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.