, one’s first month of rent or mortgage payment, and costs needed to furnish their new apartment with essential needs.

If the leaders of medical education are serious about fulfilling their promise to diversify medicine, then they must become intentional about overhauling the financial infrastructure that only serves to support those who come from high-income backgrounds. We can no longer afford to be complicit in the widening gap of opportunity that is dependent on socioeconomic status. This is an issue that cannot await the slow movement of assembling a task force to make recommendations; it is an urgent issue, one that demands immediate attention.

HH: Chris, I think these three recommendations are excellent and I agree that they each have potential to begin to address the inequities caused by the social determinants. I would like to offer a few additional ideas to further underscore your points:

 

  1. Medical schools must meet financial need with scholarships, not loans, whenever possible. Medical schools who have received major donations have made debt reduction a priority, but not all schools have access to such resources and not all students receive this money based on need. Institutions must sharpen their pencils and hold themselves accountable by prioritizing need-based aid. Medical schools should consider the position taken by some colleges and universities where tuition is covered for any student with a family income less than a pre-determined threshold.
  2. Medical schools must measure and share the cost of education with students with greater rigor and clarity. The guiding factor should not be to be competitive with peer institutions, but instead, to consider the students’ best interests.
  3. Financial counselling must be effective and meet students where they are. Such counselling is an accreditation requirement for all medical schools, but if the programs in place do not meet the needs of students—especially for those from low socioeconomic backgrounds—then schools must rethink and redesign these programs using a model of co-creation with students themselves.
  4. Schools should make more extensive efforts to identify food and housing insecurity among their students. They must also be prepared to provide laptops, transportation, and other necessities when needed.
  5. Medical education leaders should work together to find solutions to the serious financial gap in the UME to GME transition.

I can appreciate the frustration you and others feel as a result of the lack of action related to these issues—a lack of action that, as you note, has persisted for many years. With COVID-19 highlighting many inequities in health care and the racial reckoning that we as a nation continue to confront, medical education leaders must consider in earnest the needs of medical students and residents if we truly hope to diversify our profession and eliminate inequities in educational outcomes. We owe it to our students and residents to provide learning environments that are safe, equitable, and offer abundant opportunities to thrive.

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