First-generation physicians: The pursuit of academic surgery

In order to deliver the highest quality of care to our patients, the healthcare workforce must be diverse, empathetic, and representative of the nation’s population. Diversity, equity, and inclusion efforts are thus tasked with amplifying and creating space for the perspective of physicians from historically underrepresented backgrounds, including first-generation (FG) students. The Association of American Medical Colleges (AAMC) defines FG medical students as applicants whose parents have not earned an associate or higher degree in the United States.¹ It is estimated that approximately 12.4% of 2021–2022 medical school matriculants meet this criteria.² This dismal statistic is evident at multiple steps along the leaky pipeline to medical school, most profoundly in the medical school application process, where studies show that FG students are less likely to both apply and be accepted to medical school when compared to non-FG students.^3,4 Additionally, FG students are more likely to come from lower-income households, which creates further barriers for students on the path to higher education; 27% of FG students are from households with a combined income of less than $20,000, compared to 6% of non-FG students.³ A 2023 study in the Journal of American Medical Associations (JAMA) revealed that students with a household income of <$50,000 have an adjusted relative risk of just 0.52 (95% CI 0.50–0.54) of acceptance into medical school when compared to students with a household income of >$200,000.⁴

Just under 50% of the United States’ population has obtained an associate degree or greater, which means that FG students come from families, communities, and social circles that are reflective of the country and the environments in which their patients are living.⁵ FG students offer valuable perspectives and represent a large population of undergraduates but face exceptional hardship in their journeys to careers in medicine.⁶ Many of these perspectives are rooted in their experiences overcoming unique challenges. FG students must navigate academic hurdles without any “academic blueprint” from friends and family to follow. They typically lack formal or informal guidance on navigating critical aspects that lead to successful medical school matriculation, such as how to study for the Medical College Admission Test (MCAT), as well as how to confidently seek out research or mentorship opportunities.^3,7

Although a few studies have examined challenges that FG students face in college and medical school, less is known about the challenges FG students encounter beyond medical school, especially in the pursuit of careers in surgery, which is known to be highly demanding. FG students often have limited cultural capital and fewer extracurricular opportunities to list for residency applications secondary to familial obligations.¹⁰ Studies have found FG students to face greater levels of stereotype threat, prohibitive financial dilemmas, higher attrition rates, and increased anxiety.^7–10 Articles have touched on the perspectives of and unique barriers faced by FG students in medical school, but there is a paucity of data examining the experience of FG surgical residents, fellows, or faculty. In this editorial, we aim to shed light on the continuing obstacles that FG trainees face after they graduate from medical school, begin residency and/or fellowship, and enter the workforce, based on the perspectives of several FG surgeons practicing in the United States.

We identified several FG surgeons and discussed with them their experiences as FG trainees and faculty, advice for FG trainees, and strengths associated with the journey. Our discussions involved medical students, faculty from a range of surgical specialties (trauma surgery, general surgery, colorectal) and included attending surgeons at various stages of their careers (Surgical Fellowship Director, Vice Chair of Surgery for Diversity, Equity, and Inclusion, Associate Professor of Surgery). We consider these perspectives alongside evidence from the literature to identify areas for further study in the future. The discussants declined to be named individually.

Several contributors to our discussions noted that they often felt a pervasive sense of inferiority and imposter syndrome at various stages in their medical training. FG surgeons reported this arose in a range of situations, some of which were outside the classroom or ward. They also noted that this feeling of exclusion persisted beyond medical school and throughout residency. This is a poorly documented phenomenon, as most studies on FG students stop following trainees after medical school graduation.^3,7–12 For example, one discussant described that as an intern, he was “launched” into the professional world: a world of conferences, exclusive events, and first impressions. He felt he was expected to learn how to comport himself and “look like a surgeon,” which was particularly challenging given that nobody in his family had even attended college. As an intern, attending black-tie events, such as the chief residents’ graduation, provoked a foreign feeling. Furthermore, for this discussant, having had different life experiences as a FG trainee made it difficult to contribute to discussions on topics such as golf, cars, and vacations with peers. He found that many trainees came from families who had been in medicine for many generations, and this was often a talking point in conversations from which he was necessarily excluded.

One discussant described his experience navigating medical school and residency as if everyone else had the upper hand from the beginning: “Being FG requires guidance. It often feels as if everyone has memorized a guidebook you did not even know existed.” To mitigate this, he noted that it may be helpful for FG trainees to find advisors who are aware of their FG status and can help them navigate what feels like a hidden curriculum, especially during the residency and fellowship application process. This aligns with research showing that FG applicants are disadvantaged throughout application processes and highlights the increased need for continued mentorship.^7,11

One of our discussants reflected on the narrative he told himself during medical school and residency: for FG students, it seems as if the environment is not meant for or supportive of you. He reflected on this point, and postulated: “Is it first gens saying it to ourselves or are people saying it to us? Maybe a combination of both.” Although some of this sentiment is based on FG students’ lived experiences, our discussants suggested that some part may be attributable to students’ tendencies to isolate and self-perpetuate an idea that they are not enough because of their background. Our discussants stressed that FG students must try to undo the narrative they tell themselves about not belonging. “Tell yourself you belong and don’t question that fact.”

For FG students and trainees, learning how to thrive in an academic environment requires adaptation to new and unique ways to perform and interact. For many, FG status is a specific identity that compounds and influences all of their experiences. Our discussants highlighted the importance of authenticity and the challenges associated with code-switching, or adapting one’s behavior to different people and situations. These conversations also underscored the relevance of intersectionality, as 51% of FG undergraduate students identify as underrepresented minorities (URM) while only 30% of non-FG undergrads are from minority backgrounds.³ FG medical students come from varying racial, ethnic, and financial backgrounds, yet despite these differences, studies have shown many uniting characteristics of FG students, such as increased resilience and altruism when compared to their non- FG counterparts.¹²

In light of the numerous challenges facing FG students, it is unsurprising that studies have demonstrated greater resilience among FG students compared to their non-FG counterparts.¹² This trait was highlighted during the discussions as one that FG surgeons valued in themselves the most— their ability to push forward despite obstacles, both internal and external. FG students are more likely to demonstrate determination, persistence, optimism, academic resilience, civic-mindedness, and proactivity, all of which are core traits of effective physicians.¹² FG students have also been shown to report higher levels of stress, lower levels of self-care, higher fatigue, and less social support.¹² In our discussions, the uniting themes across participating surgeons included imposter syndrome, mentorship, undoing the narrative, confidence, resilience, and community.

Although undergraduate universities have made efforts to develop FG-centered educational and administrative programs to address some of the challenges faced by FG students, similar programs are less frequently encountered in the realm of medical education. In one example, the David Geffen School of Medicine at the University of California, Los Angeles has developed a comprehensive program aimed at supporting FG students and their families through community-building, mentorship opportunities and academic support.¹¹ Programs like these are working towards raising awareness of the FG experience in medical education and creating a culture of recognition, support, and inclusion. Two proposed methods that may improve the retention of FG students are enhancing structured pathway mentorship and improving the visibility of minorities in medicine.¹¹ Other potential solutions to common problems that FG and URM physician-scientists face include elucidating hidden challenges and resources, while also helping students navigate the “gratitude tax:” the concept that underrepresented individuals have a feeling of obligation to the academic institution and to future generations of underrepresented students for being given the opportunity to be a physician.¹³ This newly described nuance to the minority tax affects both inner decision-making processes and personal ambitions.¹³

FG students should be an important consideration as organizations and training programs work towards creating and supporting a workforce reflective of the populations they serve. Challenges facing FG students, including academic culture readiness, financial issues, family stressors, imposter syndrome, and lack of professional and social networks, must be addressed at every stage of the medical education process. Many of the structural supports and programs that will welcome and support FG students are likely to also improve the recruitment, retention, and promotion of other underrepresented groups and all medical trainees. This is important because workforce diversity has been shown to result in better outcomes for patients.^14,15 In summary, working to understand and appreciate the experience of the FG surgical trainee in medical school and the time beyond will allow for further meaningful insights into physician training and a more diverse physician workforce ultimately resulting in better medical care.