First-Gen Med Students Rely on Grit to Navigate Challenges

Catherine Havemann, MD, is the first in her family to graduate from college. When she first arrived at Mount Holyoke College, South Hadley, Massachusetts, she encountered an “unknown and shocking” spectrum of wealth and privilege.

Although one of her undergraduate advisors discouraged Havemann from entering medicine, two other advisors, themselves former first-generation (FG) college students, supported her ambition to become a physician.

Today, Havemann is a research fellow and junior faculty member at the University of North Carolina, Chapel Hill, North Carolina. Her own student experiences at Vanderbilt University School of Medicine, Nashville, Tennessee, inspired her contributions to a study on FG medical students published in JAMA Network Open. “We realized that there was a paucity of research on this subject, and it became a very personal project for us,” said Havemann, who was a chief resident in emergency medicine at the University of Chicago, Chicago, when the research was conducted.

Havemann and her colleagues conducted qualitative interviews with 37 students from 27 US medical schools who were considered FG — ie, the first in their family to graduate college — and attend medical school.

Nearly one third of the students were non-Hispanic White, while about one fourth were non-Hispanic Black or African American. The interviewees also included individuals of Hispanic, Latino, or Spanish, non-Hispanic Asian or Asian American, or American Indian or Alaska Native origin.

FG students tend to be older, from traditionally marginalized racial and ethnic groups, children of immigrants or are immigrants themselves, or come from low-income families, according to the study. In addition, they tend to be underrepresented in medicine, with only about 12%-14% of students enrolled in US medical schools.

Four themes emerged in the interviews: Isolation and exclusion related to being a newcomer to medicine; difficulty meeting basic or educational needs like rent or textbooks; a lack of faculty or institutional support; and a sense of needing resilience to survive.

A ‘Deeply Personal’ Study

Toward the end of her first year of medical school, Havemann struggled academically. After having to remediate a course, she learned that she had a previously undiagnosed learning disability and later paid out of pocket for a course focused on study methods for students like her.

The isolating experience prompted Havemann to wonder how other FG students navigate labyrinthine support systems in large institutions.

“I was no stranger to struggle — overcoming challenge is an inherent part of the FGLI background — but feeling like the odd one out academically really magnified the sense of being an outsider in medical education, which doesn’t have a lot of people like me,” Havemann said.

Study coauthor Mytien Nguyen, MSc, an MD/PhD candidate at Yale School of Medicine, New Haven, Connecticut, also identified personally with the themes that emerged from the research.

Nguyen, who arrived in the United States from Vietnam at the age of 8 and grew up in Vermont, said she was the first in her family to graduate from high school.

“I had to learn the hard way how different I was from the other students,” she said. “Most people can afford MCAT prep courses, for example, but I couldn’t.”

Indeed, Havemann said, many — if not most — FG students are also low-income and are often called FG/low-income (FGLI).

“Even those who may not technically qualify as ‘low-income’ still face financial challenges…because they are often supporting their families and juggling one or two jobs as well as studies,” she said. That “has a significant downstream effect on our studying, test scores, stress levels, and well-being.”

Nguyen, who is the president of FGLIMed, a community advocacy organization for FGLI medical students, noted that there are many “hidden costs” in medical school — for example, events and social activities with monetary fees. “We can’t afford them, so we’re excluded and can’t participate. By default, we therefore have challenges in creating social networks and finding support that others don’t have.”

White coats, study materials, textbooks, fees for board examinations, and similar expenses add up quickly and aren’t always included in scholarships or financial aid packages. Some medical schools even require students to own a vehicle, coauthor Hyacinth Mason, PhD, MPH, assistant dean of students, Tufts University School of Medicine, Boston, told Medscape Medical News.

Hidden Costs and Financial Challenges

One study participant said she was expected to have access to personal transportation on clerkships and had to sign a contract as part of admissions saying she would buy a car — an expense well beyond her means.

“No one in her family had ever owned a car, much less learned how to drive. And she herself could not afford one. It expanded my understanding of the hidden reality faced by many students,” said Mason, who is also an associate professor of Public Health and Community Medicine at Tufts University School of Medicine and a member of the Association of American Medical Colleges (AAMC) taskforce that created the First-Generation Student Toolkit.

Mason recommends that medical schools assess how their students fare financially. What policies are needed to address their financial burden? Can scholarships or philanthropy be expanded to include some of medical school’s “hidden costs?”

Every school has different approaches, Nguyen said. There is no national scholarship fund for FGLI medical students, but she and her colleagues urge schools to create policies offering financial support for students beyond just tuition.

Nguyen encourages medical schools to create a more flexible curriculum, for example, because balancing several jobs and family responsibilities can lead to falling behind academically. FGLI students tend to take leave of absence at higher rates than their peers, she said, so creating flexibility regarding time to graduate without penalties is one way to help, she said.

Expanding Diversity, Equity, and Inclusion (DEI)

Encouraging diversity initiatives must go beyond the admission process and be an ongoing process that encompasses the whole student, according to Norma Poll-Hunter, PhD, Equity, Diversity and Inclusion Leader, AAMC.

“Admission is a starting point, but it doesn’t necessarily translate into being fully integrated into the medical school community and culture and having access to everything an institution has to offer,” she told Medscape Medical News.

Poll-Hunter recommended that institutions focus on “holistic” student affairs, initiatives, or interventions” to address food insecurity and overall inclusion and think about how to support students financially.

These students experience “unique stressors,” she noted. They have all of the academic and social pressures faced by all medical students, plus a host of other stressors — financial, psychosocial, and academic.

“In order for people to succeed, they need to feel a sense of belonging because if you don’t feel like you fit in, you’re more likely to drop out,” she said. “So we want institutions to pay attention to the experiences of these first-generation students. We don’t want to lose talent, especially since we’re facing a physician workforce shortage.”

Medical schools’ efforts on this front are now coming under pressure from activists and some lawmakers who aim to ban race-based DEI initiatives in higher education, including medical schools, after last year’s US Supreme Court decision effectively overturning affirmative action programs.

“This will undermine access to resources for many first-generation and low-income students,” Poll-Hunter commented.

The AAMC has a statement about the importance of DEI in healthcare and medical education. https://www.aamc.org/about-us/mission-areas/medical-education/my-story-matters

Nguyen’s background will inform her medical practice, giving her first-hand knowledge of what many patients need.

“My medical exposure prior to medical school was predominantly serving as an interpreter for my parents when they had medical appointments. Through that role, I was able to see what healthcare for immigrants looks like,” she said.

As access to medical education has expanded greatly over the past 5src years, Mason added, “We need a deeper focus on providing holistic support that ensures all students have what they need to live out their promise as physicians.”

The Burden Should Not Fall Upon the Students

“Grit” and “resilience” cannot be the sole or primary mechanisms of survival, the authors wrote.

“All too often, the burden is on us — the students — to educate our peers and sometimes even our professors not only about the realities we live but about immigrant, low-income, or disadvantaged patients,” Nguyen said.

Mason encourages physicians and staff to “develop nonjudgmental relationships with students, and in doing that, you will notice ways to be of support.”

Havemann suggested: “Ask thoughtful and well-intended questions before assuming incompetence or malintent,” she said. “Many people from diverse backgrounds are not familiar with implicit sociocultural expectations. These expectations should be made explicit. Think about ways in which medicine is like its own little universe, with its own cultural norms. Welcome all students — but especially FGLI students — the way you would welcome a foreign exchange student into your home, introducing them to norms and practices they may not be familiar with.”

Havemann emphasized that faculty and advisors “have enormous power to influence the course of someone’s life and, when given a choice, lean into encouragement rather than discouragement.”

Too many students are given discouraging messages by their advisors or faculty members, she said. “For students who have heard many versions of ‘no’ on their path to medicine, a single resounding ‘yes’ can be life-changing and profoundly impactful, way beyond what you might think.”

Warm Reception

Havemann called the reception of the study “warm and lovely.”

“Of course, we wanted first-generation students to read this, and they responded with a lot of validation with statements like ‘this speaks to my experiences’.”

But Havemann hopes to “grow the reach of the project to faculty and medical school leadership so it becomes meaningful to people who make decisions about the structure of medical education.”

She noted that many people from underrepresented backgrounds “tend to turn difficult experiences into scholarship, projects, initiatives, and community building. In my case, this focus is the meat of my professional identity, outside of my clinical work.”

Havemann hopes that their work will ultimately reach medical school deans and other decision-makers.

Resources for FGLI Medical Students

An increasing number of medical schools host groups dedicated to serving this unique population of students.

In 2src23, Yale School of Medicine launched a new First-Generation Low-Income Longitudinal Mentorship Program to “support, resources, mentorship, and networking opportunities; and to help overcome potential adversity and facilitate career progression.”

Tufts University School of Medicine hosts an annual First-Generation College Celebration that brings together FG students, residents, faculty and staff, and their supporters to advance their visibility and recognition.

The experts interviewed recommended other organizations for FGLI student support and resources.

Summer programs held at universities across the country for FGLI students seeking support and increased access in entering the healthcare professions

Mentoring in Medicine

https://medicalmentor.org

This nonprofit organization works with underprivileged students from third grade through health professional schools.

Tour for Diversity in Medicine

https://www.mightycause.com/organization/Tour4diversity

Conceived by former medical student leaders, this is a grassroots effort to educate, advise, and inspire future Underrepresented Minorities health professionals with terminal degrees.

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape Medical News and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).