First-generation medical students face unique challenges and need more targeted support, say researchers

Medical research is increasingly informed by recognition of diversity's key role in addressing health equity. But when it comes to medical education, there's a group that has remained not just underrepresented but also under-researched: first-generation (first-gen) medical students—those whose parents have not earned bachelor's degrees.

These students are more likely to be older, identify as racial or ethnic minorities, be immigrants or children of immigrants, or come from low-income families. Along with anecdotal evidence, the minimal previous research indicates that these students face some unique struggles on top of the common challenges most medical students encounter.

"It became clear to me that schools—even the great ones that are intentional and diligent about building diverse classes—are not truly ready to receive first-gen students," said Catherine Havemann, MD, an emergency medicine chief resident at UChicago Medicine. "Admission isn't the same as full access to the institution. Sometimes support doesn't exist, and other times it's off-target."

To increase understanding of the first-gen experience and identify opportunities for educators and administrators to provide the most meaningful support, Havemann helped lead a team of researchers to perform an in-depth qualitative study. They analyzed data collected in interviews with a diverse group of medical students recruited from 27 medical schools across the U.S.

The results, published in JAMA, have the potential to inform efforts at increasing educational equity at both the institutional and individual level.

Struggles shared among a diverse first-generation population

Overall, the study confirmed that first-gen medical students feel that they face disproportionate adversity throughout their education and do not receive the support they need to compensate for that. Participants identified four main themes: feelings of isolation and exclusion; difficulties accessing basic resources such as food, rent, transportation and textbooks; a general lack of institutional support; and pressure to rely on personal "grit" and resilience for survival.

Some issues highlighted in the data were relatively unsurprising, such as financial difficulties.

"No matter which subset of first-gen students we talk to, money is a foundational part of the challenges they face—even if they're not technically low-income," said Havemann, the paper's first author. "Within the medical community, we need to talk more about the discomfort of disadvantaged students entering incredibly wealthy institutions with mostly wealthy peers. What does it mean to create some basic degree of equity?"

Other issues emerged as more persistent than the researchers had anticipated. For example, interviewees frequently mentioned transportation problems, such as situations where student loans don't cover the cost of having a car but medical school necessitates one. An especially striking theme was that many students reported being overtly discouraged by mentors or teachers during their education.

"People who meet the criteria for medical school admission are being told 'This is not for you,'" Havemann said. "It's disheartening to see, and it makes me think differently about my career as an aspiring educator. Saying 'yes'—even in a small way—to someone who has heard a lifetime of 'no' can make all the difference. To think there are people out there discouraging others is frankly appalling."

Responding to the findings

Havemann said the paper resonated strongly with student communities online following its publication.

"Responses ranged from 'This is obvious' and 'Water is wet' to 'Why doesn't my school understand this?' or 'We knew this already—where are the solutions?'" she said.

As a former first-gen student herself, she was struck by the consistency of experience revealed by the study's results. "It was validating as a researcher but also profoundly validating as a person."

But while the student response online served as important confirmation that the study's findings are representative, the real target audience is the educators who have the power to make a difference.

"I would love for them to read this paper and feel what a powerful position they're in to make a more equitable world," Havemann said. "Even the little things matter a lot."

Even as she and others conduct more research on this topic, Havemann said institutions can and should already be taking steps to provide better support for first-generation medical students.

"People like to talk about using holistic review in admissions to look at the whole student—we also have to look at holistic support once they enroll," she said.

Future studies will dive deeper into themes like professional identity formation, financial challenges, burnout and sense of belonging. Now that the qualitative groundwork has been laid, researchers can design more nuanced quantitative and mixed-method studies.

"For example, I'd like to quantify the percentage of first-gen students who are not only trying to support themselves but also keeping the lights on for their parents," Havemann said. "I think the answers would be gutting."