Association of Socioeconomic Status With Alpha Omega Alpha Honor Society Membership Among Medical Students

Alpha Omega Alpha (AΩA) honor society membership is the hallmark of academic achievement in undergraduate medical education, and AΩA membership is associated with future success in academic medicine.¹ AΩA members are chosen based on academic performance, leadership, patient care, and service.² Nevertheless, studies have shown racial/ethnic disparities in AΩA membership.^3,4 Whether similar disparities in AΩA membership exist across socioeconomic strata remains unknown. To address this knowledge gap, we investigated the association between AΩA membership and medical student socioeconomic status.

In this cross-sectional study, we obtained deidentified data from the Association of American Medical Colleges (AAMC) describing medical students applying to residency between 2018 and 2020 who matriculated in the 2014-2015 and 2015-2016 academic years. We determined students’ AΩA membership through the AAMC’s data applications and services⁵ along with socioeconomic measures, including parental education, childhood household income, Pell grant assistance, and whether the student had been a beneficiary of state or federal financial assistance programs for low-income families. Additional characteristics included sex, self-reported race/ethnicity, and Medical College Admission Test (MCAT) scores. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline and was approved by the Yale University institutional review board.

Our initial cohort included 36 617 students, from which we excluded 1729 (4.9%) because their medical school had no AΩA chapter, 3609 (9.8%) because AΩA elections occurred in senior year and results were not reported to the AAMC, and 1014 (2.7%) because the socioeconomic measures were unknown. Race/ethnicity was reported by students and categorized into the following groups: non-Hispanic White, non-Hispanic Asian, non-Hispanic Black or African American, Hispanic, non-Hispanic American Indian, Alaskan Native, Hawaiian Native, and other Pacific Islander, or other. Students who identified with more than 1 racial/ethnic category were categorized as multiracial.

We compared differences between AΩA members and nonmembers using the χ² test. We used logistic regression to model the association between measures of socioeconomic status and AΩA membership, adjusting for students’ demographic characteristics and MCAT scores. Owing to the collinearity between childhood household income, Pell grant assistance, and state or federal financial aid, childhood household income was selected for inclusion in the multivariate model to provide the greatest distinction in economic advantage between students. Statistical analyses were performed using Stata, version 16.1 (StataCorp). A 2-sided P < .05 defined statistical significance.

Among 30 265 students in the study cohort, 4504 (14.9%) were first-generation college graduates, 9130 (30.2%) reported childhood household income less than $75 000, and 6862 (22.7%) and 5796 (19.2%) were Pell grant and state or federal financial assistance recipients, respectively. The percentage of students identifying as first-generation college graduates (598 of 5745 members [10.4%] vs 3906 of 24 519 nonmembers [15.9%]), reporting childhood household income less than $75 000 (1238 of 5745 members [21.4%] vs 7892 of 24 519 nonmembers [32.2%]), and receiving Pell grants (887 of 5745 members [15.4%] vs 5975 of 24 519 nonmembers [24.4%]) or state or federal financial assistance (746 of 5745 members [13.0%] vs 5050 of 24 519 nonmembers [20.6%]) was lower for AΩA members compared with nonmembers (P < .001) (Table 1).

In our fully adjusted multivariable model, students reporting a childhood household income less than $125 000 (2700 of 5745 members [47.0%] vs 13 705 of 24 519 nonmembers [55.9%]) were less likely to be AΩA members than students reporting a household income of at least $200 000 (1005 of 5745 members [17.5%] vs 2981 of 24 519 nonmembers [12.1%]) (Table 2). This disparity was greatest for students reporting a childhood household income less than $50 000 (549 of 5745 members [9.6%] vs 4541 of 24 519 nonmembers [18.5%]), for whom the odds of AΩA membership were 46% lower than the odds for students whose childhood household income totaled $200 000 or more (adjusted odds ratio, 0.54; 95% CI, 0.48-0.62) (Table 2). Female students were more likely than male students to be members (adjusted odds ratio: 1.17; 95%CI: 1.10-1.24), and Asian (adjusted odds ratio, 0.50; 95% CI, 0.46-0.55), Black or African American (adjusted odds ratio, 0.33; 95% CI, 0.27-0.40), Hispanic (adjusted odds ratio, 0.61; 95% CI, 0.52-0.71), and multiracial students (adjusted odds ratio, 0.67; 95% CI, 0.58-0.76) were less likely to be AΩA members than White students. MCAT scores were strongly associated with AΩA membership (Table 2). We found no significant interaction between socioeconomic measures and race/ethnicity.

Our study’s major finding is that students from backgrounds with lower income than their peers were less likely to be AΩA members. Consistent with prior studies,^2,3 our results show persistent and striking racial/ethnic disparities in AΩA membership, even after adjusting for socioeconomic measures and standardized test scores. Our study has limitations. Childhood income was self-reported and may not fully reflect parental financial resources, including assets. Furthermore, our study involved a 2-year time frame and may not represent historical trends in AΩA membership. However, to our knowledge, this study is the largest and only examination of AΩA membership by socioeconomic status to date. Although AΩA membership has been recognized as a marker of merit, our findings suggest that AΩA membership may also be an indicator of privilege. Medical schools must ensure that the learning environment allows all students to thrive irrespective of their backgrounds.

Accepted for Publication: March 29, 2021.

Published: June 2, 2021. doi:10.1001/jamanetworkopen.2021.10730

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Nguyen M et al. JAMA Network Open.

Corresponding Author: Mytien Nguyen, MS, MD-PhD Program, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510 (mytien.nguyen@yale.edu).

Author Contributions: Ms Nguyen and Dr Boatright had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Nguyen, Mason, O’Connor, Nunez-Smith, Boatright.

Acquisition, analysis, or interpretation of data: Nguyen, O'Connor, McDade, Latimore, Boatright.

Drafting of the manuscript: Nguyen, O’Connor, Latimore, Boatright.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Nguyen, Boatright.

Obtained funding: Nguyen, Latimore, Boatright.

Administrative, technical, or material support: Nguyen, Mason, McDade, Boatright.

Supervision: Nunez-Smith, Latimore, Boatright.

Conflict of Interest Disclosures: Dr Nunez-Smith reported receiving grants and speaker’s fee from Genentech outside the submitted work. No other disclosures were reported.

Funding/Support: Ms Nguyen is supported by National Institutes of Health Medical Scientist Training Program Training grant T32GM136651. Dr Boatright is supported by National Institutes of Health grant R01GM137411.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Additional Contributions: An additional critical review of the manuscript was performed by the Association of American Medical Colleges, Washington, DC. They did not receive financial compensation for their contributions.