The class ceiling for tomorrow’s junior doctors
As junior doctors fight to hold on to their terms and conditions, I worry about my own situation and that of future medical students. A medical degree now costs on average £45 000 (€58 240; $64 650) in tuition fees, plus £30 000 in maintenance payments. Grants and bursaries have been frozen or withdrawn and replaced with static loans. Three private medical schools will be operating by 2017, yet the foundation programme was oversubscribed in January 2015 for the fifth year in a row. Medical school summer vacations, once reserved for recuperation and overdraft repayment, are now for CV padding: unpaid internships or shadowing. How many 17 year olds have the bravado to take on a medical degree or the parents to fund it?
In 2012, the year tuition fees were trebled, the Social Mobility and Child Poverty Commission announced that medicine “lags behind other professions” in the focus and priority it accords to widening access and promoting social mobility. The Selecting for Excellence report that followed makes for predictable reading: over half of all medical students come from the wealthiest 10% of households (£90 000 average annual income). By contrast, only 8% of medical students were eligible for free school meals, compared with 21% of pupils nationally. Even before the fee increase, BMA research suggested that a medical student’s family handed their child on average £15 000 in cash maintenance, on top of loans, to get through the course. That amounts to the entire annual income of some families. With tuition fees bound to increase, it’s no wonder so few working class children go into medicine—only the wealthy can afford it.
Despite the efforts of widening participation initiatives, the problem is more complicated than simply inspiring working class students to apply to medical school. We also need to tackle the financial barriers to a medical education. A study by McManus and colleagues showed that a high mark in the UK Clinical Aptitude Test entrance exam had little bearing on future performance at medical school. Applicants who are from wealthier backgrounds can often afford tutoring to ace their way through these exams, which creates an unfair and distorted playing field.
Means testing tuition fees and maintenance loans will remove a barrier to students from poorer backgrounds. It might seem counterintuitive to raise fees further, but the additional cash could fund more substantive financial aid for the poorest students. Given the figures in the Selecting for Excellence report, many medical students’ families could certainly afford it.
Some might question the need for more medical professionals from working class backgrounds. However, a greater number of doctors from working class backgrounds will mean that there are more doctors who reflect the patient population. Since the 1980 Black report, we’ve known that working class patients experience greater healthcare inequalities. When a doctor and patient share social characteristics, such as class, consultation, communication, and outcomes are better. Similarly, the increase in the number of female doctors has improved healthcare for women. What’s better for the disadvantaged in society is often better for all.
When I was a child, my family received working tax credits, which made sure my sister and I never went to school hungry or without the materials we needed. At college, we received educational maintenance allowance, which allowed us to work part time instead of full time during our studies. During my first degree, I received the full grant, which meant I could focus on my studies during term time, rather than worrying about how to pay rent. But now, these initiatives have either been sacrificed at the altar of austerity or are being threatened by it, once again raising financial barriers to medicine for students from working class backgrounds.
I doubt I would be writing this article now if it were not for the support that society collectively gave me and thousands of others like me. I hope that by training as a doctor, I can give back to that same society.
Unaddressed, these financial barriers deny working class students the social right to pursue a career in medicine. The public and the profession miss out on a workforce that reflects the diversity of the nation. It is time to remove these unfair and irrational obstacles to all willing and able applicants.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.Joseph O’Keeffe, second year graduate medical student
A1 University of Leicester
Follow Joseph on Twitter @JOCaoihm
- 1Rimmer A. Tackling oversubscription of the foundation programme. BMJ Careers 27 Mar 2015. http://careers.bmj.com/careers/advice/view-article.html?id=20021602.
- 2Selecting for Excellence Project Group. Selecting for excellence final report. Medical Schools Council 2014, pp 2 22.
- 3Sell S. Medical students borrow £15,000 from parents. GP Online 15 April 2010. www.gponline.com/medical-students-borrow-15000-parents/article/995924
- 4Rimmer A. Private school students perform less well at medical school. BMJ Careers 24 Dec 2013. http://careers.bmj.com/careers/advice/Private_school_students_perform_less_well_at_medical_school.
- 5Boulton M, Tuckett D, Olson C, et al. Social class and the general practice consultation. Sociol Health Illn 1986;8:325-50. .
- 6Carnes M, Morrissey C, Geller SE. Women’s health and women’s leadership in academic medicine: hitting the same glass ceiling? J Womens Health (Larchmt) 2008;17:1453-62. doi :.