“We cannot use the rituals of graduation as a public demonstration of inequity.”
Graduating from medical school is a joyous, celebratory ritual of passage. In recognition of their important achievement, graduates are awarded the title of “medical doctor.” It is a wonderous pause in the emerging careers of young physicians—and all graduates should be able to participate in it equally.
A talented, inquisitive fourth-year medical student mentee of mine, who is headed for psychiatry residency, recently told me about the “hooding ceremony” at her upcoming graduation. As she shared her experience, 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—the parents—would be able to place that ceremonial collar around our children’s shoulders and welcome them into this special club of doctors.
I was quickly brought up short as my mentee’s experience revealed an underbelly to this ritual: a blind spot for me that 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 in search of educational opportunities for her and her sister, a move that entailed a significant loss of social and financial status for her father. Her parents experienced significant hardship as they 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 profoundly painful fact that she and her parents would be treated as “second class” at the moment of her highest achievement. Those with privilege, wealth, and 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 us. My own experience of privilege had obstructed my ability to see this clearly.
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 included many meetings and discussions and a class survey. Eventually, changes were made to the graduation ritual—but for future years. To make the celebration equitable, beginning in 2024, only the deans will hood the graduates.
Although my mentee is rightfully proud that her efforts have shed light on this issue and promoted positive change, she is nonetheless sad that at her only medical school graduation, her father will not be able to participate 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, it serves to differentiate graduates along class lines and contributes to marginalizing first-generation graduates. This second-class status is more often experienced by students of color, those 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 years in medical school, she nonetheless came to the field with privileges that paved her way. My husband’s and my wealth and familiarity with the workings of medical institutions smoothed her path. We cannot use the rituals of graduation as a public demonstration of inequity.
Although race and socioeconomic class 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 country’s racist and classist history mean that few students of color and few from lower-income communities see many individuals who look like them on the graduation podium or at the office.
The medical education system and the profession at large have certainly made enormous strides toward expanding diversity, equity, and inclusion in our training and practices. Substantial efforts have been made to recruit underserved minorities and begin to grow a workforce more dedicated to caring for communities that have previously been ignored.2 Discussions about the social determinants of health have become widespread, improving our understanding of how social structures impact illness and patient care.
Nevertheless, 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 giving them higher-class status than other health workers and groups in our society.
As we try to confront the legacy of American classism and racism, we in the medical profession must confront the ways in which 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 eradicating persistent racial and class disparities.
Our graduation rituals and ceremonies allow us to reflect on our values and on our continuing need to do better. Graduation should celebrate all our young colleagues’ achievements equally and focus our attention on the equity we aspire to achieve both within our ranks and in society.
Dr Cooper is an associate clinical professor in the UC San Francisco (UCSF) Department of Psychiatry and Behavioral Sciences and cofounder and president of the Climate Psychiatry Alliance.
Disclaimer: All author comments are made in the author’s individual capacity, 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