To effectively practice medicine, we as medical trainees and physicians have to acknowledge the privileged position we are in and the barriers that our patients face.
This privilege exists in part because many entering the profession are advantaged in the first place: traditional medical admissions processes benefit those of higher socioeconomic status. Admissions offices across North America are beginning to create innovative solutions to bridge this gap.
The other part of the privilege has to do with the profession itself: medicine is placed on a pedestal in society, with a high amount of trust placed in us by patients. Even within health care, physicians are often viewed as the unequivocal leaders, something that is appropriately changing with more inter-professional models of care.
Recognizing privilege is important because high quality patient care depends on it. Patients sometimes struggle to be understood by physicians who mean well, but for whom issues like marginalization, poverty, or limited health literacy are simply not as real. We are trained to explore the intersection between health care and social issues, yet when it comes down to it, we may only “refer to social work.”
For example, there is a lot more physicians can do for patients in poverty, from asking patients if they’ve applied for government programs to screening for conditions that are more common among low-income populations.
Moreover, unrecognized privilege is a breeding ground for bias. Both anecdotal writing and published research have shown that health care is rife with stereotyping and microagressions that impact patient care.
This is not the explicit discrimination we are quick to denounce. Instead, it is subconscious, such as assuming patients with disabilities are not sexually active, or that their presenting issue is necessarily related to their disability. It might also mean under-treating pain in patients of certain classes or races because of subconscious assumptions about the potential for medication abuse, or a false belief that they have higher pain tolerances.
Our ability to self-reflect impacts the way we interact with other practitioners as well. While it is never malicious, medical trainees and physicians sometimes make the subconscious assumption that other professionals are not as capable. This type of hierarchical thinking can lead to more problematic issues such as verbal abuse and sexual harassment, especially towards those considered lower on the health care “ladder.”
Despite the clear importance of this, and many “calls to action,” much more can be done.
Admissions offices should continue to use outreach programs, financial aid, and widened selection criteria to build classes that are representative of the patients they will be serving.
However, there are also plenty of things we can do within the profession itself and its training.
First, quite simply, there must be a collective paradigm shift. It is not enough to stand idly by and hope that the health system will be swept up by the tide of social progress around us.
We must actively create and support initiatives to improve social justice in medicine, give back to our communities, and position medicine as a profession that does not buy into the societal hierarchy and superiority often ascribed to it. No more should the clinicians that care about social justice be considered the “advocacy types,” but instead just clinicians.
Second, we must find better ways to help medical students develop a deep understanding of privilege. Medical education has progressed, producing more socially conscious physicians than ever before, but we must not be complacent in this.
Every school has a course about the social determinants of health, but these courses are often considered the fluff that you quickly cram, or the experiences that give you a break from the real learning. On this sort of mentality, former Daily Show host Jon Stewart once said that “if you’re tired of hearing about it, imagine how exhausting it is living it.”
That said however, perhaps there is good reason that these courses are not taken seriously. Feedback and data from students must be integrated to create immersive experiences that effectively teach these concepts.
The content should also be scheduled in a way that makes it a priority, instead of being found exclusively the week before exams, when students have more pressing concerns.
It must also be dispersed throughout curricula. For example, though it is commonplace to learn about race as a disease risk factor, this is usually taught without explanation about why these risk factors exist. This is problematic, since often the cause has less to do with genetics, and more to do with socioeconomics and systemic inequities.
To supplement curriculum changes, student leaders should work to create more spaces to have open, non-judgmental discussions on topics like discrimination.
Third, we must encourage medical organizations and student societies to be bodies for bigger change. A classmate once said it best when she lamented that the most advocacy we were engaged in was for fewer mandatory seminars.
There is a worry that our place in medical school is not to be “political,” but part of acknowledging our privilege means engaging with the world around us and pushing for social change. This is slowly shifting, as was seen when student Medical Societies released statements last year standing in solidarity with Black Lives Matter.
Finally, maybe the most powerful action is reflection. It is easy to become defensive and quickly tell ourselves that we know know our patients may face barriers, or that we can rattle off the social determinants of health. It is another thing to actually believe that this privilege exists, address our personal blind spots, speak up in health care settings, and go the extra mile to actively work against inequities felt by our patients.
As medical students, perhaps sometimes we need to spend less time debating the relative incomes of various specialties, and more time remembering that no matter what, we are extremely fortunate.
Medicine is a profession commonly associated with elitism. We have to ask ourselves if that is the identity we want to have.