Massive disparities in medical school admissions by social class

There are massive disparities in medical school admissions by social class, mainly because pupils from working class backgrounds see medical school as distant, unreal, and culturally alien, according to two studies in this week's BMJ.

These findings question the impact of the government's commitment to widening participation in higher education.

In the first study, researchers used data on UK medical school admissions from 1996 to 2000 to calculate the proportion of admissions from various subgroups of the population (standardised admission ratios).

They found that white and black pupils from the highest social class (social class I) were between 30 and 100 times more likely to gain a place at medical school than those from the poorest social classes (social classes IV and V).

Asian pupils seemed to compensate better for poor origins, but those from social class I were still 6-10 times more likely to gain a place than those from classes IV or V.

When they calculated the ratios by ethnicity and social class, they found a 600-fold difference between the most over-represented group (Asians from social class I) and the most under-represented group (blacks from social class IV).

Standardised admission ratios for males were lower than those for females, with around 60 percent of medical school places now going to women. These sex differences did not vary by social class, but they did vary by ethnicity, with Asians having similar ratios for men and women, but black and white men were significantly under-represented compared with women.

Equal representation at medical school across all social and ethnic subgroups is probably an inappropriate goal, but the findings of this study suggest that many able and ambitious pupils from poor backgrounds are not achieving their potential.

A second study looked at the reasons for these differences. Focus groups were conducted with 68 high ability pupils aged 14-16 years from different backgrounds in six secondary schools in London, ranging from inner city comprehensives to a selective private school. Discussions explored the pupils' perceptions and aspirations about medical school.

There were few differences by sex or ethnicity, but striking differences by socioeconomic status.

Pupils from lower socioeconomic groups held stereotyped and superficial perceptions of doctors, saw medical school as culturally alien and geared towards "posh" students. They greatly underestimated their own chances of gaining a place and staying the course.

Whilst they saw medicine as having potential financial rewards in the distant future, they perceived prohibitive personal risk in the more immediate term. They viewed medical school as high-pressure and boring – a necessary sacrifice for the chance of affluence later in life.

In contrast, pupils from affluent backgrounds viewed medicine as one of a menu of challenging career options with intrinsic rewards such as personal fulfilment and achievement.

All pupils interviewed had some concerns about the costs of study, but only those from poor backgrounds saw costs as constraining their choices.

The authors conclude that policies to widen participation in medical education must go beyond "topping up knowledge" and address the complex social and cultural environment within which individual life choices are embedded.

If the NHS is to understand and serve the community, the make-up of its workforce should reflect that community, write experts in an accompanying editorial.

Although the relationship between top up fees and widening participation is problematic, the need for widening participation in medicine is essential and is one that we must embrace. "We have much to gain from taking part and a wealth of wasted potential if we do not," they conclude.