Medicine, Social Mobility and Our Moral Imagination: Ideas in Progress…

It took me a while to fathom out the conversation I had at the age of seventeen with my headmaster.

‘Well, Thomas, what are your plans?’ He always insisted on interviewing sixth formers before they applied to university, this in the days before schools had career advisors.

‘I want to study medicine, sir.’ I replied with the conviction born of ignorance. He stiffened behind his desk. For a moment I thought he thought I had blasphemed. I rubbed my eyes.

‘Medicine, eh? Not an easy field to get into. Do you have any family connections with the profession? What does your father do?’

‘He’s a photographer, sir, at the steel works.’ I could sense the rigidity intensify. His pouch of Players Navy Shag, I remember, on the floor by his desk.

‘A photographer.’ He rustled his way through my school record, wiping his nose on the reverse side of his regimental tie as he did so. ‘Look Thomas,’ he continued ‘Not a good idea, medicine. Why not try something else.’

I waited while the rustling continued, mouth dry. The last thing I wanted to be when I grew up was a dentist. Outside the bell rang, followed almost immediately by thunderous hooves cavalcading down the corridor.

‘Yes, some…er…closely related profession.’ He let my file slip from his fingers, and looked at me for the first time. ‘I hear that Liverpool University has places for mechanical engineers.’

 

Apart from anything else this little scene taught me about myself (and it taught me a great deal), it opened my eyes to a popular belief about the medical profession; that being a doctor is genetically determined. Looking back it is clear that that is what my headmaster must have believed. The view that access to medical school is strongly familial was investigated years ago by one of Britain’s leading psychiatric geneticists, Peter McGuffin. They (Huckle and McGuffin, 1991) gave preclinical medical students in the University of Wales College of Medicine a questionnaire and found that 13% of the medical students’ first-degree relatives had attended medical school compared with 0.22% in the general population, a ‘relative risk’ of 61. Although they acknowledged that environmental and cultural factors probably had a part to play, they concluded that genetic factors were also important, probably through their influence on ‘general intelligence’.

There is no denying that academic excellence is the most important criterion for medical school entry, whether or not you consider this to be determined by genetic factors. Medicine is one of the most popular career choices, and the intense competition for entrance to medical school means that universities can afford to be choosy. These days they won’t consider students who have anything less than three straight A grades at A-level (the examinations sat by young people at the end of their time at secondary school). It is, of course, de rigueur that these are sciences, usually chemistry, physics and biology, or mathematics[1]. This means that arty-farty types like me would be unlikely to get in to study medicine these days. My origins are working class, and although I just about scraped the requisite grades in chemistry, physics and biology to get in to medical school in 1967, I really didn’t like science (except chemistry) and preferred to spend my time reading Freud, Marx, and R. D. Laing. In any case these days, as it was when I was a tyro, the best A-level grades are achieved by students attending the best schools. In Britain this means those educated in public schools, nests of privilege like Eton, Harrow and Westminster. With annual fees for boarders in excess of £30,000 ($47,000), these are places that only the very rich can afford to send their children.

Not all doctors come from such backgrounds, but the evidence suggests that although medical students have become more representative of the diversity of modern society in terms of gender and ethnicity, people from less privileged backgrounds have failed to benefit from these changes. A study undertaken by the British Medical Association found that in 2008 students from higher socio-economic groups dominated medical school entrants (BMA, 2009):

  • 71 per cent of students accepted into medical school came from the top three socio-economic classes, while 15 per cent were from the lower four classes
  • 38 per cent of students accepted into medical school were from socio-economic class I, indicating higher managerial and professional backgrounds
  • 2 per cent of accepted students came from socio-economic class VII, indicating routine manual occupational backgrounds

 

To be fair, medicine is not the sole culprit. In Britain, access to virtually all the professions favours those from socio-economically privileged backgrounds. In January 2009 the last Labour Government set up the Panel on Fair Access to the Professions, and its work continues under the coalition government in the guise of the Independent Reviewer on Social Mobility and Child Poverty. Its first report (Panel on Fair Access to the Professions, 2009) compared two birth cohorts, one from 1958, one from 1970. Over this period most of the professions, including medicine, had a rise in the proportion of members born into households with greater than average income. The report predicted that if these trends continued, a typical professional in the future will grow up in a family that is better off than seven in ten of all families in the country. This would have the effect of slowing down social mobility. The Panel set out over 80 recommendations for government, professions and educational institutions to improve equality of access and increase social mobility.

At the end of May 2012, the Independent Reviewer published an interim report on progress in opening up access to the professions, an important plank in government plans to increase social mobility. The outcome is disappointing. Although the civil service and legal professions have both made some progress, the medical profession lags behind, both in terms of its focus and the priority it attaches to the issue: ‘It has a long way to go when it comes to making access fairer, diversifying its workforce and raising social mobility.’ (Independent Reviewer, 2012: p. 3). Although the evidence suggests that the profession now recruits a more diverse work force in terms of gender and ethnicity than it did twenty years ago, it has shown little commitment to ensuring fair access to people from economically disadvantaged backgrounds. Data from 2010/11 on those who succeeded in getting a university place shows that 57% of medical students came from the top income groups and only 7% from the bottom, with 22% of all medical and dental undergraduates being educated at private schools. Although a few medical schools shine out and are making genuine attempts to reach out to young people from socio-economically disadvantaged backgrounds, the response rate to the Independent Reviewer’s inquiry was poor. This indicates that in broad terms the profession does not see fostering social mobility as a priority. He concludes:

Medicine has a long way to go when it comes to making access fairer, diversifying its workforce and raising social mobility. It lags behind some other professions both in the focus and the priority it accords to these issues. (Independent Reviewer, 2012: 48]

 

So, where does this leave us? We have evidence of persistent inequalities in access to medicine as a career, at a time when the practice of medicine is dominated more than ever by science and technology. But we also know from Richard Wilkinson and Kate Pickett’s work (Wilkinson & Pickett, 2009) that more than any other profession, members of the medical profession daily come into contact with those members of our society, the marginalized, the poor, the disadvantaged, whose lives are most ravaged by inequalities and the injustices this entails. These are the people whose health and well-being is most likely to suffer as a result of income inequality, those with the most complex mélange of physical, mental health and social problems. Despite this, most of their medical attendants are unlikely to have first hand experience of what it is like to struggle in poverty, trying to provide a loving and caring family environment in which to raise children. This isn’t to say that doctors from privileged backgrounds are not capable of genuine care and compassion, or what Nel Noddings (1986), the feminist philosopher of caring calls sympathy (in contrast to empathy). Some of the most wonderfully sensitive clinicians I have ever worked with came from wealthy, privileged backgrounds. But my argument is that there is a moral compass that guides caring way beyond the Cartesian subject of the self-contained clinician, way beyond even the confines of the so-called doctor-patient relationship, that takes caring out into the wider cultural world that permeates us all. This is the moral sense of caring that enables us to see our differences from and nearness to someone we are caring-for mirrored both in the other person and ourselves, and our families of origin that shaped us and gave original meaning to our lives. This is one aspect of what I referred to as a dialogical view of subjectivity in my last blog.

There is a view that none of this matters; it’s just airy-fairy nonsense from an arty farty writer. Medicine and psychiatry are so highly dependent on science and technology that it must be the case that the selection of students ensures that future doctors have the potential to keep abreast of scientific developments, and add to them. But that presupposes that the practice of medicine is only dependent on science and technology. It also presupposes that the extent of the social distance between doctors and their patients is of no importance in the practice of medicine. In an eloquent and moving essay published in The Lancet, Arthur Kleinman (2008) sees the paradox of contemporary medicine in terms of the balance between science/technology and art. This has shifted so far in the direction of the former that the latter has become ‘…a pale shadow, a fragile remnant of what had for centuries been crucial to the work of the doctor.’ Doctors, like laypeople, belong to a shared culture, and as such they are just as dependent on imagination and the widest possible range of moral responses that originate in that culture in order to care for others. This is precisely why it is so important that as a professional group, the medical profession must reflect the widest possible range of values, beliefs, spiritualities, faiths, and sexualities. And all this must be coupled with an endless palette of human emotional experience, of love, happiness, joy, despair, rage and anger. Equality of access to medicine is not only important as part of a range of measures to tackle income inequality, but it is vital if we are to readjust the balance between art and science in the practice of medicine.

 

Footnote

If you agree with the sentiments expressed in my last two blogs, both of which draw heavily on The Spirit Level, you might be interested to know that they are currently trying to raise funds to produce a documentary based on the book. Please visit the website for more information and make a donation http://www.indiegogo.com/spiritlevelfilm?c=home&a=628593. They have already raised $33,000 of the $50,000 they need. There is also an excellent website http://www.equalitytrust.org.uk/resource/the-spirit-level with many resources.

 

References

British Medical Association (2009) Equality and diversity in UK medical schools accessed on 31st May 2012 at http://www.bma.org.uk/equality_diversity/age/equalityanddiversityinukmedschools.jsp#.T8cror94q_4

Huckle, P. & McGuffin, P. (1991) Familial factors in going to medical school. Medical Education, 25, 13 – 15.

Independent Reviewer on Social Mobility and Child Poverty (2012) Fair Access to Professional Careers: A progress report by the Independent Reviewer on Social Mobility and Child Poverty accessed on 1st June 2012 at http://www.cabinetoffice.gov.uk/resource-library/fair-access-professional-careers-progress-report  on 31st May 2012

Kleinman, A. (2008) Catastrophe and caregiving: the failure of medicine as an art. Lancet, 371, 9606, 22 – 23. 9 Also available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2808%2960057-4/fulltext

Panel on Fair Access to the Professions (2009)  Unleashing Aspiration: The Final Report of the Panel on Fair Access to the Professions, The Cabinet Office, accessed on 31st May 2012 at  http://webarchive.nationalarchives.gov.uk/+/http://www.cabinetoffice.gov.uk/strategy/work_areas/accessprofessions.aspx

Noddings, N. (1986) Caring: A Feminine Approach to Ethics and Moral Education.Berkeley, University of California Press.

Wilkinson, R. & Pickett, K. (2009) The Spirit Level: Why Equality is Better for Everyone. London, Allen Lane (Penguin Books).

 

 

13 COMMENTS

  1. I enjoyed reading this. It stirs many thoughts and ideas.

    I watched the video on indiegogo.com – “I do believe this country is too unequal and the gap between rich and poor doesn’t just harm the poor, it harms us all, and it’s something government must tackle”.

    Actually, it isn’t up to governments. I’ll offer my vision:

    YouTube (490 million unique users every month – google data)

    The most subscribed channel on YouTube belongs to RayWilliam Johnson. He has 5,354,349 subscribers and his channel is introduced with the following message:

    “I’m an alcoholic garden gnome with a taste for comic books and hip-hop music. I’ve also been known to produce a few good shows.” His current video, “Kids on Drugs”, is 12 hours old and shows 581,275 views.

    The top three channels with the most subscribers are comedy and entertainment. The top 100 list is found here: http://vidstatsx.com/youtube-top-100-most-subscribed-channels

    This is the content that people want, seek and choose. Why is it up to government to tackle society’s choice interests? Isn’t it up to society? They are the ones who create the content they want, and they have the ability to seek out educational and / or Humanitarian issues. Comedy and Entertainment appears to be the greater value, not Educational and Humanitarian.

    Harvard University has only 47,094 subscribers and their current video, 3 days old, shows only 1,737 views. Interestingly, Harvard’s current video is about inequality:

    Lawrence Summers: What Kind of Inequality is OK? || American Conversation Essentials.
    http://www.youtube.com/user/Harvard

    Lastly, I’d like to share this 2 minute video from the comedy, “Idiocracy”. I recommend the full length movie. Video clip contains vulgar language.

    “The Doctor”
    http://youtu.be/5_3u1LVLYVE

    It is my opinion that responsibility is in the hands of society itself.

  2. Not only does medicine draw from the well-off, it’s a rarified culture in itself.

    I’m continually struck by the absolute lack of real-life work experience in psychiatrists and psychotherapists, too. Most of their clients have some kind of wage-slave job, which in itself generates enormous stress and isolation, yet mental health professionals have no understanding of the context of their complaints.

    If they only knew how stultifying yet pressured most corporate jobs are, they would be slower to diagnose depression, anxiety, and ADHD in people who are unhappy at their jobs but trapped in them — also sedentary, trapped at their desks.

  3. For the next British government inquiry, I hear they’ll be trying to remedy the unfair and unequal access to Ferrari and Bugatti sports cars. Inequality of car choices can hopefully be remedied, then we can all have houses the same size, and all be eligible to compete in the Olympics. Instead of once every four years, the Olympics will TAKE four years to get through giving everyone their natural born right to compete in the 100 meter dash.

    I agree of course though, the professions are mostly for people who were raised by professionals. Your birth determines to a large part your social station. Always has, always will.

    I don’t agree with the claims made about ‘science and technology’ in relation to psychiatry here. What technology? 1950s tranquilizer drugs rehashed 20 times over? And a pathetic bible of labels called the DSM?

    Of course the best schools produce the best grades, but I’ve never heard of someone with the best grades getting denied entry to medical school just because their father was a manual laborer.

    Musing on inequality is good and well, but it’s psychiatrists of all family backgrounds that are kneecapping and crippling millions of people for life, shoving them onto disability welfare and filling their heads with self fulfilling prophecies of doom and iatrogenic disability dressed up as disability created by nature.

    The psychiatrist from the poorest immigrant background, is just as likely as the son of millionaires psychiatrist to cripple young people and fill their heads with lies when they let them out of the hospital and send them home with a lifelong label prophecy of doom, and a lifetimes supply of free money (albeit subsistence level welfare), and psychiatric drugs.

    Just as the wealthiest son of millionaires who has personal problems and winds up in the best gold plated private psychiatric “hospital” is just as likely to lose his life potential by believing in the biopsychiatric lies his head will be filled with.

    So even if medical schools are perceived to not be equal opportunity social mobility factories, psychiatric “hospitals” private and public, gold plated health insurance or rock bottom involuntary public sector “intervention”, can all be counted on to be equal opportunity life destroyers.

    Whether you’re living on the streets and you’re scooped up for a while by psychiatry and labeled and drugged, or you’re an happy and jilted Kennedy ex-wife (as shown recently), the garbage lies you’re fed by psychiatry about you being a powerless passive ‘sufferer’ of a fake brain disease, and the handful of neurotoxins in pill form you’re handed, are equal opportunity life destroyers and hope destroyers.

    The Church of Psychiatry, whether ministered in gilded hallowed rarefied Kennedy compounds or in the prison system, is a faith that can easily decimate the lives of anyone unfortunate enough to be asked (or coerced) to swallow its communion wafers.

    • It is true. The world’s people do suffer. I have such sorrow and remorse for my two decades spent in the psychiatric and “mental” health care system. I will carry the grief of it with me, always – for it has been the life of MY SOUL. Things *could* have been better. Time to heal my soul now, which means I have to learn to love those two decades – no matter how difficult that *will* be.

      anonymous, I value and appreciate (love) your “voice”. The care you show is so stunning.

      Thank you for standing up for me and fighting for me. For so many of us. And for yourself.

      I hope I haven’t alienated you (or other readers) by sharing my personal sentiments. But then again, it would just go to show how much *WORK* we have to do, to be comfortable with being admired, praised, valued and acknowledged – because for some people, that’s PAINFUL. Or embarrassing. Or awkward. Or greatly discouraged.

      Thanks, anonymous. *smiles*

      • “Time to heal my soul now, which means I have to learn to love those two decades – no matter how difficult that *will* be.”

        I support your efforts to do this, but for me, my lost years, are years I can never love.

        They are gone. The photographs of me from then, with psychiatrically drugged eyes, make me cry. The many years of life I lived impaired by psychiatric drugs and lies, are just a monstrosity where my every single waking moment was molested by this ridiculous belief system and its life force diminishing drugs.

        When I think of the movies I watched, the relationships I formed and tried to maintain, even the love I felt, and made, it was ALL BRUTALLY interfered with by this disgusting ideology.

        I wasn’t me. Deep down some part of me was still me, but mostly I was just another ghastly living, breathing example of biopsychiatry’s sickening ‘handiwork’, much like the guy jerking around in his chair suffering from T.D.

        Don’t shower me with too much praise. I made a moderately serious error in judgment recently with the severity of some of my commentary on this site. For that I’m trying to be more temperate.

        Two decades for you, you’re a survivor of enormous magnitude then. Just try and focus on the fact you got out, and remember there are many who never will get out it seems. Try your best to stay healthy in body now, now that you’re free and clear of the toxic drugs. So you can have more than two decades of the real you.

        Always remember literally millions of people from the 20th century and 12% of this century, lie in graves, having never been free from the moment they were sucked into the vortex, until a few decades later when their bodies gave out. Their potential crushed. A crime of genocidal proportions. That’s why people get uncomfortable around the trashed lives psychiatry leaves in its wake, most people thought they’d pondered a moment on what the worst thing that could ever be done to somebody was, and then psychiatry upped the ante.

        It’s good at upping the ante in terms of diabolical and depraved ways to destroy human life.

        But that is a heartfelt response to you mjk. I’ll let my main comment stand in response to the article, which I thought was a well thought through article.

        • “For that I’m trying to be more temperate.” – and in my eyes, for that you deserve even more praise. Aren’t I a real antagonist?

          an·tag·o·nist
          n.

          4. BIOCHEMISTRY A chemical substance that interferes with the physiological action of another, especially by combining with and blocking its nerve receptor.

          Does psychiatry ever pack their pills with antagonist? I wonder if antagonist can be purchased over the counter, as a nutritional supplement.

          (I have a rather bizarre Sense of Humor)

          I agree with your rage at the harm and damage of psychiatry. I dare not outright express my own, or else something somewhere is bound to catch on fire.

          “The photographs of me from then, with psychiatrically drugged eyes, make me cry.”

          I’m glad you mention that because I have pictures which show a distinct difference in me, pre-trauma and post-trauma. I survived TWO massive traumas between the ages of 4 and 5 and the evidence is visual, thanks to photography.

          For the people who believe that we’re born with “mental” BRAIN disease, my childhood photos prove otherwise. Wouldn’t surprise me though; too often, “they” (human beings) deny (invalidate, negate) solid evidence when it contradicts their training (ritual beliefs).

          Oh well.

  4. Have you ever read Emile Durkheim’s study on the sociological reaction to suicide? It uncovers the way society takes a purely singular event, strips it of it’s emotion, and makes it their’s. It becomes about their view, and not about the person who was lost. Psychiatry’s biggest complication outside of monetary bias (in the US) is they have spent so much time trying to shove us into neat, little drawers with nice, confining labels, that they fail to see the simplicity. 1. People don’t fit in drawers or labels. Second, being crazy isn’t about selfishness, lack of empathy, narcissism or any of the other neat terms they use to describe me and my ilk in PSYCH 101. If you can’t figure out the cause, the treatment, the cure for my disorder, don’t presume to have foresight into my hopes and intentions. And when you let both of those go, learn to think sideways. That’s what being mentally ill is really, your mind finds new ways to see things in order to protect us. I think the lie of us being self serving sociopaths is comforting to others: to rob us of our humanity. I recently gave a presentation on suicidal thoughts and behaviors in Bipolar 1 and the reason no one noticed, and a girl was absolutely devoted to the idea that this was based on the fact that we were selfish, drama queens, incapable of loving others. I asked her, why do people read Plath, Poe, Hemingway? Why do we listen to Janis Joplin and Jim Morrison and still stare at Van Gogh? Most of them were Bipolar, (in my opinion) Because you feel something and you don’t even mean to. Being crazy isn’t about not feeling; it’s about feeling everything all the time in waves and a constant danger of being pulled down by the undertow. Our humanity, our individualism, that’s the best of us.

  5. Hi
    a colleauge in Denmark made me aware of your article and after reading it, I felt like saying that it is indeed encouraging to read since I am writing a thesis based upon my experiences as a therapist. Late Tom Andersen used to say that we need to write and talk in a way which create feelings inside the ones who read or listen. Your article corresponds with that. It is necessary to try to give life to the stories we tell and to realize that we are talking and writing about living people. So thanks again! Carina

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