I had arrived a few minutes before clinic and was looking through the panoramic windows of the hospital’s newest wing. Staring at the expanse before me, I recognized a solitary attic window. It was a familiar sight because I had spent my childhood in that attic, living with my parents and often visited by the rats and roaches, our unwanted guests. Growing up, I spent hours watching the hospital through that attic window. Never did it cross my young mind, that years later, I would be staring back from the hospital, with a stethoscope around my neck.
I was standing in a position of privilege, distanced from my former self by the education and socioeconomic capital I now possess. Before entering medicine, “privilege” was not a word I used much in conversation. High school was the last time I talked about privilege.
Privilege means to have advantages in society by virtue of belonging to a certain group. To be of a certain ethnicity, to be educated, to be part of a higher socioeconomic class — these were all privileges described by my classmates. During this discussion, I grew increasingly perplexed as aspects of my upbringing that I thought were privileges were seen as otherwise.
My family was supported by a homeless shelter before we moved into subsidized housing — the attic near the hospital. Food came from the food bank or soup kitchens. Clothing was second hand from the church donation bins. My parents did not have a university education, but they found jobs as factory workers and on most days, we seemed to have enough to get by.
To me, these were all part of a mundane, normal life, but in the context of privilege, these aspects suddenly became salient as a mark of “underprivilege.” Placed at a school attended by mostly middle-class students, this underprivileged experience became part of my identity, and to be different was incredibly isolating.
This identity of subordinance provided the impetus for me to pursue higher education. To be told that fields such as medicine or law were not in the realm of my socioeconomic class, that they carried an enormous financial investment with uncertain admission, made me resent my underprivileged identity even more. I wanted to be able to give my family the privileges we didn’t have and to break away from a cycle of poverty.
I studied hard and worked two part-time jobs during university to fund my medical school applications, but throughout the whole process, it was clear that one had to come from privilege to easily apply and assimilate into the medical culture.
In fact, not only are a disproportionate number of students from families of higher socioeconomic class, they come prepared with the social and cultural capital to navigate the medical school environment. Upon acceptance, I became a part of this new culture. Not wanting to be different, I hid my identity to feel included.
It wasn’t until I left the classroom that these sentiments began to change. I remember the single mother, with limited time to take off work, miss her own appointments to attend her daughter’s appointments instead. I saw patients who did not take their medications because they were too expensive. Patients with a language barrier who incorrectly interpreted their treatment plan because they didn’t understand. I saw myself and the experiences of my family in the lives of these patients, and I realized that I did fit into medicine — I fit in with my patients.
Although I initially tried to distance myself from my identity, I now acknowledge that it is a part of me I shouldn’t erase. To come from this background grants a different, more subtle form of privilege beyond that of wealth and social networks. I call it an “empathic privilege” that allows one to be more cognizant of the social determinants of health that patients often leave unspoken when seeking medical care.
In another sense, I also feel comfort in the presence of patients with lower socioeconomic status, whereas others might feel unease and frustration, because working with these patients helps close the gap between my identities.
I share my story because those with the underprivileged identity do exist in medicine, but they are a silent minority. Race and gender are easy to see, but low socioeconomic status may not be visible. Speaking about underprivilege may seem out of place, when now, as a result of luck and circumstance, you land among the most privileged.
Medical schools continue moving toward making the admissions process more equitable and diverse. However, measures to maintain and support diversity beyond the intake stage are often not in place. Students are then put in the position of negotiating a dual identity — one consistent with the medical culture, the other staying true to their social and cultural origins.
Medical schools should look one step back and one step forward in the admissions process. Before students from under-represented backgrounds can begin to use application subsidies or affirmative action initiatives, getting them to contemplate medicine in the first place requires an alignment between their identity and the identity associated with this vocation.
I encourage medical students and practicing physicians to be open about their stories, to humanize the identity of medicine so it doesn’t seem so lofty to those at a lower starting line — to show that a lived experience in poverty is valued by medical schools as much as, if not more than, having volunteered at a homeless shelter.
Looking forward, schools should continue diversity initiatives postadmission, whereby physicians from under-represented backgrounds support a culture of mentorship for like students, to facilitate development of their identity and strengths.
I am grateful to have lived in the dual worlds of underprivilege and privilege. I know what it feels like to not have choice, to have external factors, such as money and other people, dictate the path of my life. For many patients, it may feel the same — when their bodies and their lives are now in the hands of others.
Underprivilege has also taught me the importance of valuing chances, to hold on to them, offering my wholehearted effort toward these opportunities, because they were the threads of luck that helped pull me to the side of privilege. These experiences have taught me more about empathy and hard work than any medical school class could, and for that, to have been underprivileged is perhaps the greatest privilege in medicine.
Author: Stephanie Y. Zhou
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