September.4.2017

The strange world of medical school for working-class and Indigenous students: doing extreme social mobility

By Caragh Brosnan and Erica Southgate

What happens when becoming a doctor is a battle between staying true to yourself and fitting in to an elite profession? It sounds dramatic, but this is the struggle that working-class and Indigenous students face when entering the strange world of medical school.

Medicine – the final equity frontier?

Medical school has traditionally been the domain of white, upper middle-class males. There have been gradual shifts over time, with females and non-Anglo students now well represented. But when it comes to social class and Indigeneity, it’s a different story.

Medical schools have been slower to respond to the opening-up of higher education to diverse groups evident in teaching and nursing degrees. It’s a similar pattern in law. These high-status degrees represent the final frontiers for the widening access agenda in higher education. In undergraduate medical degrees, just 10% of students come from low-socioeconomic status (LSES) backgrounds and 1.9% are from Indigenous backgrounds. Proportional representation relative to the population would see 25% of students from LSES and 2.3% from Indigenous backgrounds.

What are the hurdles?

Are the privileged favoured in medical school admissions processes? Or are working-class and Indigenous students not applying? In Australia, low-socioeconomic status students have a higher success rate in medical school applications than their high-SES peers, but apply in smaller numbers. The exceptionally high ATAR for medicine is a substantial barrier for people from these backgrounds, as is the multi-phased admissions process, including hurdles such as the expensive Undergraduate Medicine and Health Sciences Admission Test. British and Australian research shows that low-socioeconomic status students imagine that medical school is full of ‘posh’ geniuses, and that they will not fit in.

Medical school: a strange new land

Working-class and Indigenous students find themselves in a clear minority when they arrive at medical school. Starting university is a tough transition for many students, but this is compounded by the pressure of the intensive coursework of medicine and trying to develop a sense of belonging in an exclusive environment. We recently interviewed medical students who were the first-in-family to go to university – most were working-class and a significant proportion Indigenous. These students had to be particularly strategic to succeed in the profession while struggling to remain connected to their families and communities.

Medical education involves socialisation into an elite, high-paid profession. Many of our interviewees entered medical school expecting not to fit in, and they did notice how different they were. Other students had ‘money to throw around’, and were ‘a different breed’, more ‘polished’ and ‘clean cut’. In contrast, some of our participants described themselves as ‘a bit rough around the edges’.

The students had to work hard to build knowledge and connections around medical careers that their middle- and upper-class peers already seemed to have. One told us that:

everyone seemed a lot more confident because a lot of them had planned to do medicine since they’d entered high school and had always wanted to do medicine. A lot of people have parents that are doctors and people in their family that are doctors, so I really had no idea, I didn’t know what actually happened after medical school.

‘99% medical student, 1% bogan’: Forging professional identity

Students described gradually becoming more confident in the world of medicine, but this involved a shift in identity and behaviour. Some changed the way they spoke, adopting the professional communication style taught within the degree.

How were these students seen by their families and communities? Becoming more like a ‘doctor’ meant creating a rift between their old and new identities, a source of tension for students themselves and people they had grown up with. One described her friends making comments like, ‘You won’t come back to [our town] when you’re rich’. An Indigenous student was uncomfortable with the high status afforded doctors – status was for her most often reserved for community Elders.

Our research showed these students were caught between two worlds: no longer fitting easily into their old lives, nor into medical culture. One said, regarding the other students on her course:

I do find it hard to relate to people that are from rich families….I don’t know, there are all these things that I’ve seen and done that are different to what they may have seen and done…

Interviewees recognised that their backgrounds were a professional asset that gave them an advantage when treating patients, most of whom also do not share the privileged background of doctors. An Indigenous student noticed that many students were ‘quite clueless with Indigenous health’. Another said that because of his ‘very humble’ background, growing up in an environment where people had little money and poor health, he understands where patients are coming from.

What stood out was the commitment of these students to return to their communities as doctors. The areas they came from – typically low-SES, rural or Indigenous community – are the very places most in need of better healthcare access. Encouraging doctors to work in these regions has always been a challenge, and there’s evidence that the best strategy is to recruit students who grew up in these areas.

Having this goal of returning to serve community meant that participants were not prepared to forfeit their identities to fit some medical professional norm. Instead they were learning to succeed in both worlds. One participant proudly told us he was ‘99% medical student, 1% bogan’. Another said:

I might have to be a slightly more refined version of myself as a doctor. But I think with the patients I’ll still be okay and with my family, I’ll still be much the same.

Understanding extreme social mobility

Australia’s comparatively good rates of social mobility are less apparent in high status professions. The proposed increase in university fees, especially for degrees like medicine, may well curtail what limited mobility exists. It’s important for educators and policy makers to better understand journeys of extreme social mobility. Understanding how people from ‘humble’ backgrounds make their extraordinary journey into, through and beyond medical school is important if the profession is to diversify and become more inclusive of the truly talented, regardless of social background.

 

Erica Southgate is an Associate Professor at the School of Education, University of Newcastle, Australia. She is her first in her family to go to university. In 2016, as national Equity Fellow, she conducted research on increasing access to high status professions such as medicine, law and engineering for young people experiencing disadvantage and marginalisation. She believes emerging technologies such as virtual and augmented reality can be used to broaden the career education of young people and is the author of the report: ‘Immersed in the future: A roadmap of existing and emerging technology for career exploration.’ https://www.ncsehe.edu.au/wp-content/uploads/2016/08/Immersed-In-The-Future-A-Roadmap-of-Existing-and-Emerging-Technologies-for-Career-Exploration.pdf

 

 

Caragh Brosnan is a Senior Lecturer in Sociology at the University of Newcastle, Australia. Her research focuses particularly on understanding how different kinds of knowledge come to be valued in scientific and health professional practice and education. She recently led an ARC Discovery Early Career Researcher Award project, Complementary and alternative medicine degrees: new configurations of knowledge, professional autonomy and the university. This explored how what is taught in complementary and alternative medicine (CAM) degrees reflects the professional status of CAM, at the same time examining the broader relationship between professions and the university. Caragh’s work on medical education has focussed on issues of equity and access, as well as on the construction of legitimate knowledge in medical curricula. Her publications include the edited collections, the Handbook of the Sociology of Medical Education (Routledge 2009) and Bourdieusian Prospects (Routledge 2017).

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