American College of Physicians: Internal Medicine — Doctors for Adults ®


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The privilege gap within medicine

From the August ACP Hospitalist, copyright © 2012 by the American College of Physicians

By Farzon A. Nahvi

As awareness of income inequality in America has increased, a lot has been written about its effect on the nation's culture. Beyond concerns about the increasing concentration of wealth and power, this inequality has created a chasm in America's social spheres. “The affluent and the middle class really constitute two separate cultures now that are deeply alienated from one another,” noted author Timothy Noah in his book The Great Divergence: America's Growing Inequality Crisis and What We Can Do About It. While this chasm exists throughout our culture, it is particularly poignant in the world of health care.

According to 2005 data from the Association of American Medical Colleges, more than 60% of medical students come from families in the top quintile of household income, with only 20% coming from families in the bottom three quintiles. The median family income of American medical students is over $100,000, meaning the average medical student comes from the top 15% in terms of income. Of course, medical students become doctors, further stratifying themselves as high-income earners.

Photo courtesy of Farzon A. Nahvi.

Photo courtesy of Farzon A. Nahvi.

Patients, on the other hand, are in a different boat—they are America. Rich, poor and in-between. Everyone, even the uninsured, receives health care. The end result is that hospitals have become a unique culture all their own, where well-meaning but privileged health care providers are tasked with caring for patients who sometimes struggle to have their problems understood.

As a medical student in New York City, I've seen what happens when these cultures get tossed together. I've seen a patient chastised for not taking his medications when he couldn't afford the copay. I've seen a doctor grumble about a patient using the emergency department for her basic care…which she did because she worked seven days a week and couldn't afford time off for an office appointment. I've seen a neurologist scorn a patient for taking her children out of school for another child's appointment because there was nobody to pick them all up from the bus stop. I've seen a patient criticized for taking a cab instead of an ambulance to the emergency department because he feared the cost of the ambulance.

Admittedly, each of these situations was frustrating. But in each situation, the patient was doing the best she could in the circumstance she was in. The physician, too, was well meaning, but simply did not understand, or did not know to ask the right questions to be able to understand, why the patient did what she did. And each time, the doctor walked away frustrated, believing the patient was less committed to her own health than the doctor was. Each time, the patient walked away without having been fully understood.

If a valid concern about our politicians is that their wealth makes them out of touch with their constituents, the same may be true of doctors and their patients. It's a tall order to expect physicians accustomed to the benefits of privilege to recognize and understand the problems the average person faces. And no matter how advanced the science, empathy is, after all, what drives good medicine.

One solution is to steer a more representative slice of the American population into medicine. Fundamentally, we need to make medical education more affordable to those who currently don't view it as a viable option. In the meantime, medical schools can create outreach programs, as they do for women and minorities, to attract low- and middle-income students toward careers in medicine. Diversity of backgrounds should be treated as an asset by admissions committees. Cultural competency training can be used as well, to better train students from all backgrounds about the patients they will be treating.

Health care went through a series of evolutionary changes as the gender gap closed in medicine, resulting in both a better medical culture and better care for patients. We've already seen that doctors who better reflect our population can help advance health care. We're now due for a second dose of this treatment.

As more attention is given to income inequality in America, let's use this moment to focus on the privilege gap that pervades our health care system—and once again improve our medical culture and care.

Mr. Nahvi is a fourth-year medical student at New York University School of Medicine.


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