Are First-Generation College Students Underrepresented in Medical School?

Introduction:

Recruitment of first-generation medical students is essential to improving diversity and inclusion in US medical colleges. First-generation students offer unique experiential insights that foster empathy and cultural competency in the learning environment and improve health outcomes for patients. However, little is known about their demographic characteristics or career goals. Despite their crucial role in health care, first-generation medical students remain an understudied and disadvantaged minority in American medical colleges.

Defining First-Generation Medical Students:

First-generation college-graduate students are individuals whose parents did not complete a postsecondary undergraduate degree (i.e., associates, bachelors, masters, or doctoral). The American Association of Colleges of Osteopathic Medicine (AACOM) defines first-generation (FG) students as those whose parents did not complete a four-year undergraduate degree. It is important to note that there are a few different accepted definitions of first-generation students.

Underrepresentation of First-Generation Students:

Understanding of first-generation medical students is inferred from a few qualitative studies and acceptance/matriculation data, which has found that first-generation undergraduate students are underrepresented within medical schools. Preliminary data estimates only 14.6% of allopathic medical school matriculants were first-generation in 2021-2022. With the addition of the FG indicator to the AAMC application in 2017-2018, it was estimated that only 12.4 percent of MD medical students matriculating in 2021-2022 were FG. Medical school matriculants from 2002 to 2015 and found that first-generation students made up just 7.1% of incoming classes by the end of the study period - down from 8.7% in 2002. This cross-sectional study of US medical student matriculants found a decrease in the number of matriculants who were first-generation. Recent research has been released showing there is a statistical but not meaningful difference in osteopathic FG students in the areas of growth mindset, purpose, resilience and psychological symptoms, however we would like to see studies such as this one repeated in students engaged in their first through fourth years of medical school and in practice, rather than just incoming osteopathic students.

Benefits of First-Generation Medical Students:

First generation students offer significant benefits to medical education and health care by bringing experiences and perspectives that may more closely align with those of their patients, qualities that foster enhanced cultural competency and empathy. Diverse health care teams result in better patient experiences, improve health care delivery to underserved regions, and help reduce health care disparities, underscoring the importance of this population of student doctors. FG students import diversity, cultural competency and inclusion into the medical field. With their diverse life experiences, they often empathize with patients in different ways than their continuing-generation peers. A demographic study found FG physicians are more likely to practice in underserved areas, potentially due to their similar backgrounds. Our results suggests that enrollment of first-generation students may increase the number of physicians who are willing to serve underserved populations.

Demographic Characteristics and Career Goals:

While first-generation college students are known to be diverse in terms of gender, race/ethnicity, and socioeconomic status, the demographic composition of first-generation medical students is less clear. Recent data show that first-generation medical students have been predominantly non-Hispanic White, female, and over 23 years of age, but it is unclear if first-generation medical students still share these characteristics.

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To address this gap, one study aimed to describe first-generation students’ (1) demographic backgrounds; (2) career intentions; and (3) interest in loan forgiveness programs singularly and compared to their peers among third-year medical students at a private, urban medical school.

In this study, thirteen percent of respondents identified as first-generation medical students (n=26). First-generation medical students were more likely to be male, aged 21-26 years, White, and non-Hispanic/Latino. First-generation students were significantly more likely to report wanting to care for underserved populations (35%, n=9 vs 21%, n=35, P=.05). First-generation students were significantly more likely to report intent to enter a loan forgiveness program (31%, n=8 vs 12%, n=20, P=.002).

Barriers to Success for First-Generation Medical Students:

While FG matriculation has increased, there appear to be significant barriers to success once in medical school. Research regarding FG students enrolled in medical school has identified several key points. Please note that much of the research below on FG medical students is on those in MD or MD/PhD programs; research exclusively on FG students in DO programs may yield different findings. FG students are less likely to enroll in medical school than their continuing-generation colleagues. Those who are also low-income students are even less likely to enroll in medical school. The complex intersectionality of the FG identity also lends itself to increased financial and social barriers, as many FG students are also members of other underrepresented groups in medicine, such as low socioeconomic status or racial minorities. Another barrier experienced by FG students is navigating the hidden curriculum of medicine, such as dealing with mental health and understanding the dichotomy between what is taught in official curricula and the actual culture of practiced medicine. While skills of grit and resilience are qualities valued highly in the medical field, a study at Indiana University School of Medicine showed FG students experience increased levels of fatigue, stress, financial worries, a lower quality of life and lower social support ratings than their continuing-generation counterparts.

Financial Challenges:

“No matter which subset of first-gen students we talk to, money is a foundational part of the challenges they face - even if they're not technically low-income,” said Havemann, the paper’s first author. “Within the medical community, we need to talk more about the discomfort of disadvantaged students entering incredibly wealthy institutions with mostly wealthy peers. The proportion of first-generation students with parental income in the top 5% of US household income was very small (<5% of all first-generation students) and stagnant over time (from 1.4% in 2002 to 0.8% in 2015), while the proportion of first-generation students with parental income in the lowest (first) quintile increased over time (from 13.3% in 2002 to 17.1% in 2015). Graduating first-generation medical students had a higher amount of total educational debt compared with non-first-generation students, with a significantly increasing debt ratio between 2002 (ratio, 1.12) and 2015 (ratio, 1.31) (P = .004).

The Importance of Support Systems:

Social, cultural and institutional support (social capital, financial stability, food security, stress management, disability services) are paramount to supporting this group of students and continuing to foster their success in medical school. These larger systemic supports require smaller advocacy to occur first.

Addressing the Disparities:

To increase recruitment of first-generation medical students and begin closing the gap in health disparities for patients in underserved areas, a break from traditional medical school admission processes is required. Efforts to recruit and support first-generation medical students should not end at admission. Our results support the call to action for medical schools to create mentorship opportunities for first-generation medical students geared to their specific interests and needs. Information sessions and academic advising regarding loan forgiveness program requirements and ways to work with underserved populations will prepare students to make informed choices about residency and future career opportunities.

The Role of Medical Schools:

medical schools must help first-generation medical students realize their full potential. At our urban, private, medical school, first-generation students were more interested in loan-forgiveness programs and having career goals related to addressing health disparities than other students.

A Call for Structural Reform:

The findings come as many institutions grapple with how to improve diversity pipelines and support systems. Greater awareness of the FG identity would facilitate the creation of other FG organizations similar to what we have started at KCU-COM. The diversity that FG physicians bring to the medical field is critically important, especially in underserved communities, where many FG physicians grew up.

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