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I HAVE recently had time to commit to researching my ancestry. I was not surprised to see that as far back as I could trace, my family has worked solely in manual occupations.
Whereas the men tended to be the heads of households, the women held so-called domestic duties roles and did not work in paid professions until my maternal grandmother started work in a shop. I am the daughter of a gardener and a cleaner – two childhood sweethearts who met in the village they grew up in, never owned property, never drove a car, never had a passport and, up until recently, kept their money as cash under the mattress.
Despite struggling to accept my place in society throughout my teenage years – and even more so as I began my medical training – I have, in my post-graduate years, come to see my humble beginnings as an asset to the medical profession. But in the UK (where I trained), with only 4% of doctors hailing from low socio-economic background, and similar statistics in Australia, it seems that I am a rare breed. New schemes and projects to recruit more working-class state-educated students into medical school are popping up, such as the special entry access schemes at La Trobe University. Personally, I think this cannot come soon enough.
I studied at what is considered one of the most prestigious universities in England, acquiring my place there first on a premedical course designed to widen participation. The university historically has a terrible record of admitting students like me from state schools, with nearly 40% of its 2017 places going to privately educated students. To put this into perspective, privately educated students make up 7% of the total population of students in England. I spent my years at university feeling like a fish out of water, transported into a world that I wasn’t sure I belonged in and with people I wasn’t sure how to speak to. Attending a university with some of the most privileged students in the country but going home at holidays to my mum’s government housing estate allowed me to walk in two different worlds. While I thought I was learning how to communicate effectively with patients in my group tutorials, it was in fact in the duality of my experience at the student bar and at my mum’s bingo hall that the real learning was happening.
Undertaking a medical degree is no mean feat. It remains one of the longest degrees at university and requires a commitment to lifelong learning. The commitment for such learning no doubt comes from many different sources for different people – parental pressure, financial incentive etc.
For me, my long nights of study, my days of lectures, my failed exams that knocked me to my knees, and the successful retakes that got me back up again came from my working-class roots. Whether I knew that at the time or not is a different matter. Growing up, I witnessed the struggles of finances, no more so than when I asked my father to pay for a tutor that everyone else was seeing to help my chemistry grades. Unbeknownst to me until after his death, he was coming home from his 12-hour day job gardening, eating a quick sandwich, and going out until sunset to be able to afford my 45 minutes of extra help every week.
An Australian report in 2018 showed that the gap between the rich and poor continues to grow, with the top 1% of earners earning more in a fortnight than the lowest 5% earned in a year.
The wealth differences between those from the working class and those from the most affluent end of society have an undeniable impact on young peoples’ life experiences. I came to university anticipating it would be a long, hard journey, but growing up in a home where I witnessed strong work ethics pushing against daily struggles gave me strength with my ongoing training and with the often long and tiring on-call shifts.
The difference in life expectancy in Australia between the rich and the poor is nearly 20 years, and is almost double that between Indigenous and non-Indigenous people. It is vital that our health care workforce includes people with lived experience of hardship and marginalisation.
I remember vividly an Aboriginal woman I met in the intensive care unit during one of my first weeks of working in Central Australia. We had just told her that we did not expect her husband to survive a bout of illness and I asked her if she had someone to be with her overnight. She looked me in the eye, smiled and said: “I am Aboriginal. I have known dying and I have known grief since I was a child”.
This had a profound impact on me. I could go some way to understanding this woman, because I grew up poor and I had also seen pain and death from a young age. By the time I graduated as a doctor, I had lost all four of my grandparents, a parent, an uncle and two cousins.
Now, when I console my patients who are facing a bereavement, it not only comes from a place of kindness but of knowing, and it is this empathy in medical professionals that has been identified as an important quality patients look for when choosing a doctor. Domestic violence, alcoholism, drug misuse, and suicide are not only issues we encounter as doctors with our patients, but all too frequently in our own lives. Their impact is often felt harder when living with social disadvantage.
It was Rudyard Kipling in his poem to his son who said:
“If you can walk with the crowd and keep your virtue, or walk with Kings nor lose the common touch … Yours is the earth and everything that’s in it.”
This is what I feel I do with my medical degree daily. At times, coming from a working-class home and entering a professional workplace has felt like walking in two different worlds. And while throughout my time at university this was a dichotomy I grappled with and frequently detested, I have since come to view it as a strength over my 6 years of clinical practice. I value my roots and see them as an asset that enables me to work effectively with a diverse patient cohort.
My mother was 41 years old when she fell pregnant with me. She has told me the story of having an amniocentesis for her pregnancy and distinctly feeling that she had no say in the matter, that she was lost in a midst of medical words that alienated her from a conversation she was sure involved her but that she did not feel part of. In her own words, the doctors who performed her procedure were from a “different world” to us and she didn’t know how to be part of it. I understand what it was like for my mum and dad not to feel part of the medical world and not to know how to ask questions or advocate for their own health. I am careful, because of my family experience, to not create a medical world that the patient feels excluded from, and that especially extends to my disadvantaged patients.
In my daily practice, I strive to challenge a system that continues to disadvantage the disadvantaged. I encourage all my medical colleagues to do the same, because it most certainly takes more than one type of person to be a doctor, and it is my firm belief that it is in our diversity that we truly find our strength as a profession.
With special thanks to Katie Smith for her support and suggestions for this article.
Sarah Saunders completed a BA (Hons) in Medical Humanities alongside her medical degree and enjoys the social complexities of medical practice. She is currently working as an Australian College of Rural and Remote Medicine registrar in the Northern Territory.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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A very eloquently written article which I could not agree more with. I am sure it will inspire others to pursue medicine as a career. Thank you for sharing.
I’d nominate the single factor that’s most important to both scaring off less privileged applicants and driving noxious financial behaviours is high university fees. Look at all those above who found Commonwealth Scholarships to be a key part of access. Look at the USA where 7-figure graduate debt almost requires immediate high-billing.
Money spent on education is not a government cost, it’s an investment in a social good.
As doctors we advocate for social goods related to health and health care. We should also be strong advocates for investment in education. For medical care, this will help to produce a diverse workforce. More generally, an educated population seems more likely to be a healthy population.
University fees are a social ill.
Very poignant article. My daughter has just started her biomedical degree (she’s hoping to study medicine at some point and be a pediatric oncologist) and has been raised in a single parent household with no child support. We lived in poverty for nearly ten years until I started working fulltime and studying my degree in health science fulltime. We live in a rural town and I worked an hour from home, often ringing them and giving them cooking lessons over the phone. We are lucky to live in a town where people swap food produce and help out with each other’s kids. I believe my daughter’s humble beginnings will help her communicate effectively with patients and understand the complexity of health determinants.
Sarah, your parents’ love and support, and the sacrifices your father put in to afford your chemistry tutoring brought tears to my eyes. Your family may be lacking in terms of finances, but it is certainly not lacking in love and care.
Thank you for your heart felt piece. Beautifully written.
Its real, it may vary in Australia and especially more recently and with the institution, time and place. Equality of access is and cultural milieu origins have to cause tensions between and within
Thanks for the insightful and generous piece Sarah
I understand where Sarah is coming from. From a high school education in the UK, I came to Melbourne to do medicine. I later returned to the UK as a surgeon for two years for the training and work. This snobbishness Sahra refers to applies to UK, not to Australia. My medical year included European migrants including myself and a large component of Jewish boys and girls, a large component from Melbourne high schools, and a large component from every private school in Melbourne and Geelong. In Melbourne I found no distinction but in the UK yes
My graduating class (last decade) had more students from one high-SES metropolitan private school than from all public schools in the state put together. Enough said.
Anonymous 10) makes a the valuable observation that the old “Commonwealth Scholarship” scheme helped enormously to facilitate able students from lower socioeconomic backgrounds to study at University including in Medical Degree courses. I also depended on the scholarship to graduate in 1979, being the first in my family to attend University on campus (my father completing a Bachelor of Education by distance education while working full time, and raising his three sons, was the first to attain a university education).
Any attempt to” increase diversity” (a loathsome phrase of inherent elitist shorthand) must start with pre-tertiary education and financial sufficiency during University education.
Beautifully written, insightful piece. Sure to inspire others to pursue their dreams of Medicine. Thank you for sharing.
The whole question of privilege versus impoverished backgrounds leading to Med School needs more research. This article is an endearing revelation from a lovely person. But it is my observation over years that those with PTSD from severe poverty are more likely to become greedy practitioners when they finally make it ( Check out a certain corner of plastic surgery for example . . ), and the hand-on- heart Christian missionaries more likely come from privileges upper middle class (? Because they can be rescued by family money if plans go pear-shaped!!)
Though the views and sentiments are admirable and well intended though comes across to me as critical of the current status of medical graduates in Australia. This is a purely an opinion piece not based any research or data to back up its title and so should be treated as such. It lacks understanding, knowledge or balanced appraisal on the background and selection of current and past medical graduates in Australia, with a somewhat biased assessment in time and place due to the writer being educated in the UK. Due to significant changes in the funding of Tertiary Education in Australia in the 70s, I had the opportunity to attend University and Medical School despite going to a rural high school. I was also the product of a father, a career farmer only educated to Year 7 due to the Depression and a school teacher mother who came to Australia as a 13 year old WWII refugee not speaking any English. Because of the profound changes in tertiary funding, I got a chance because I studied and worked hard since that family experience was the reality of my life but also many others of my cohort. My graduating class was a mix of the educational and ethic diversity as well as social class of current Australian life at the time. My partner is also a medical graduate of rural and non-professional parents and refugees and attended a local public high school. We are both grateful what Australia and the educational and medical system has given us, and while we would now be considered “privileged” and upper middle class professionals, our minds and values are still clearly based on where and what we came from.
Before medical school I came from a background that was at times welfare dependant. My schooling was just not geared towards medical school entrance. I found the university experience frequently isolating with an assumed level of financial support and “cultural knowledge”that I simply didn’t possess. People of a non upper middle class background were in an extreme minority.I suspect that many of my colleagues only had the best of intentions when they made sometimes very hurtful comments or assumptions about me. Privilege is blind to itself and to class.
Now working in specialty practice in a disadvantaged area it still astounds me that many of the profession are semi- blind to the grinding effects of financial and economic inequality on their’ patients lives. This is before other more overt differences are factored in.
Thank you for raising these important points. I note the ‘what the blazes are you on about’ comment by C below, which I find to be harsh, judgemental and invalidating towards you. It is sad to see contributions with this vibe displayed in the commentary segment accompanying your heartfelt piece. I expect medical practitioners to have appropriate manners and communication skills no matter what their background.
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In my opinion the low number of doctors from impoverished backgrounds definitely remains an issue. So many people receiving medical care come from such backgrounds. I do not believe that the school that is attended is the best measure of background. Children from affluent backgrounds attend public schools these days, and children attending private schools can have a developmental history replete with significant adversity (despite affluence) that can be beneficial. It’s the point that you’re making of the need for more doctors who actually understand what it’s like to live in the same ‘real world’ as the patients. Thanks again.
Well ‘C’ let me tell you what she is on about.
UK Uni of Leicester 1998 intake, I was one of precisely 12 northerners in a year of 140. I could talk to precisely 2 other students about the topic of rugby league as an example of such diveristy.
However >40% of the year were Indian subconinental Asian.
Diversity there….
After the theoretical years we were sent on a 2 week ‘meeting with poor people’ attachment in areas of Leicester deemed sufficiently scummy. I couldn’t believe it. All the street lamps worked, no broken windows, no cars on bricks. It was a damn sight better than my home town. It caused me a lot of angst, I was the closest I ever was to using the Uni counsellor then.
Then when on hospital attachments away form the eye of Uni staff and within the realm of hospital consultants, the sly comments started about my accent, and one anaesthetist said stuff in a changing room away from anyone that was bad enough for him to stop himself in his own tracks before he went any further.
I am left thinking that the public school of Victoria have very very little in common with comprehensive schools in Northern England in the 90s. Perhaps our medical school experiences differ so much Sarah and I’s experiences are
particular to us.
C:
As a Melbourne University Alumna, I would be very interested to see which public schools these ‘50%’ of students came from. There’s a huge difference between MacRob/University high/Melbourne high and your average rural secondary college. Don’t think your statistic proves diversity of socioeconomic status in any way…
I certainly did not witness this diversity during my MD.
Thank you for such a thoughtful and insightful discussion. I couldn’t agree more. There is a vast difference between the simple recognition of another’s suffering and the deeper knowledge that comes from experiencing it (or something similar) yourself. Understanding through shared experience can’t be taught in medical school. It is a precious gift that we can bring to the care of our patients to make their experiences in the healthcare system more humane and positive.
what the blazes are you on about ?
50% of the University of Melbourne Medicine students in my year came from public high schools.
surely that’s a big enough percentage for diversity.
Furthermore just because someone came from a private school doesn’t mean they are from upper class background.
My parents were labourer immigrants that left school at year 10 to work, and yet they saved up enough to put me through private school education.
I got my MBBS presented in early 1968 having completed the course in 1967. My father was a clerk in the SA Railways, but his family were miners from Cornwall who came to Moonta Mines in SA. My mother’s family in Sheffield UK were bricklayers and police officers. Bob Menzies’ Commonwealth Scholarships helped someone from my background to do Medicine, though I think my family, including my older sister who worked in real estate, would have put me through had I not won the scholarship. My year included 4 others from the same western suburb state high school.