My (Christian Hardoy) family's roots are planted in the blue-collar world, as my grandfather was a sheepherder turned gardener and my father built his career in landscaping. Growing up in a small agricultural town ingrained the value of perseverance in me, but it also came with unique challenges for someone interested in medicine. Many of my peers had doctors in the family or physician family friends to help them tailor their applications to medical school. Lacking such connections, I just had to do what my family had always done: forge my own path and get to work. Though I had the benefit of a blue-collar work ethic, it remained unaccompanied by the generational wealth or social capital that often facilitates acceptance into medical school. I had deep concerns over whether I could successfully pursue a career in medicine due to this perceived disadvantage and the role of nepotism in medical education. Now, looking back as a medical student who routinely interviews potential MD candidates, I can only come to one conclusion: my concerns were valid.
The idea that nepotism plays a role in medical school admissions is not novel, yet its prevalence continues to impact both the ability and motivation of aspiring medical students. A by the Association of American Medical Colleges (AAMC) found that over 75% of incoming medical students are from families in the top 40% of U.S. income brackets, and 93% have parents with a bachelor's degree or higher in executive, managerial, or professional occupations. Being the child of a wealthy or physician parent offers advantages and opportunities such as physician shadowing, extracurricular activities, and mentorship that may be out of reach for underrepresented communities or people of lower socioeconomic status. With a growing number of medical school applications -- for the 2020 application cycle -- the competition is fiercer and the benefit of personally knowing a physician and having access to opportunities is growing.
The Consequences of Nepotism
In medicine, personal connections are immensely beneficial to nearly all aspects of a person's career. They can impact everything from medical school or residency selection criteria to journal publishing to training opportunities.
Let's explore an example of how these connections could play a role in ranking residency applicants. One of residency selection criteria revealed that clerkship evaluations, senior elective evaluations, having honors grades, U.S. Medical Licensing Examination (USMLE) Step 2 scores, and grades in senior electives all play significant roles in residency selection. Clerkship grades were ranked the highest among selection factors. This provides an avenue through which nepotism and social capital can provide an advantage, as evaluations of student performance during clinical rotations are often variable in nature. Furthermore, by University of California Davis found that evaluators plays a greater role in medical student scores than the student themselves. The concept of an ideal medical student varies from preceptor to preceptor, and with clerkships, elective evaluations, and letters of recommendation playing an important role in the residency admissions process, the opinions of just a select few evaluators become important. Getting into medical school is already a challenge without connections, but once accepted, the challenge to make oneself "belong" becomes important for academic success. While age, gender, and race remain outside of student control, fitting into the arbitrary mold of what a medical student should be is strengthened by the relationships they have had throughout their academic career. The potential for , , and nepotism, in producing clinical evaluations is simply too high, as they may permit assessments that may be unfair and inherently variable. Such evaluations may play an even bigger role now that the USMLE Step 1 exam changed to a pass/fail system, removing one of the (arguably) more objective criteria. While it is critical to assess clinical ability and "untestable" qualities such as empathy or teamwork ability, placing too much influence in the hands of a few preceptors renders the residency admissions process less objective to medical students from families with no medical background or underrepresented groups.
Nepotism may also manifest in the form of publications and contributions to medical literature. One that editorial board membership significantly increased one's chances of being published compared to those without such ties. Another of biomedical journals found that the most published author was a member of the editorial board 61% of the time. A of PLOS ONE papers showed that 48% of coauthors did not satisfy the requirements for authorship, highlighting the dangers of nepotistic connections that can result in resume-enhancing authorship without significant contribution. Connections and affiliations can falsely boost a student's scientific standing.
Toward Promoting Equity
So, what can be done to combat the risks of nepotism and bias in medical education and training?
First, medical admissions processes must improve their emphasis on inclusivity through outreach and mentorship programs for potential students from disadvantaged backgrounds. Furthermore, there must be a change in how grades are given during clerkship years. We suggest that the submission format should be made transparent. This means clear and realistic expectations for students are laid out at the beginning of clerkships so students understand the grading process. This could also include an objective rubric, with evaluations conducted by a group of preceptors rather than just one person.
Regarding admissions, requiring applicants to disclose familial, financial, or other connections and conflicts of interest can help to identify those with potentially unfair advantages. Such policies would prompt an objective form of review from someone with no connections to the applicant and identify nepotistic influences on applicants' experiences. Identified non-disclosures would subsequently be considered ethics violations. Lastly, evaluators and admissions officers themselves must be subject to regular internal review processes to ensure that inter-rater reliability is consistent at each medical school.
The training and advancement of those who have no connections in medicine remain important, as diverse care teams that include physicians of minority backgrounds have been shown to patient health outcomes. It is time we safeguard an equitable advancement process in medical education.
is a second-year medical student at the University of California Irvine. is a second-year medical student at the University of California Irvine.