Medical practice is a calling. It’s not a job, it’s not a career — it’s a vocation. And if you really love your vocation, you’ll let nothing stand in your way. Certainly not something as trivial and crass as money. After all, once you’re in practice, you’ll be raking it in, right? So why worry about that now, when you’re just beginning your medical education?

That attitude is pervasive, and it’s badly wrong. Money matters to how you experience medical training. It matters a lot.

Medical practice is a calling. How many people outside medicine work 36 hours at a stretch? I saw a resident who worked a 24-hour call, and then, because of unusual circumstances, had to immediately do another 24-hour call; she was on for a total of 48 hours. Very, very few careers will ever expect that of you, much less that you do that while making decisions about care that determine whether patients live or die. It’s a level of responsibility coupled with physical and mental demands that make medicine an unimaginable career choice for anyone who doesn’t have a calling to it.

With that in mind, let’s consider the impact of money on your experiences during medical training. At my school, we weren’t warned until well after we’d started that we were going to be expected to have our own cars for clinical rotations. We certainly weren’t budgeted money for buying or renting a car in our student loans, which left me personally around 2,000 dollars a month for all expenses after paying tuition and fees. In a city where a one-bedroom or studio apartment can easily run 1,500 dollars, add on the necessary expenses of phone, internet, utilities, and insurance, not to mention food, and you can see why many students share housing and yet are still chronically broke. My class struggled to figure out how to buy cars or rent cars or use Uber or public transit across a wide geographical region on our limited budgets, and the response from the administration was very simple–“Tough.” It wasn’t their problem.

Let’s imagine I had been able to have my own car, something I owned free and clear and was able to use every day. Let’s think about stress. Burnout is a buzzword in modern medicine. Medical students report struggling with depression and anxiety at high rates. You know what would really help with that? Mental health care. Of course, health insurance isn’t covered during medical school, and finding a therapist who takes Medicaid is a challenge.

Our school funded several free therapists — during business hours. Good luck getting out of duties at any point between 7 a.m. and 5 p.m. as a clinical medical student, especially on a regular basis. Even if you did, those counselors were master’s level, with no guarantee of quality. I made an appointment for marriage counseling, only to have tired gender roles regurgitated at me; since I’m a woman, wasn’t cleaning really my job? (No, my job is to be a medical student, and it’s full-time. That counselor has since left the school.) We never went back.

Wealthier classmates could afford mental health care by professionals with more training who were able to see them outside of work hours. They were also able to do things like take vacations, eat at restaurants, use meal delivery services, visit massage therapists, and so on. After dealing with paying rent and bills, my idea of a vacation was staying at home and eating Ramen. It’s not quite as relaxing as heading to Cancun for a few days.

Many medical students come from medical families. Attending physicians generally make a good living, so these classmates come in with financial security they may not even fully understand. Odds are they have never lived with food insecurity or struggled to pay rent. (“But we had a budget!” doesn’t count; rich people can do math, too.)

While poor students can and do get into medical school, the entire process of selection for medical school is biased in favor of wealthier applicants. Who can afford to pay tutors? Expensive prep courses for the MCAT? Ample time during the day to study, without working to pay the bills? Who can afford to take the MCAT multiple times, or pay multiple rounds of expensive fees to apply to medical schools? Rich kids. And rich kids are the children of rich parents — that’s how wealth in the U.S. works.

These applicants, who go on to become medical trainees, may not understand why their patients struggle with affording medication, with housing, with being unable to take time off work to recuperate. Plenty of things that are illegal still happen regularly to American workers.

Medical schools attempt to keep their students’ apparent debt loads down. It makes them look more appealing to prospective applicants. How do they do that? By trying to ensure that their students borrow as little as possible. It looks good on paper, and in practice translates to a student who needs to buy a suit for interviews — and can’t figure out how to do that on a budget that’s already been slashed to the bone. Private loans with extortionate interest rates are mooted as an option, but with the poisonous proviso that you must report them to the school and your financial aid may be cut in turn. Medical students like me are recruited in part because we come from rural and underserved areas; we’re more likely to go back and practice in those areas than people from cities. But that means poor students are recruited and admitted to med schools that are not prepared to offer truly sufficient financial assistance.

In short, medical schools are not designed for poor students. Our experience of medical training suffers badly in comparison to the experience of rich students. And pretending that it shouldn’t matter because we all love medicine only favors one group — the rich, who already have what they need to make it through.

Kristin Puhl is a medical student and can be reached on Twitter @kristinpuhl.

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