“As we attempt to confront the legacy of American classism and racism, we in the medical profession must confront the ways that our own institutions unwittingly continue to reflect and mirror broader social realities.”
Medical school graduation is rightfully a joyous, celebratory ritual of passage, recognizing the important achievement of years of learning by awarding graduates the title of “medical doctor.” It is a wonderous pause in the developing careers of young physicians that all graduates should be able to participate in equally.
A talented and inquisitive fourth-year medical student mentee destined to psychiatry residency shared her experience with me as details for the “hooding ceremony” of her school’s upcoming graduation were revealed. As she told me of the plans, memories of my own daughter’s graduation from my and my husband’s alma mater came to mind. We and other physician parents reveled in the excitement of that special moment when we, her parents, would place that ceremonial collar around her shoulders, welcoming her into this special club of doctors.
I was quickly brought up short as my mentee’s experience revealed an underbelly to this ritual enactment: a blind spot for me and one many may share. Blind spots are understandable, especially for those of us who are privileged. Our responsibility is to do what we can to act on these blind spots when they become apparent.
My mentee is a Bangladeshi immigrant whose family came to the United States for educational opportunities for her and her sister, which entailed a significant social status and financial loss for her father. They experienced significant hardship; both her parents became invisible immigrant workers in the service industry, sacrificing much while providing opportunities for their children.
My student showed me the other side of the hooding ritual; the profound and painful experience that she and her parents would be treated as “second class” at her highest moment of achievement. Those with privilege, wealth, and prior generational access to professional status are celebrated in a special way. My mentee and her family would not be seen or treated equally. The graduation ritual would separate the two. My own experience of privilege had obstructed my ability to clearly see this.
This student, who is brave and uses her voice effectively, brought up her concerns to the deans. She expected to be easily understood—but the process was not so simple. The resultant brouhaha at the school included many meetings and discussions and a class survey. Eventually, changes in the graduation ritual were made, but for future years. To make the celebration equitable for all, beginning in 2024, deans exclusively would hood all graduates.
Although my mentee is rightfully proud that her efforts have contributed to bringing awareness and change to this issue, she nonetheless is sad that forher only medical school graduation, her father will not take part in hooding her. Her experience is one we must take seriously.
The hooding ritual allows parents with advanced degrees this unique honor. Although likely unintentional, this serves to differentiate categories of graduates along class lines and contributes to marginalizing first-generation graduates. This second-class status is more often experienced by students of color, students from working-class backgrounds, first-generation college graduates, and new immigrants.
My personal story underscores these disparities. Without diminishing my daughter’s hard work during her medical education, my daughter nonetheless clearly came to the field with privileges that paved her road. My husband and my wealth and familiarity of the workings of medical institutions smoothed her path. We cannot use the rituals of graduation as a public demonstration of inequity.
Although socioeconomic class and race are not equivalent, their intersectionality cannot be missed. Classism has been defined as the “institutional, cultural … practices and beliefs that assign differential value to people according to socio-economic class … [which inherently] creates excessive inequality.”1
Historically, both people of color and those without wealth have had less access to higher medical education. The vestiges of our racist and class-based history result in the reality that few students of color and few from lower-income communities do not see many individuals who look like them on the graduation podium or in the office.
Our medical education system and the broader profession have certainly made enormous strides in expanding diversity, equity, and inclusion into our training and practices. Substantial efforts have been made in recruitment of underserved minorities, beginning to grow a workforce more dedicated to caring for communities that have previously been ignored.2 Discussions surrounding the social determinants of health have become widespread, improving our understanding of how social structures impact illness and patient care.
Nonetheless, our medical education system supports and prepares young physicians to enter a system that regrettably still promotes and protects privileged elites, sustaining power and wealth hierarchies. These class inequities separate physicians by anointing higher-class status from other health workers and groups in our society.
As we attempt to confront the legacy of American classism and racism, we in the medical profession must confront the ways that our own institutions unwittingly continue to reflect and mirror broader social realities. We need to confront and work to correct the apparatus of class status embedded in our professional hierarchies. The symbols we choose to use must reflect our commitment to working toward eradication of the persistent racial and class disparities.
Our graduation rituals and ceremonies provide moments to reflect on our values and our continued need to persist in doing better. Graduation should celebrate all our young colleagues’ achievements and focus our attention on the equity we aspire to achieve both within our ranks and in our broader role in society.
Dr Cooper is an associate clinical professor in the University of California San Francisco (UCSF) Department of Psychiatry and Behavioral Sciences, and co-founder and president of the Climate Psychiatry Alliance.
Disclaimer: All the author’s comments were made in the author’s individual capacity and not on behalf of UCSF, and have not been reviewed or approved by UCSF.
1. Classism. Stanford University Student Affairs. Accessed April 25, 2023. https://studentaffairs.stanford.edu/stanford-against-hate/classism
2. Disrupting the status quo: special report of the UC Health Sciences Diversity, Equity and Inclusion Task Force. University of California Health. September 2020. Accessed April 25, 2023. https://www.ucop.edu/uc-health/_files/uc-health-sciences-diversity-taskforce-report.pdf