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. 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.
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.
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).
 See http://www.thestudentroom.co.uk/wiki/Medical_School_A_Level_Requirements, accessed 30th May 2012.