Elsevier

Social Science & Medicine

Volume 184, July 2017, Pages 84-98
Social Science & Medicine

Subjective social status and premedical students' attitudes towards medical school

https://doi.org/10.1016/j.socscimed.2017.05.004Get rights and content

Highlights

  • Little is known about how premeds' social status shapes medical school outlook.

  • Low status premeds experience greater doubts about attending medical school.

  • Lower status premeds internalize community expectations to attend medical school.

  • Divergent aspirations are largely explained by differences in financial strains.

Abstract

Although students from lower socioeconomic backgrounds are more likely to depart from the medical education pipeline, little is known about how premedical students' social origins influence the adversities they face, the resources they possess, or the internal struggles they confront in deciding whether or not to pursue a career in medicine. Using original data collected from premedical students at a flagship state university in the Midwest (N = 364), this study explores how subjective social status shapes students' reservations about medical school attendance and their perceptions of external pressure to pursue a career in medicine. Status-based discrepancies in financial strains, social capital, and interpersonal stressors—and the degree to which variation across these measures mediates status differences in medical school outlook—are also explored. Net of objective measures of social class, results suggest that doubts about attending medical school and feeling that not attending medical school will let down one's community are more prevalent among premeds who identify as lower status. These group differences are explained—at least in part—by lower status premedical students' perceptions of financial hardships, more limited reserves of social capital, and more frequent encounters with class-based discrimination and with educators who discourage their career aspirations.

Introduction

Medical education and physician socialization have long been of vital interest to medical sociologists (Becker et al., 1961, Bloom, 1971, Bosk, 1979). Research in this area has been re-invigorated in recent years (Brooks and Bosk, 2012, Underman and Hirshfield, 2016), with contemporary studies turning a critical eye towards the narratives that premedical students construct to endure against the rigors of the premedical track (Lin et al., 2014). Despite this burgeoning literature, there is still much that remains unknown about those at the outset of their journey into the medical profession. A good deal of our knowledge concerning contemporary premedical students comes from research that primarily draws upon institutional records limited to cursory information regarding students' demographic characteristics, SAT scores, and grades in coursework (Alexander et al., 2009, Barr et al., 2008). While this work has been invaluable to our understanding of premedical students' academic trajectories, these data are less able to speak to the ways in which premedical students' social location might shape their social relationships, experiences of interpersonal and financial stressors, and ultimately, their medical school aspirations. Although the premedical track has often been depicted as a series of initiation rituals that medical school aspirants face on equal footing, a key contribution of this research is to highlight how premedical students' experiences can vary widely as a function of their social status.

Insights into the unique experiences of trainees from lower social class backgrounds have been conspicuously absent from social science accounts of medical education. Since 1987, the Association of American Medical Colleges (AAMC) has administered the Matriculating Student Questionnaire—which collects information regarding students' personal and family background—to all incoming medical students. Using this information to partition each year's incoming cohort into income quintiles, the pronounced effect of social status on medical school admission is clear. Between 1987 and 2005, the percentage of medical school admits from the highest quintile did not dip below 48.1%, whereas the percentage of matriculating students from the lowest income quintile did not once eclipse 5.5% (Jolly, 2008). In the United States, severe medical care shortages are projected to occur as early as 2020, with these shortages hitting already at-risk, low income inner-city and rural areas the hardest (AAMC, 2013). Because past research suggests that physicians belonging to underrepresented groups are considerably more likely than their more privileged colleagues to work in these areas (Xu et al., 1997) the loss of this group poses direct consequences for population health. Consequently, a greater understanding of the issues confronted by lower status premedical students during the undergraduate years is essential. To examine the experiences of this group, this study draws upon novel data collected from freshman and sophomore premeds at Midwest University—a large, research university in the Midwestern United States.

The central questions of this article align with recent calls to examine the educational ambitions of premedical students at earlier stages in their academic careers, with an emphasis on the experiences of students belonging to vulnerable populations (Lin et al., 2013). By examining how social status influences the stressors that premedical students face and the resources they possess, this research sheds light on the distinctive hardships countenanced by lower status premedical students and how these experiences inform their attitudes towards medical school.

Social Status has long been the subject of intense theoretical and empirical scrutiny within the social sciences. Contemporary discourse on social status acknowledges the concept's inherently dualist nature, comprising both an objective component (e.g., income, wealth), as well as a subjective aspect that taps into an individual's assessment of where he or she stands within the social hierarchy.

To date, measures of objective social status have been more frequently employed in the social science literature. Decades of research have centered on the extent to which different indicators of objective social status—and combinations of these measures—accurately capture one's relative standing in society. More often than not, these indices include measures of educational attainment, occupational status, income, and wealth (Blau and Duncan, 1967, Hauser and Warren, 1997). In stark contrast, subjective social status can be conceptualized as a social psychological construct that captures an individual's perception of his or her position within the social hierarchy (Jackman and Jackman, 1973, Kornhauser, 1950). Summarized more succinctly, “a person belongs to a class if he feels himself a member of it” (Kornhauser, 1950: p.338). Although researchers have been slow to adopt measures of subjective status, one area in which it has gained prominence in recent years is research aimed at understanding the durable status gradient in mortality and health (Adler et al., 2000, Demakakos et al., 2008, Singh-Manoux et al., 2005).

Theoretical elaborations on the association between subjective and objective social status speculate that material wealth spurs the formation of subjective social class identities (Bourdieu, 1985, Bourdieu, 1987). Findings from empirical research employing both objective and subjective measures of status support this contention, highlighting a high degree of correspondence between one's social status as derived from traditional, objective measures and where one ranks him or herself within a society's social hierarchy (Singh-Manoux et al., 2003). In line with this research, I hypothesize:

H1

Premedical students whose objective measures of status are indicative of higher social standing (i.e., respondents whose parents have higher levels of education, who were raised in neighborhoods with higher median incomes, and who attended a private high school) are less likely to identify as low or middle status on a measure of subjective social status.

Premedical culture has long been characterized as hyper-competitive, with premedical students portrayed as more grade-oriented than their non-premed counterparts. In line with these stereotypes, research indicates that undergraduates view their premedical peers as more competitive, self-disciplined, and goal-oriented (Sade et al., 1984). Although this work highlights the some of the widely held stereotypes about premedical students, other research suggests that tales of “cutthroat,” premedical students are more frequently than not, the product of hearsay (Conrad, 1986).

Premedical students negotiate a number of obstacles in the pursuit of their chosen profession. Beyond rigorous coursework, hindrances include trepidation about the lengthy training process, intense competition for grades, and the availability of less demanding but similarly compensated career options (Lovecchio and Dundes, 2002). A related concern is the prospect of multiple post-graduate years spent paying off student loans. A 2008 report from the AAMC indicates that approximately 20% of medical school graduates leave school with debts totaling $200,000 or more (Steinbrook, 2008). While one might speculate that these concerns are more salient among premedical students from lower and working class backgrounds, to date we know relatively little about how social status influences either the stressors premedical students' encounter or their medical school outlook.

Because medical school admission is the ultimate goal for premedical students, an essential aspect of the premedical experience is how students think about and evaluate their chances of going to medical school (Lin et al., 2014). In this study, I examine two measures of how premedical students think about medical school application and enrollment: doubts about medical school attendance, and experiences of community pressure to attend medical school.

Research suggests that the precipitous decline in medical school aspirations among lower status students occurs between high school and college graduation. Using parental education as a proxy for social status, a report by the AAMC found that although 59% of high school sophomores with parents possessing less than a college degree sought to attend medical school, only 15% of this group ultimately ended up applying (Morrison and Cort, 2014). In light of evidence that undergraduates from lower social strata are less likely to apply and to gain admission to medical school relative to their higher status counterparts, there is reason to suspect that these students will hold less sanguine views about medical school attendance. Thus the following is proposed:

H2

Low status premedical students are more likely than their middle and high status peers to have doubts about attending medical school.

Research on the college experiences of undergraduates from lower class backgrounds attending elite universities suggests that these students develop complex relationships with their home communities over the course of their college careers. Compared to their peers, these students experience a more profound loss of community as they make the initial transition from home to residential campuses (Lee and Kramer, 2013). Additionally, these students experience acute internal tensions as they balance lingering allegiances to their working class roots with an emerging disapproval of the social values commonly held by those in their home communities (Lehmann, 2013). Because their sheer existence on predominantly middle and upper class college campuses—i.e., places like MU—serves as a continual reminder of their “otherness,” these students may be cognitively primed to think about their behaviors and decision-making through the lens of their home communities (Steele and Aronson, 1995). For premedical students, this may lead to the internalization of community expectations that they continue on to medical school.

Alternatively, research in the sociology of education finds that parents' expectations for their children's educational attainment shapes the aspirations that children come to hold for themselves (Looker and Pineo, 1983). These expectations vary along social class lines, with parents from middle class backgrounds substantially more likely to expect their children to obtain a bachelor's degree than working class parents (Roska and Potter, 2011). Other research finds that young adults with highly educated parents are more likely to pursue a professional degree or doctoral studies than students whose parents possess lower levels of education (Mullen et al., 2003). As such, premedical students from higher status backgrounds may feel that attending medical school is “expected” of them and internalize these pressures. In light of these findings, I offer two competing hypotheses:

H3a

Low status premedical students are more likely than their middle and high status peers to feel that they will let down their community if they do not enroll in medical school.

H3b

Middle and high status premedical students are more likely than low status peers to feel that they will let down their community if they do not enroll in medical school.

Status-based differences in medical school aspirations among early career premeds may stem from a variety of social factors principally determined by one's social class origins. Drawing upon research in the stress process and social capital traditions (Lin et al., 1981, Pearlin et al., 1981), this study identifies three facets of the social world that may help to account for status group differences in medical school outlook: financial strains, social capital, and interpersonal stressors.

Research on the social distribution of stress indicates that individuals from lower status backgrounds are significantly more likely than those of higher status to experience a variety of stressors (Turner and Avison, 2003). Given that the life chances of children are tightly coupled with their parents' social standing, students from lower status backgrounds are more susceptible to a variety of stressors compared to their high status peers. For instance, recent research indicates that undergraduates from lower class families are less likely than their upper class peers to be insulated from financial hardships like student debt (Houle, 2013). Consonant with this research, I predict that lower status premeds will report significantly greater financial strains than their more privileged counterparts:

H4a

Low status premedical students are more likely than their middle and high status peers to worry about their family's ability to “get by” financially.

H4b

Low status premedical students are more likely than their middle and high status peers to worry about their ability to pay for tuition.

Network-based social capital represents a useful concept for operationalizing undergraduates' access to material and symbolic resources through their social relationships (Lin, 2001). For high status undergraduates, networks might include influential members who are able to leverage their own personal contacts to help students gain access to highly competitive internships or attain employment post-graduation. In light of the finding that low status college students possess less social capital compared to their more privileged peers (Moren Cross and Lin, 2008) the following hypothesis is offered:

H5a

Low status premedical students have lower levels of network-based social capital than their middle and high status peers.

For premedical students, a personal relationship with a physician may prove invaluable to navigating the premedical track. A study of premedical students by Barr et al. (2008) finds that one of the few factors associated with an increased interest in premedical studies between the start of freshman year and the end of sophomore year is having a physician in one's family. Although the reasons underlying this association are unclear, it is possible that the hard fought wisdom and targeted advice provided by family members in the medical profession help make the arduous journey to medical school more manageable. Extrapolating from research which finds that lower and working class Americans are significantly less likely than members of the upper class to report ties to physicians and other professionals (Cornwell and Cornwell, 2008), the following is hypothesized:

H5b

Low status premedical students are less likely than their middle and high status peers to have a doctor in the family.

Premedical students may experience discrete or recurrent interpersonal stressors that serve to irrevocably alter their medical school aspirations. Although undergraduate institutions across the United States vary widely in terms of the socioeconomic profile of the students they serve, research indicates that lower income students who attend colleges where affluence is visible (i.e., places like MU) experience a number of difficulties. Specifically, this work finds that working class students report feelings of alienation—both from peers and from the college community—that persist throughout their college careers (Lee and Kramer, 2013, Stuber, 2011). Beyond an already heightened awareness of their distinctiveness on campus, lower status students may also experience subtle acts of class-based discrimination and micro-aggressions that lead to greater cynicism and a sense that they do not fully “belong.” Based on this literature, and research which suggests that lower status individuals are more likely than those occupying higher social strata to report experiences of class-based discrimination (Kessler et al., 1999), the following is hypothesized:

H6a

Low status premedical students are more likely than their middle and high status peers to experience social class-based discrimination.

Personal relationships with faculty members are integral to undergraduates' success (Chambliss and Takacs, 2014), and students who feel that their teachers respect and care about them are more apt to hold positive views towards school (Hallinan, 2008). Yet, decades of research indicate that student-teacher interactions are colored by students' social class standing (Becker, 1952, Lareau, 2011). Compared to their upper class peers, working class undergraduates are exceedingly reluctant to seek out help from instructors or to attend office hours (Jack, 2016). When they do interact with faculty, lower class undergraduates are less likely to view these exchanges positively or to be satisfied with the advising that they receive (Kim and Sax, 2009). Consequently, the following is hypothesized:

H6b

Low status premedical students are more likely than their middle and high status peers to be discouraged from pursuing their desired career by a teacher or advisor.

The literature on financial strains, social capital, and interpersonal stressors yields a number of insights into how these factors might help to explain status differences in medical school aspirations. In terms of doubts about medical school attendance, among students from lower status backgrounds, fragile family finances might make the prospect of an even lengthier, more costly, educational track untenable in the face of mounting financial pressures. Furthermore, in light of the importance of internships—especially shadowing opportunities—for medical school admission, smaller reserves of social capital might dim the hopes that these students have for successful medical school application. In a similar vein, because having a physician in one's family is predictive of continued premedical interest (Barr et al., 2008), low status premeds' reduced likelihood of having a doctor in the family has clear implications for the medical career aspirations of this group. In terms of interpersonal strains, experiences of class-based discrimination might foster a pessimism among lower status premeds that leads them to develop misgivings about medical school attendance. Finally, given the importance of supportive relationships with faculty for academic success (Chambliss and Takacs, 2014), dispiriting interactions with university faculty and advisors by low status premeds might prove especially damaging to their medical school ambitions.

Each of these circumstances—greater financial duress, smaller stores of social capital, experiences of class-based discrimination, and unfair treatment by faculty—may also prime lower status students to think about their academic successes (and failures) in the context of their home communities. Consciously or not, these students may internalize community expectations that they follow through on their earlier academic promise and attend medical school. As such, adjusting for these factors might help to explain the internalized pressure to attend medical school that low status students feel more acutely than their more privileged peers. In sum, this body of research leads to the culminating hypothesis:

H7

Adjusting for financial strains, social capital, and interpersonal stressors will significantly mediate social status differences in attitudes towards medical school.

Section snippets

Site & sample

Data for the College Experiences of Premedical Students (CEPS) Study were collected from undergraduates at Midwest University (MU), a flagship research university in the Midwest. MU is located in a suburban town with a population of slightly over 80,000 residents. The university itself boasts an undergraduate population of over 38,000 and 57% of students claim in-state residency. Costs for attendance range from $24,800 for in-state students to $48,600 for out-of-state students.

Given the study's

The association between objective and subjective measures of social status

Table 3 presents results from a multinomial logistic regression in which subjective social status is regressed on objective status and control variables. These results provide uniform support for hypothesis 1. Compared to respondents whose parents hold a graduate degree, respondents whose parents have less than a Bachelor's degree were significantly more likely to categorize themselves as either low (RRR = 9.08, p < 0.001) or middle status (RRR = 3.75, p < 0.001) compared to high status.

Discussion

Although physician socialization and medical education have enjoyed renewed interest from social scientists, we still know relatively little about those at the beginning of their journey into the medial profession. Past research indicates that students of lower social standing are less likely to follow through on earlier plans to attend medical school (Morrison and Cort, 2014). Given that medical school graduates from this group are more likely to work in underserved communities (Xu et al., 1997

Acknowledgements

Support for this project was provided by the National Science Foundation Dissertation Improvement Grant #1519056. This study was approved by the Internal Review Board at Indiana University-Bloomington: Protocol #1411744719.

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