When a person feels that they do not belong in a certain environment, such as medical school, it can affect performance, retention, and satisfaction [1]. Person-environment fit (PE fit) theory addresses the consequences of a person’s environment being aligned or misaligned; and has been commonly applied to employment and organizational settings [2,3,4,5]. In the healthcare realm, PE fit theory was first applied to explore the relationships between geriatric patients’ changing functional abilities, the characteristics of their environments, and their quality-of-life outcomes [6,7,8,9,10,11]. The goal of PE fit theory in industrial–organizational psychology is to match people to employment and develop their careers [12,13,14,15,16]. A common goal in the healthcare occupational realm has been to explore factors affecting medical professionals’ job satisfaction, including identifying individual and organizational characteristics linked to PE fit [17,18,19]. Past studies have suggested that this theory can also be used to understand the varied experiences of higher education students [20,21,22].

Our aim in this study was to apply PE fit theory to the medical education sphere, and specifically to explore common themes applicable to the medical school experiences of learners from lower-socioeconomic status (SES) backgrounds. For this study, PE fit theory is defined as the interactions between an individual’s characteristics and their environments, whereby environments can affect that individual’s motivation, performance, self-esteem, mental health, and other personal characteristics. Of course, individuals also affect their environments [23]. PE fit theorists try to describe and build conceptual models for core features of the complex relationships between individuals and their environments.

Group status-sorting factors related to income, education, and career bestow a level of social or cultural privilege on individuals in any given environment. Most medical students in the USA were raised in upper- or middle-income families and have parents who possess at least 4-year college degrees [24, 25]—thus having greater access to educational opportunities than do people from lower-SES families. Indeed, parental experience with higher education is protective against medical school attrition [26].

Patient populations are currently much more racially, ethnically, and economically diverse than their doctors. The medical education community has emphasized its commitment to diversifying the physician workforce to meet diverse patient needs, address social accountability, and pursue health equity [27]. However, attracting diverse learners can lead to a mismatch between traditional learning environments and the expectations of these newly expanded student populations. An individual learner may experience this as a misfit between their own goals and what the learning environment, or profession, has to offer them. PE fit theory can be used to illuminate the disparate experiences of underrepresented students in medical education [20,21,22].

Medical education is a long and impactful process that involves moving from the periphery to the center of caring for others [28]. Learners are expected to develop a professional identity along with the knowledge and skills necessary to be an excellent physician. A recent study by Kay et al. demonstrated that medical students experience cognitive disequilibrium and the need to adapt their mental models at key points in medical school [29]. While these experiences are necessary catalysts for professional identify formation, they can also be very difficult and leave students needing additional support [29,30,31,32].

Cognitive changes due to environment pressures are part of the normal developmental process. However, PE fit research demonstrates that one’s “environmental press” can be more or less intense [33]. Students with backgrounds or characteristics that are very divergent from the norm are likely to experience a more extreme and continuous environmental press—a stress-inducing mismatch between themselves and their environments.

The perceived match for students with different environments and specialty cultures can be helpful to explore in career advising. The Association of American Medical College’s Careers in Medicine program provides guidance to students in order to identify the best specialty for that person’s interests and abilities [34]. They found in a 2022 study that the most important factors to medical students considering resident placements were “fit” with personality, interests, and skills, along with content knowledge of the specialty [35].

Concerns have been raised regarding the use of the term “fit” in selection processes due to histories of exclusion and bias in medical school admissions and residency selections [36]. However, it is important to note that “fit” has a broader meaning and includes both the preferences of learners and the characteristics of programs [37]. The concept of fit can also be used to illuminate specific ways training programs can evolve to become more welcoming, inclusive, and fair to diverse learners. The concept of fit represents a deep vein of theory and research regarding general principles of human behavior in organizational environments [38].

While other social theories focus on the individual or environment, PE fit theory is unique in its emphasis on the relationships between the two [39]. Researchers note that these relationships are complex and can change over time, due to changes in individuals and/or changes in their environments [39].

The dynamics of fit are affected by the power imbalance between individuals and institutions. The bulk of evidence from career outcomes research is that the fit dimensions on the organizational side are substantially more important than those on the individual side [5, 40]. Burnout, stress, physical health, cognitive function, and even “flow” in problem-solving are all affected by powerful organization-level patterns [41,42,43,44]. These patterns tend to systematically advantage those in traditionally overrepresented groups by poorly fitting those who have been historically underrepresented [45, 46]. Based on PE fit theory and prior studies, lower-SES students should be expected to experience educational difficulties related to disproportionate lack of networks, information, and financial resources. The present study applies and extends PE fit theory in the context of US medical education.