We need more medical students from low-income backgrounds

The current approach to medical school admissions relies almost entirely on the assumption that doctors will treat the patients who need them the most. But, for the most part, doctors don’t choose to practice based on where patients need them the most; instead, doctors are more likely to go back to where they grew up or stay in the town or city in which they went to school. And, unfortunately, our doctors rarely come from low income families. Medical students are much more likely to come from privileged backgrounds compared to the average Canadian.

There are many reasons why Canadian patients with low socioeconomic status have less access to health care. One of them has to do with doctors choosing not to practise in lower income neighbourhoods and regions. Instead, they tend to serve patient populations that reflect their own personal backgrounds.

So, accepting more people from low-income areas into medical school can help address the inequity in our health system.

Traditionally, admissions processes looked only at the finishing line achievements of their applicants, which gives an advantage to those who have had more household support and resources to excel at school and in extra-curricular activities. Slowly, the medical education community is becoming more aware of the need to look also at a student’s starting line, thereby leveling the playing field. Still, we don’t feel that enough is being done to improve admissions processes to address underservice to low income communities.

The Association of Faculties of Medicine of Canada (AFMC) recommended in 2010 that medical schools look for students who are representative of the Canadian population. In doing so, the AFMC also recommended that schools address barriers that these students face, like costly application and tuition fees. These financial barriers are particularly discouraging for students from underrepresented low income communities.

Applying to medical school can be dauntingly expensive. Application fees for all six schools in Ontario alone cost over $800. The hidden costs are even greater. Travel and accommodation for interviews, mandatory pre-application components like the Medical College Admissions Test (MCAT), as well as test and interview preparation, can amount to additional hundreds and sometimes thousands of dollars. These barriers discriminate against applicants with low socioeconomic backgrounds, and may partially explain why Canadian medical students are more likely to have a higher family income compared to the general population.

We are happy to see that various medical faculties across the country recognize this problem by using specialized admissions criteria for some applicants, such as Aboriginal and rural applicants. There are also mentorship programs, such as the Pathways to Medicine program in Calgary and Altitude mentorship in Ontario, which aim to increase access to medical school for underrepresented groups.  The Northern Ontario School of Medicine is a shining example of targeted recruitment gone right, with many graduating physicians choosing to practice in rural and remote communities.

But these programs are the exception rather than the rule. We need more initiatives like these at medical schools, but we also need universal policies to ensure that admission processes don’t favour those who come from wealthy backgrounds. We don’t have to look far to find innovative solutions. Our southern counterparts at the Association of American Medical Colleges (AAMC) have recently rolled out a clever, simple, and easy-to-use tool that aims to help medical schools identify applicants with low socioeconomic status and award them additional application points. It’s based on parental education and occupation, two of the gold standards for measuring socioeconomic status, and has shown promise in preliminary studies. Eligible American students also have access to a Fee Assistance Program to help pay for application and MCAT fees.

Quebec also has lessons to teach in how to support diversity in medical school enrollment at a provincial level: from 2001 to 2007, tuition fees at Ontario medical schools rose 35%, while those at Quebec medical schools did not. The impact of Quebec’s tuition cap? Over those six years, medical students in Quebec were 22% more likely to have grown up in a low income neighbourhood compared to students from other Canadian provinces.

All Canadian applicants could benefit tremendously from having programs at the provincial, national and school-level that champion a medical school population that is reflective of society at large. More importantly, it would show students from disadvantaged backgrounds that there is a place for them in medicine, a field which has been called elitist and out of reach.

Hopeful high school students and undergraduates too often turn away from medicine. They are intimidated by upfront application costs, expensive tuition, and the socioeconomic exclusivity of the profession. That inequity threatens the principles of health care for all upon which the Canadian approach to medicine is founded. Curbing this issue can start at the level of medical admissions to create a physician workforce that more closely represents, and ultimately, better serves Canadians.

Rishad Khan is a medical student at the Schulich School of Medicine and Dentistry. Tavis Apramian is a medical education researcher and medical student at the Schulich School of Medicine and Dentistry.

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  1. Dr. Lisa Thain

    Well said!!
    There is no question that many people return to their home community to practice after medical training. Encouraging enrolment from rural and underserved populations should increase service in these communities. However, it would seem reasonable that advantages in terms of application and funding support come with a price, that of a guarantee that the person provide at least a minimum number of years back in their community, in order to ensure that the advantages given these applicants result directly in increased service to the communities from which they come. This approach should also resolve any concern that there might be reverse discrimination against the traditionally privileged applicants and students.

  2. Kyle Pearce

    Another challenge in primary care is that there are few business models that offer an opportunity to practice in the way that many younger docs want: work-life balance, sharing the clinical workload with interdisciplinary providers, incorporating technology, integrating prevention and even working on social determinants of health. These new models require imagination, and innovation in areas like clinical workflow, governance and patient engagement – and my suspicion is that these are too difficult for young people new to the industry to create on their own. We need to help imagine and create the next generation of primary care to really get the benefits of a new generation of family physician.

  3. Hick John

    The only way to ensure that low-income students are afforded a fairer opportunity to get into medicine is to base admissions on as many OBJECTIVE criteria as one can, namely GPA and MCAT. Nothing else.

    The wealthy often pad their applications with world travels, sports and violin competitions. The low-income are too busy working at McDonald’s to fund their university educations, or studying more because its the only shot they have at a successful life – they can’t waste time with mission trips or water polo.

    Take away the padding and everyone is on much more even ground.

    Once admitted, low-income students should NOT be expected to “return to their communities” as seems to be the major “societal aim” in recruiting low-income students, as if its a condition of their admissions that they go into rural primary care. This would create a two-tier medical education system based on parental income, and that is clearly unjust.

    • Tom

      Hi John,
      I definitely understand your point, but as an undergrad who works 30hrs a week and commutes to campus it’s extremely difficult to maintain a GPA worthy of admission to medical school, not because I cant get the A, but because its exhausting studying for an exam or working on an assignment after working an 8hr shift. Whereas the MCAT, in my case was not problematic since it was a one-and-done test, maintaining a high GPA was. The student who takes 10 courses in a year, while working, and receives all A’s except for one class where he/she gets a B, has seriously hurt their GPA for that year. If one honestly believes that a student with a 3.70 GPA is a better candidate for medical school than a student with a 3.90 GPA, then it should also be understood that it’s the kid who’s working while studying who gets the short end of that stick. GPA and MCAT alone are not sufficient to solve this issue.

  4. Farah

    Northern Ontario School of Medicine produces poor quality physicians.

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