To the Editor: Much has been written about growing disparities in America. Nowhere, however, are these disparities more poignant than in the world of health care.
Data from the Association of American Medical Colleges1 show that over 60% of medical students come from families in the top quintile of household income, with only 20% coming from families who earned in the bottom three quintiles. Similarly, the median family income of American medical students is over $100,000.1 In other words, the average medical student comes from the upper 15% of America. Patients, on the other hand, are often in a different boat—They are all of America: rich, poor, and in between. The unfortunate consequence of this is that patients sometimes struggle to be understood by well-meaning but, ultimately, privileged doctors who sometimes cannot relate to patients from other backgrounds.
A familiar scene, for example, is the patient who repeatedly tells his physician that he doesn’t take his medications because he “forgets.” Sincere and hard-working physicians around the country spend hours with patients of this kind, developing techniques and special tricks to help them remember their medications. Often, however, the patient’s real problem is one of finances, not memory—an inability to afford the co-pay, an unwillingness to take time off from work to get to the pharmacy, or skipping “forgotten” doses to cut costs, for example. No matter how well-meaning, it often does not occur to the more privileged that such issues even exist. Worse, patients can feel embarrassed to speak about money issues in front of a doctor who has clearly never experienced them.
The stopgap fix is to better train all students to deal with all types of patients. A true long-term solution, however, is to steer more representative slices of America—individuals from all income levels—into medicine. There are many ideas for how to do this, from special recruitment strategies to arrangements for financial aid. Fundamentally though, for change to occur, admission committees need to recognize the importance of getting more middle- and low-income students into our medical education system.
Of course, this wouldn’t be the first time that eliminating an inequality led to better medicine—We’ve seen this before. As shown in a 2002 review,2 patients have already benefitted from better care as the gender gap closed in medicine, and many would argue that medical culture has improved for everyone as the percentage of female physicians has increased. We could once again benefit from the closing of another gap—this time, the privilege gap.
Farzon A. Nahvi, MD
Resident in emergency medicine at NYU/Bellevue; [email protected]
1. Association of American Medical Colleges. Medical Educational Costs and Student Debt: A Working Group Report to the AAMC Governance. 2005 Washington, DC Association of American Medical Colleges http://www.neomed.edu/students/es/finaid/secure/step5/edcostsanddebt.pdf
. Accessed February 26, 2013
2. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: A meta-analytic review. JAMA. 2002;288:756–764