*Patient’s name has been changed
As a medical student on my primary care rotation, I reviewed my next patient’s medical records. Ms. Jones* was a 47-year-old female with a past medical history of breast cancer. Upon entering the room, she appeared nervous and tense, and, unsurprisingly, was picking at her fingernails — a telltale sign of a particularly anxious state.
I began the encounter with a lukewarm “How are you?” knowing very well that this was likely the last question she wanted to hear. Ms. Jones released a deep sigh, “Well, I lost my job. My insurance benefits are about to expire, and I am a single mom. My oncologist is out-of-network, and I can’t afford my treatment. I just…” she paused, looked down, and returned to her fingernails.
“Ms. Jones, I understand that you have a lot going on in your life. This must be difficult,” I hear myself recite reflexively as I internally scream. There is so much more I would like to say. I know this is unfair. The system is failing you, just as it has failed me. You are strong.
I did what I could within the confines of a 15-minute encounter to ensure Ms. Jones felt heard — I allowed her to speak without interruption, maintained eye contact, summarized what she had shared with me, and suggested some local resources for counseling. However, after she left, I reflected on my own experience with the healthcare system before I became a part of it.
“You need to refill your prescription and take your medication regularly,” I recall a doctor remarking sternly. My eyes welled with tears as I looked down and whispered, “I know.”
The doctor stopped in her tracks, realizing there was more to my story. I was a 20-year-old college Pell Grant recipient with neither familial financial support nor a consistently employed parent whose insurance plan I could occupy. I had just convinced my university to expand my financial aid to cover health insurance so I could finally make this appointment. I was proud of myself for that progress — until this doctor’s comment tore me down.
In that moment, what I had needed was an open-minded, empathetic provider to simply ask me why I had not followed up or taken my medication as prescribed. Had this occurred, I may have felt support, rather than shame. It may have also granted me the autonomy to shape my own narrative, rather than be written off as “non-compliant.” Studies have shown that high patient perception of physician empathy is significantly associated with increased patient satisfaction, physician-patient trust, and patient compliance. Additionally, empathy is proven to be driven by an understanding of, awareness of, and sensitivity to another being, which often is augmented by similar, shared experience.
This is where socioeconomic diversity among healthcare professionals can play a critical role.
While the words “health disparities” and “social determinants of health” are now widely known by the medical community, most providers have never shared the experiences of their patients when trying to access timely, continuous healthcare in the face of financial strain. Living within the lowest income quintile is associated with decreased quality of self-reported health and lower medication adherence. However, just 5% of matriculating U.S. medical students are from the lowest U.S. income quintile, while a resounding 51% are from the top quintile.
Although some may say that providers can become sensitive to their patients’ struggles by taking a careful social history, resolute understanding of the complex emotional impact of income dictating health status can, unfortunately, only be fully learned through lived experience.
As the middle-class wanes and our population becomes increasingly stratified by high versus low income, it is imperative that medical school admission departments intentionally correct the income-driven diaspora that exists within their matriculant pools. Doing so would require vast institutional change, including expansion of financial assistance, reduction of tuition, and increased loan forgiveness opportunities at the resident and attending physician level. By cultivating a new generation of young physicians that more closely resembles the U.S. population, providers can treat patients with awareness of the multifactorial history that accompanies their chief complaint. This awareness can drive action such as involving social work, sharing community resources, or increasing follow up. Ultimately, these touch-points can help patients like Ms. Jones and my younger self feel more supported and understood, while ameliorating the persistent income-based disparities within the U.S. healthcare system.
Lauren Hucko is a fourth-year MD/MPH student at the University of Miami Miller School of Medicine.
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