Efforts in Undergraduate Medical Education to Improve Socioeconomic Status Diversity

Abstract

Purpose

Despite the importance of socioeconomic status (SES) diversity within the health care workforce, little progress has been made toward this elusive goal. Although centuries of structural disadvantage underlie this stagnation, medical schools are well positioned to increase enrollment and retention of students from low-SES backgrounds. In this research report, the authors investigate existing efforts in undergraduate medical education to improve SES diversity.

Method

The authors analyzed the Association of American Medical Colleges Medical School Admissions Requirements database, the American Association of Colleges of Osteopathic Medicine Choose DO Explorer tool, and official medical school websites from December 2022 to May 2023 to examine undergraduate medical education initiatives across 156 allopathic and 56 osteopathic medical schools. They searched for SES diversity efforts in 4 domains: publication of student body demographics (including low-SES or first-generation status), need-based financial aid, low-SES support or affinity groups, and faculty or alumni mentorship programs for low-SES students.

Results

The authors found that 18 medical schools (8.5%) publicly report SES demographic information, 33 (15.6%) report having mentorship programs for low-SES students, 52 (24.5%) report having support or affinity groups for these students, and 154 (72.6%) report offering some level of need-based financial assistance. A greater proportion of MD and public medical schools (128 [82.1%] and 84 [80.0%], respectively) had any kind of SES initiative when compared with DO schools and private medical schools (40 [71.4%] and 84 [78.5%], respectively).

Conclusions

Medical schools can support students from lower-SES backgrounds by publicly reporting classwide SES demographics; dedicating staff and faculty to diversity, equity, and inclusion efforts; measuring and reporting debt burden by stratified student demographics; and introducing innovative financing solutions.

In 2021, the American Medical Association adopted a policy to increase diversity in the physician workforce. It encouraged medical schools to “adopt and utilize activities that bolster efforts to include and support individuals who are underrepresented in medicine.”¹ The Association of American Medical Colleges (AAMC), which defines diversity as “all aspects of human differences including but not limited to socioeconomic status, race, ethnicity, language, nationality, sex, gender identity, sexual orientation, religion, geography, disability, and age,” similarly recognized the value of diversity for improving health.² One important aspect of diversity is socioeconomic status (SES). Research shows that people with a lower SES tend to be the least healthy, report a lower satisfaction of care, and generally face higher mortality rates.3–5 At the same time, the literature also shows that health care workforce diversity can improve patient outcomes through greater physician-patient concordance.^6,7 For example, a randomized controlled trial⁸ showed that Black patients were more likely to accept preventive services when they met with a Black physician compared with when they met with a physician who was not Black. Physicians with similar backgrounds as their patients are likely able to better gain their trust, understand social and cultural barriers to care, and approach the visit with fewer biases. Given that nearly 12% of the U.S. population (37.9 million people) lives in poverty, it is critical for the medical profession to produce physicians who have lived experiences with the various forces that create, maintain, and perpetuate poverty.

The medical profession has found the goal of achieving SES diversity to be elusive. According to data from the AAMC, between 2007 and 2017, only 5% of medical school matriculants hailed from the lowest household-income quintile, whereas 76% of matriculants came from the top 2 household-income quintiles.⁹ Other research shows that, from 2014 to 2019, the percentage of medical school matriculants reporting household income of $125,000 or greater increased annually, whereas the percentage of applicants and matriculants reporting household income less than $75,000 decreased annually.¹⁰ AAMC data from 2018 to 2024, which measured SES by parental education attainment, revealed a persistently low percentage of medical student matriculants with a parent whose highest level of education completed was less than a bachelor’s degree.¹¹ The challenge of diversifying the field of medicine persists because students from lower-SES backgrounds face significant obstacles to becoming physicians, including the high cost of medical education.¹² These obstacles likely also contribute to their higher likelihood of discontinuing medical education,¹³ further worsening the shortage of physicians from low-SES backgrounds.

Although these disparities are rooted in centuries of structural disadvantage, medical schools are well positioned to improve the enrollment and retention of students from low-SES backgrounds. This objective is particularly salient now given the U.S. Supreme Court ruling, Students for Fair Admissions v. Harvard, which overturned race-conscious admissions in higher education.¹⁴ The link of race, ethnicity, and SES¹⁵ makes SES a characteristic through which the medical profession can produce a racially and ethnically representative physician workforce. Separately, improving SES diversity in and of itself is a necessary goal toward ensuring that the physician workforce is fully representative of the U.S. population. To do so, medical schools must focus on efforts to improve and sustain SES diversity. Although medical school–led programs to support low-SES students exist,¹⁶ data regarding the availability and type of programs to address these disparities are scarce. To bridge this knowledge gap, we investigated current efforts aimed at enhancing SES diversity in undergraduate medical education (UME) and propose initiatives to advance this objective.

Method

Sample

We searched 169 allopathic and 56 osteopathic accredited medical schools listed in the AAMC’s Medical School Admission Requirements (MSAR) database and the American Association of Colleges of Osteopathic Medicine (AACOM) Choose DO Explorer website. We limited our sample of medical schools to the 50 U.S. states, the District of Columbia, and Puerto Rico. Medical schools in the Caribbean and Canada were excluded (n = 13). Our final study sample included 156 allopathic and 56 osteopathic accredited medical schools. Medical schools with multiple campuses to which students separately apply were counted individually (i.e., Texas Tech University, Lubbock, Texas, and the Paul L. Foster School of Medicine, Texas Tech Health, El Paso, Texas). Medical schools with multiple campuses that do not have a separate application process were counted as one (i.e., Baylor University at Houston and Temple). We documented public or private ownership status of each institution in our final sample as defined by the MSAR database and the AACOM’s Choose DO Explorer website. This work did not require institutional review board approval because it involved the review and analysis of publicly available data.

Data collection

The SES diversity efforts were categorized a priori into 4 domains (Table 1). Domain 1 focused on the publication of student body demographics, including low-SES or first-generation status. It excluded reporting of the AAMC’s “disadvantaged” metric in the MSAR database, given that this metric is self-reported by all medical school applicants who may identify as disadvantaged for nonfinancial reasons. Domain 2 included the provision of need-based financial aid, including scholarships, fellowships, and loans. We also included medical schools offering free tuition to all students. Domain 3 focused on support or affinity groups for students from low-SES backgrounds. Domain 4 included faculty and alumni mentorship programs tailored to low-SES students. To identify efforts within these domains, we first extracted information from the AAMC’s MSAR database and AACOM’s Choose DO Explorer website, which provide information on each medical school’s admissions data, student life, and financial aid. We then searched Google and individual official medical school websites for student demographics and the broad search terms financial aid for financial support, community groups or student groups for affinity organizations, and mentorship for mentorship programs. Data were collected from December 2022 to May 2023.

Table 1.

Study Domains, Definitions, and Examples Extracted From Publicly Available Data, December 2022 to May 2023^a

Domains	Definition	Examples
Student body demographics	Percentage or number of first-generation college students, percentage of students who were eligible for Pell Grants, percentage of students from low-SES backgrounds	UCSD School of Medicine: 25% socioeconomic diversity in class of 2026; University of Louisville School of Medicine: 21% with low SES in class of 2027
Financial assistance	Institutional need–based scholarships, low-interest loans with repayment deferred until after graduation	University of Arizona–Phoenix: Underrepresented in Medicine Scholarship; Frank H. Netter M.D. School of Medicine at Quinnipiac University: need-based scholarship; Harvard Medical School: Wolfson Loan
Support or affinity groups	Organizations that provide social support and/or create community by creating a space for students who share the identity of having a low-SES background, being financially disadvantaged, or being the first person in their families to attend college	Kirk Kerkorian School of Medicine at UNLV: First Generation Low-Income Interest Group; University of Texas Medical Branch at Galveston: First in Family Student Interest Group
Mentorship program	Faculty-student or alumni-student mentorship programs that focus on the professional and personal development of students from low-SES backgrounds	EMPACT Program at Emory School of Medicine; Students in Medicine Academia Research and Training (SMART) at University of Missouri–Kansas City School of Medicine

Abbreviations: EMPACT, Engage, Mentor, Prepare, Advocate for, Cultivate, and Teach; SES, socioeconomic status; UCSD, University of California San Diego; UNLV, University of Nevada Las Vegas.

^aExamples are from medical school websites and their partner university websites and press releases.

Data analysis

Two researchers independently identified and categorized these efforts using Microsoft Excel (Microsoft Corp., Redmond, Washington). Discrepancies were resolved collaboratively. We then calculated the number and percentage of medical schools with each initiative by ownership status, degree conferral status (MD vs DO), and in aggregate. We excluded financial assistance funded by government programs because we were focused on institutional resources provided by medical schools.

Results

Only 18 medical schools (8.5%) provided demographic information related to SES (Table 2). These schools typically relied on indicators, such as Pell Grant and/or Fee Assistance Program eligibility, or self-reported identifiers, such as first-generation, low-income status. Forty-four schools (20.8%) reported the number or percentage of first-generation students. One hundred fifty-four schools (72.6%) reported offering need-based financial assistance, including low-interest loans and school-sponsored scholarships. Fifty-two schools (24.5%) reported having affinity or support groups, which encompassed student-led organizations and organized conferences. Affinity or support groups were composed of self-organized groups of students with the shared identity of low SES or of being financially disadvantaged. Affinity groups centered around being first-generation college students were also included. Thirty-three medical schools (15.6%) reported having a faculty- or alumni-led mentorship program, many of which were run conjointly through affinity groups. Specific examples from each domain are listed in Table 1. Notably, a higher number of MD schools implemented some form of SES initiative compared with DO schools (128 [82.1%] vs 40 [71.4%]). Similarly, a slightly higher number of public medical schools had nearly any kind (except for support groups) of SES initiative (84 [80.0%] vs 84 [78.5%]). Only 4 medical schools publicly reported an SES initiative in each of the 4 domains.

Table 2.

Reporting of SES Initiatives by Medical Schools Listed on the AAMC and AACOM Websites^a

Category	All medical schools (N = 212), no. (%)	MD medical schools (n = 156), no. (%)	DO medical schools (n = 56), no. (%)	Private medical schools (n = 107), no. (%)	Public medical schools (n = 105), no. (%)
First-generation demographics	44 (20.8)	36 (23.1)	8 (14.5)	20 (18.7)	24 (22.9)
SES demographics	18 (8.5)	17 (10.9)	1 (1.8)	6 (5.6)	12 (11.4)
Financial assistance	154 (72.6)	116 (74.4)	38 (67.9)	76 (71.0)	78 (74.3)
Support or affinity groups	52 (24.5)	47 (30.1)	5 (8.9)	31 (29.0)	21 (20.0)
Mentorship program	33 (15.6)	31 (19.9)	2 (3.6)	15 (14.0)	18 (17.1)

Abbreviations: AACOM, American Association of Colleges of Osteopathic Medicine; AAMC, Association of American Medical Colleges; DO, doctor of osteopathic medicine; MD, doctor of medicine; SES, socioeconomic status.

^aData are from https://www.aamc.org/media/5976/download.

Discussion

The recent U.S. Supreme Court ruling on affirmative action and the underrepresentation of students from low-income households in medical schools underscore the need for medical schools to design, implement, and transparently report initiatives focused on improving SES diversity. Current cultural divides placing diversity, equity, and inclusion initiatives at risk make this task even more critical.

Our findings demonstrate that most schools do not report SES demographic data. A higher percentage of medical schools report demographics on the proportion of first-generation students than the proportion of students from low-SES backgrounds, but data show that only approximately half of first-generation students typically come from low-income families.¹⁷ Low reporting is concerning because transparent demographic data represent a crucial initial step for medical schools to ensure adequate representation of students from diverse socioeconomic backgrounds. It is especially concerning because data persistently show low numbers of medical students from financially disadvantaged backgrounds.¹¹ By publicly reporting SES data, medical schools hold themselves accountable to improving diversity metrics and tracking demographic changes in their incoming classes. Tracking these data also allows medical schools to share experiences and lessons learned with peer institutions. It also allows them to measure student-wide differences in important educational outcomes, such as attrition. Public reporting also provides prospective students with essential information for making informed decisions about their educational pursuits. For example, students from lower-SES backgrounds may seek schools that tend to recruit and, presumably, better support students from their same background.

To support and incentivize medical schools in reporting and measuring these data, the Liaison Committee on Medical Education (LCME) and Commission on Osteopathic College Accreditation (COCA) could include baseline reporting guidelines on SES demographics into their respective diversity standards. Specifically, the LCME can consider recommending or mandating reporting on defined diversity categories under Element 3.3 of its standards. Currently, this element allows medical schools to determine the diversity categories they choose to measure.¹⁸ The COCA standards could incorporate such reporting recommendations or requirements under Element 12.6, which offers guidance on reporting public information.¹⁹ Reporting also falls under the AAMC’s recommendation to “determine the unique populations in your institution and monitor trends.”²⁰ At a minimum, both the LCME and COCA could facilitate the availability of such data by request, as currently done by COCA for race, ethnicity, and gender data on student, faculty, and staff demographics.¹⁹ Such guidelines would ensure that medical schools publicly disclose SES diversity statistics on their official websites, as many currently do with gender, race, and ethnicity data.

Because most medical schools do not report having affinity groups and mentorship programs, it is crucial for them to increase support for these initiatives. This is particularly important considering that a low-income background places medical students at higher risk of attrition¹³ and that peer support networks and mentorship have the potential to significantly contribute to the academic success of medical students.²¹ In part because affinity groups provide a “safe haven, opportunities for nurturing, validation, and support,” the AAMC recommends that medical schools ensure there are affinity groups to support distinct populations, such as students from low-SES backgrounds.²⁰ Similar to racial and ethnic affinity groups, students from low-SES backgrounds share early childhood and adult experiences that are core to their identities. Strong peer relationships, particularly between individuals who share similar backgrounds, may even help reduce the high prevalence of depressive symptoms among medical students, which can contribute to poor educational outcomes.²²

Mentorship programs for unique populations, such as students from low-SES backgrounds, are also encouraged by the AAMC,²⁰ perhaps in part due to the association between mentorship and trainee success, including academic productivity.²¹ Comprehensively supporting low-SES students through affinity or support and mentorship programs requires dedicated staff and faculty commitments to diversity, equity, and inclusion efforts with commensurate compensation and promotions. These commitments would ideally result in organized student groups on campus, similar to The Latino Medical Student Association and Student National Medical Association, in addition to robust mentorship pairings between supportive faculty and students across the 4 years of medical school. Notably, both support groups and mentorship programs have been documented as interventions to promote a sense of belonging for underrepresented resident physicians, highlighting the value of these initiatives in both UME and graduate medical education.²³

We found that most medical schools provide students with financial assistance. However, AAMC data from 2023 show a mean debt of $206,924 for medical school graduates with debt.²⁴ This high cost of a medical education often prevents lower-income students from entering the profession.¹² Measuring and reporting debt burden by student demographics may encourage financial inclusion as schools aim to close funding differences between students from different socioeconomic classes. Furthermore, introducing innovative financing solutions for medical school tuition and ancillary costs as described in existing literature could lessen debt burden.¹² Medical school–wide full tuition programs, as introduced by NYU Grossman School of Medicine in 2023,²⁵ may disproportionately benefit students from low-SES backgrounds who may have difficulty affording tuition and the ancillary costs of medical school. However, targeted funding for medical students from lower SES backgrounds is likely a more effective method of recruiting these students than medical school–wide full tuition programs. After NYU Grossman School of Medicine eliminated tuition, the percentage of enrolled financially disadvantaged students decreased.²⁶ By supporting low-income students financially, all students stand to benefit because diverse perspectives enrich classroom discussions and ultimately contribute to better patient care.

Overall, further research is necessary to fully understand the availability of SES diversity initiatives and their benefits in UME. It is also important to understand the incentives—better patient care, enhanced learning and well-being of students, and a mission of diversity—that lead a UME institution to create these initiatives. A commitment to responsibly manage public funds may be one incentive because a higher proportion of public medical schools reported initiatives targeting SES compared with private institutions. Other incentives to broadly encourage uptake of these initiatives are warranted. For instance, even though medical schools can create their own underrepresented in medicine definitions, medical schools may be more inclined to bolster initiatives for low-SES students if the AAMC expanded its definition to include this group.²⁷ In this research report, we shed light on the scarcity of these initiatives and offer an initial exploration of the landscape.

Study limitations include the use of self-reported information, which may result in undercounting, particularly if medical schools consider SES data confidential. Furthermore, we did not assess initiatives for underrepresented racial and ethnic minority groups, although there is a known association between race and SES.¹⁵ We also excluded financial assistance provided by government programs because of our focus on UME-led initiatives, although we recognize that medical schools invest resources to use government programs, such as the Loans for Disadvantaged Students Program run by the U.S. Department of Health and Human Services. Lastly, an analysis of pipeline programs was deemed out of scope given their focus on racial and ethnic diversity rather than socioeconomic diversity.