We could start by challenging the assumption that all medical students and junior doctors have a financial safety net to fall into, says Anna Harvey and Declan Murphy
One of the founding principles of the NHS is that access is open to all regardless of background and circumstances. This principle applies to patients—but, it seems, not so much to NHS doctors.
The substantial and persistent under-representation of medical students and doctors from poorer socioeconomic backgrounds is well-documented and most efforts to widen participation focus on improving access to medical school. However, evidence increasingly shows that sociodemographic background also affects students at medical school and beyond, with few efforts to counteract the disadvantage.
The competing priority of having to work a part-time job while at medical school can reduce students’ ability to keep up with their studies. Spending an evening in the library will always come second if money must be earnt to cover food and accommodation. Having to work during holidays to supplement your loan can mean opportunities to build your CV are missed, putting you in a worse position than more financially secure colleagues when applying for foundation jobs and specialty training.
There’s been some recognition in other sectors, such as business and journalism, that free or low-paid internships disadvantage people who can’t afford to work for nothing—but there seems to be little recognition that the same is true for medical students and doctors. It’s difficult not to panic that summers working in childcare, retail or hospitality—while learning many skills transferable to work as a doctor—are unlikely to be seen as favourably as having done a research or quality improvement project when applying for a specialty training programme.
Students with aspirations in academic medicine may present their work at conferences. These presentations are also used to differentiate candidates for job applications. Mostly, presenters must pay their own registration fees, and bursaries are few and far between. Factor in the cost of travel—sometimes internationally, accommodation, and food, which can run to thousands of pounds, and there’s another potential financial barrier to some of the most competitive jobs and specialties.
Surely trainees should receive credit relative to the quality of their work, rather than the ability to attend a conference in another country. An academic foundation year doctor’s advice to us on how to make the most of the 18 months before the application window was to “bite the bullet and spend your savings on going to conferences.” The message was clear—spending money makes you more likely to get an academic foundation post.
There’s a lack of recognition that medical students and junior doctors struggle financially without help from relatives. Strangers may react flippantly to concerns, assuming a wealthy background when they hear “medical student”—like the Student Finance adviser who cheerily responds to worries about delayed loans with: “It’s alright! You’ll be a doctor in a few years, then you won’t have to worry!”
But of course we worry. A recent study in BMJ Open found surgical trainees pay up to £26,000 for general surgery training – just for mandatory costs, like membership exams, not including extras like specialised courses. A Master’s degree (more points for applications further down the line) can cost the trainee over £12,000. Even for those who have worked full time in the NHS before embarking upon one of these training programmes, this is a significant financial burden.
It’s difficult to save for these costs as a new doctor. A central allocation system means little control over where they work, moving costs, and often high rents. New doctors are compelled to start working at the beginning of August, and often aren’t paid until the end of the month. Free accommodation for FY1 doctors, no longer a statutory requirement, is rare (except in Wales).
Transport is also an unavoidable and often substantial expense. Hospitals are expected to have good public transport routes, but this often doesn’t translate to reality—and especially can be incompatible with shifts that begin early and end late.
Geographical location is a key consideration for those applying for their FY1 posts. Final years rank twenty Foundation schools from most to least desirable, with location significantly influencing decisions.
The cost of living dissuades applicants from applying to areas like London and Oxford. For students from poorer backgrounds with little or no external sources of financial support, these areas can be inaccessible, unless they have family living in the area. But location affects the opportunities available for trainees to develop a competitive CV. London is home to almost all UK medical and surgical colleges, along with institutions such as the Royal Society of Medicine, which offer conferences and training.
The solutions need long term strategy, and funding. We could start by challenging the assumption that all medical students and junior doctors have a financial safety net to fall into, and acknowledging the systemic disadvantages faced by poorer medical students and doctors as they progress through their career.
Anna Harvey is a final year medical student at King’s College London and 2019-20 Editorial Scholar at The BMJ. Twitter: @a_c_harvey
Competing interests: Anna is an unpaid member of the editorial boards of the GKT Gazette and JSAMR and an unpaid Medics.Academy Fellow. She has worked on widening participation projects since she started medical school, including, until recently, running a magazine for aspiring medics from widening participation backgrounds.
Declan Murphy is an academic foundation year 1 doctor based in Newcastle upon Tyne and a BMJ Student SharpScratch podcaster. Twitter @1994_declan
Competing interests: Declan is a committee member of SFO UK and peer-reviewer for BMJ Student and The BMJ. He established a local widening participation to medicine scheme while at medical school, was the 2017 Student BMJ Clegg Scholar in Widening Participation in Medicine and is a member of the @BecomingaDr team.