Being a first-generation student doesn’t end in medical school: A call for more research and support after undergrad

In 2022, the First-Generation Student Organization at Kansas City University College of Osteopathic Medicine (KCU-COM) was founded to foster community among medical students whose parents have not completed a four-year undergraduate degree. While many undergraduate institutions have clubs and resources for the first-generation (FG) community, it is rare to see medical students identify with or celebrate their FG status.

Our aim is to identify the FG student population in medical schools, explore current research on this underrepresented group and outline the barriers experienced by FG students while detailing the need for advocacy.

Please note that there are a few different accepted definitions of first-generation students. The American Association of Colleges of Osteopathic Medicine (AACOM) defines first-generation (FG) students as those whose parents did not complete a four-year undergraduate degree. The Association of American Medical Colleges (AAMC) defines first-generation (FG) students as those “whose parents have not earned an associate degree or higher.” Many national organizations such as the National Association of Student Personnel Administrators (NASPA) identify FG students as individuals whose parents did not complete a four-year college degree.

Current research and barriers

The existing research on FG students is largely focused on undergraduate FG students. However, there is some limited research on graduate-level FG students, including medical students.

With the addition of the FG indicator to the AAMC application in 2017-2018, it was estimated that only 12.4 percent of MD medical students matriculating in 2021-2022 were FG. AACOM reported 14.2% of matriculating osteopathic students were FG in the 2023 cycle.

Research regarding FG students enrolled in medical school has identified several key points, which are outlined below. Please note that much of the research below on FG medical students is on those in MD or MD/PhD programs; research exclusively on FG students in DO programs may yield different findings.  

FG students are less likely to enroll in medical school than their continuing-generation colleagues. Those who are also low-income students are even less likely to enroll in medical school. Several prevailing factors identified through qualitative research may be influencing this, including inadequate pre-health mentorship, lack of social capital, financial instability/loan burden, imposter syndrome, increased levels of hardship and family responsibility during undergraduate careers and the financial-cultural barrier associated with applying to medical school.

While FG matriculation has increased, there appear to be significant barriers to success once in medical school. Qualitative cohort studies revealed notable barriers in the area of mentorship, research opportunities and shadowing: “compared with their non-first-gen peers, first-gen medical students reported lower levels of faculty role models engaging in self-care and lower levels of school support for family and personal responsibilities.”

The complex intersectionality of the FG identity also lends itself to increased financial and social barriers, as many FG students are also members of other underrepresented groups in medicine, such as low socioeconomic status or racial minorities. Increased financial stress and loan dependence, with minimal family support or background knowledge, puts FG students in a position of increased vulnerability.

Another barrier experienced by FG students is navigating the hidden curriculum of medicine, such as dealing with mental health and understanding the dichotomy between what is taught in official curricula and the actual culture of practiced medicine. A large proportion of students also experience breakaway guilt and identity pressure from their families as they pursue medical education.

Qualitative studies across allopathic and osteopathic programs have also shown that FG students are challenged in three major aspects: access to resources; lack of institutional support; and the need to self-rely on grit and resilience to survive.

While skills of grit and resilience are qualities valued highly in the medical field, a study at Indiana University School of Medicine showed FG students experience increased levels of fatigue, stress, financial worries, a lower quality of life and lower social support ratings than their continuing-generation counterparts. While some studies have been conducted exploring the unique barriers to medical education FG students face, there has not been a significant amount of research compared to FG undergraduate students or other historically underrepresented minorities, especially in osteopathic FG students.

An inclusive physician-leader population lacking medical education support

FG students import diversity, cultural competency and inclusion into the medical field. With their diverse life experiences, they often empathize with patients in different ways than their continuing-generation peers. A demographic study found FG physicians are more likely to practice in underserved areas, potentially due to their similar backgrounds. Social, cultural and institutional support (social capital, financial stability, food security, stress management, disability services) are paramount to supporting this group of students and continuing to foster their success in medical school. FG-specific scholarship opportunities, such as Federal Pell Grants or the Unigo scholarships, are no longer options to FG students upon entering medical school.

Space for intentional mentorship, research/shadowing opportunities, counseling on the hidden curriculum and cost of medical school, and financial support are of heightened importance to FG students.

Moving forward

These larger systemic supports require smaller advocacy to occur first. We would like to see more researchers study first-generation students attending colleges of osteopathic medicine so we can better understand the current demographics of FG students in DO schools. Recent research has been released showing there is a statistical but not meaningful difference in osteopathic FG students in the areas of growth mindset, purpose, resilience and psychological symptoms, however we would like to see studies such as this one repeated in students engaged in their first through fourth years of medical school and in practice, rather than just incoming osteopathic students. Additionally, future studies using AACOM data on overlapping HRSA factors, such as medically underserved communities or low SES x FG and other indicators, could prove useful to create support systems for these students.

This would enhance the osteopathic medical profession’s ability to address existing barriers and further outline how they affect FG osteopathic students, thereby uplifting this community. Increased FG research would also allow for a deeper understanding of unique attributes of osteopathic and allopathic FG students.

Specifically, we would like to see further exploration of how osteopathic medical education influences resilience, leadership characteristics, and performance of FG students in graduate medical education and practice.

Greater awareness of the FG identity would facilitate the creation of other FG organizations similar to what we have started at KCU-COM. Students entering undergraduate institutions often have FG support, scholarships and guidance to reach their goals, but this support of their identity should not disappear upon entering medical school.

The diversity that FG physicians bring to the medical field is critically important, especially in underserved communities, where many FG physicians grew up. Just as osteopathic physicians seek to treat patients holistically, the development of osteopathic physicians should be supported holistically as well.

Related reading:

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Eliminating training barriers for DO students & residents