Less science, more diversity: How Canadian medical school admissions are changing

When Melissa Shears applied to medical school, it felt like a lottery. “You hear the numbers of how many people apply, and how many people get in – it’s quite overwhelming,” she says. But now the first year Queen’s medical student has a different perspective.

“I think they look for people with really diverse and dynamic experiences, and less of a cookie cutter application,” she says. She believes her work on programs with special needs children and adults set her apart – along with her obvious passion and long-term commitment to that work.

Now that she’s at Queen’s, it feels a lot less like luck got her there. “The school looks for very specific things, and they’ve really put an effort into refining the process.”

At schools across the country, traditional entrance measurements for medical students are being questioned. Research has revealed that some aren’t very effective at choosing applicants who will develop into excellent physicians. Other procedures unfairly exclude minority groups or create a medical school class that’s overly homogenous.

As a result, some universities have dropped science as an entrance requirement, skipped the Medical College Admission Test (MCAT) or swapped out the traditional panel interview. Here’s what they’re doing instead.

Why are admissions so important?

In some schools in Europe, large cohorts of students are accepted into medical school, and the weeding out process happens during school, as students compete to be able to graduate. But in Canada, more than 98% of medical students graduate. That means the biggest barrier for them to become doctors isn’t graduating – it’s getting in in the first place. And that places a huge burden on schools to figure out how to select the best students.

“In our current construct, really what we’re doing in admissions is deciding who’s going to enter the profession,” says Geneviève Moineau, CEO of the Association of Faculties of Medicine of Canada. “That’s why we need to try our very best to get it right.”

That’s made more difficult by the fact that getting into medical school is now so competitive that the schools are choosing between top-notch students. Ontario medical schools only accepted 14% of applicants in 2015.

Schools facing this task are working backwards from a bigger question: What makes a good doctor? The University of Toronto has looked to the CanMEDS framework, offered by the Royal College of Physicians and Surgeons of Canada. In addition to good scholars, it argues, doctors need to be professional, communicate and collaborate well, show leadership and advocate for healthier societies. High quality care requires not just medical expertise but also these soft skills.

Swapping interviews for the MMI and personal essays for CASPer

The traditional way to judge motivation, maturity or interpersonal skills has been an autobiographical sketch in the application, and an interview afterwards. At many schools, after students pass the minimum grade requirements, the interview is the most important factor in deciding if students get in.

But does it work? The evidence is mixed. Structured interviews, which include standardized questions and sample answers for interviewers to judge against, are best, with raters often agreeing in their judgments. Multiple interviewers or multiple interviews also increase accuracy. But overall, being assigned to a hard or easy interviewer can make a large difference in ratings for the whole panel, and there’s evidence that an interview is too short a time for candidates to properly show off their abilities.

In response to these issues, McMaster developed the Multiple Mini Interview (MMI) in 2002. It includes eight to 10 interview stations staffed by different judges, where students share what they would do in a hypothetical situation. The concept is that this will reduce the benefit candidates would have from rehearsing answers to stock questions, like ‘Why do you want to be a doctor?’ and force more honest, impromptu answers.

Students might face questions such as how to choose between giving a transplant to a successful elderly person or a drug-addicted 20-year-old, or what they would do if a family member decided to treat a major illness with only alternative medicine. Judges are normally from the school, but at the Northern Ontario School of Medicine, they include Aboriginal elders and people from the Francophone community as well. “We want to get a broad perspective from community members on who would be appropriate for their community,” says David Marsh, deputy dean and associate dean for community engagement at NOSM.

The MMI is more predictive of success in medical school than the MCAT or GPA scores. It’s also a good predictor of success on the Objective Structured Clinical Examination (OSCE) exam, which has been linked to doctors having fewer complaints to regulatory medical authorities and better indicators of primary care, such as more appropriate medication prescribing and higher cancer screening rates.

The MMI is used at a dozen schools in Canada, including McGill, UBC, the University of Alberta, and the University of Montreal, as well as over 30 schools in the U.S. The University of Toronto does a “modified MMI” that uses four personal interviews.

Schools face a similar problem using personal statements during the screening process. They’re not predictive of preclinical performance, raters often don’t agree on their rankings, and they’re difficult to compare because of the non-standardized nature of the answers. More importantly, many students get help writing them: One study found that more than 40% of medical students had input from others on their personal statements.

That’s why McMaster created a screening tool, CasPER, to replace the personal statement. The 90-minute online test is similar to the MMI, asking candidates how they would respond to 10 to 12 different scenarios, each of which is graded by a different marker. But it’s relatively new and has been less widely implemented. McMaster has been using it for four years, and the University of Ottawa began using it this year.

Dropping science prerequisites and questioning the role of the MCAT

Some schools are debating dropping the traditional science prerequisites. The University of Alberta is among them. “We have dropped all pre-requisites, as have many schools across the country,” says Marc Moreau, assistant dean of admissions at the Faculty of Medicine and Dentistry. “We are hoping it will increase the number of students from other faculties applying to medicine, increasing our diversity.”

McMaster, the Northern Ontario School of Medicine, Queen’s University, the University of Alberta and UBC all don’t have a science prerequisite for their medical programs. At the University of Toronto, successful applicants don’t need physics or chemistry, but they are required to have two life sciences credits. The University of Calgary also doesn’t require sciences – and in internal analyses, the school found that there was no relationship between the number of science courses students had taken and how well they performed in the program.

That holds true across other schools as well, says Harold Reiter, director of educational research and development in the Faculty of Health Sciences at McMaster. “There are a number of articles looking at students from non-science backgrounds. The first year or two of medical school is more stressful for them, but once they get to the third of fourth year of medical school, they’ve caught up. And there is tremendous untapped potential there in terms of non-science students enriching medical practice and the world of medicine.”

Of course, a science background is also important for the MCATs – and the test could act as a de facto screen against humanities graduates. That’s McMaster uses only the Critical Analysis and Reasoning score from the test.

In a sense, the MCAT works – a 2007 meta-analysis found that MCAT scores predicted performance at medical school and on medical board licensing exams. But it’s biased against certain groups, including black and Latino students, and those who speak English as a second language.

It’s also not available in French. For that reason, French medical schools and the bilingual University of Ottawa don’t require it, and McGill dropped the test in 2010. The English Northern Ontario School of Medicine also doesn’t use it. “We think the MCAT is biased against Aboriginals and Francophones and people in remote and rural and remote environments,” says Marsh.

Another approach is to use the test and keep its limitations in mind, says Ian Walker, dean of admissions at the University of Calgary’s school of medicine. “It has shortcomings, but that’s something to keep in mind when you’re evaluating the results,” he says. “You need to say okay, this is your MCAT score. Are you from an aboriginal background, do you come from a demographic group that is known to be disadvantaged by this test?”

The test has also been revised, with the new 2015 version including biochemistry, psychology and sociology, in an attempt to screen for more well-rounded students. It’s too soon to say whether the research on the old test will apply to the new version as well.

Supporting minority groups & looking for diversity

The Association of Faculties of Medicine of Canada has asked schools across the country to focus on increasing the abilities of under-represented groups to enter medical school. A study from the association found that there were significantly fewer black, Filipino and Latino Canadian medical students than are present in the general population – and those with an average family income of over $100,000 were significantly overrepresented. The number of Indigenous students in schools is also a universal focus for improvement, with many schools offering separate entry streams for Indigenous Canadians.

While some schools use quotas, outreach programs designed to increase the likelihood that underrepresented minority students compete successfully also show promise. The University of Toronto offers pre-application support for black students through a program called Community of Support. It includes webinars that show how to develop strengths in an autobiographical sketch, and an opportunity to be linked to the Black Physicians Association of Ontario.

Similarly, this summer the University of Calgary will launch Pathways to Medicine Scholarship, a program geared to low-income students, especially those from rural areas or with Aboriginal ancestry. It provides $21,000 of financial assistance as well as a paid summer internship and mentorship and support from faculty. And the Ontario Medical Students Association also runs a mentorship program called Altitude, which matches first-year medical students with first-year undergraduate students from rural communities or those from lower socioeconomic backgrounds.

In the end, every school has a different approach – which is good, because every faculty is searching for a different kind of student. And “the application process is never going to be perfect,” says Reiter. “Any one tool has limitations. But with at least two different measures of the cognitive, and two of personal characteristics, we can try to triangulate. We don’t want to put all our eggs in one basket.”