“I can’t afford to see a dentist or pay for medication,” says the patient sitting across from me. “Can you help me?”
Ten years ago, I was in this patient’s shoes. I immigrated to Canada with my parents when I was 13; we were a family of three living on $12,000 a year. It was tough being poor. I worked multiple jobs to help make ends meet while attending school full-time. Studying medicine never crossed my mind as a possibility. My family experienced multiple barriers to accessing health care, but we also met compassionate physicians who made all the difference in our lives, and they are the ones who inspired me to pursue a career as a doctor.
When I started medical school in 2012, I realized I was an anomaly—it is rare for students from low socio-economic backgrounds to study medicine. While limited data has been collected on Canadian medical students’ socio-economic status (SES), a few surveys have shown that students from lower income households are significantly underrepresented. For example, a 2012 survey of four Canadian medical schools found that 57.6 percent of students came from families with a household income over $100,000 annually, a proportion eight times greater than in the general population. More recently, a 2015 national survey of first-year medical students by the Association of Faculties of Medicine of Canada (AFMC) found that 62.6 percent of respondents come from families with an annual income greater than $100,000.
The overrepresentation of students from affluent families is also found among medical school applicants. In 2018, the AFMC collected applicant data from five Canadian medical schools. Of those who provided their parental income, 54 percent reported a familial income greater than $100,000 annually.
Research has shown that diversity and equity are important in medical school admission not only for the reasons of fairness, but also for the benefit of patients, and that physicians from lower SES backgrounds are more likely to pursue primary care specialties and work with under-served populations. Further, some research has shown that patients are best cared for by physicians from a background similar to their own. “When you consider the morbidity of our population clusters in low SES groups,” says Brian Postl, chair of the AFMC board of directors and dean of medicine at the University of Manitoba, “having people with the understanding of where they come from and what stresses they feel can only help.”
What’s more, it has been suggested that a diverse medical class benefits learners and creates an environment wherein stereotypes and cultural assumptions of under-served populations can be challenged. “I think diversity brings richness to our environment, and our students really thrive in it,” says Postl.
“It comes back to our basic principle of social accountability,” says AFMC president and CEO, Geneviève Moineau. “The more representative our future physician workforce, the better we will be able to respond to the health care needs of our population.”
Barriers to medical school for low SES applicants
Many barriers exist for socio-economically disadvantaged students to be accepted into medical school and to even consider a career in medicine.
“[It starts] way before admission,” says David Latter, director of admissions at the University of Toronto’s MD program. “In high school, a poor kid often has to work a lot to support his family, while a kid from a more well-off background can study every night without having to worry about money, and can afford to hire a tutor to get straight A’s.”
There is a well-known phenomenon called the leaky pipeline, says Ian Walker, director of admissions at the University of Calgary’s undergraduate medical program. Research has shown that a significant percentage of low-income high school students who plan to apply to medical school do not follow through, compared with their non-low-income peers. “They don’t have the supports or the social capital that allow them to stay on a pathway to pursue medicine,” says Walker.
“A classic example is medical volunteering,” he adds. “If the son or daughter of a physician wants to volunteer in a health care environment, their parents will connect them to high-yield, interesting opportunities. People who are not connected end up working in the hospital’s gift shop in a front lobby.”
Getting into medical school in Canada is extremely competitive. In 2016–17, Canadian faculties accepted between three and 13.4 percent of applicants. Applicants are expected to excel academically, achieving a GPA of at least 3.9. Many volunteer in international humanitarian missions and on innovative research projects, and spend thousands of dollars on MCAT preparation, exams and application fees, and travel for interviews. Social connections, mentorship in medicine, and financial resources are extremely helpful if not essential in this process. For an applicant growing up in poverty, these kinds of resources are seldom, if ever, available. “For many students of low SES, trying to pursue a career in medicine is like performing a play without a script, and without adequate opportunities for direction and rehearsal,” wrote Jessica Bok in 2010.
Some research has pointed to the possibility that medical schools are preoccupied with a pursuit of prestige and admitting for “excellence”. For example, emphasis on the importance of applicants’ high academic achievement on medical schools’ websites suggests that other criteria take less priority. “A picture emerges whereby the ideal applicant is the one who, by virtue of his or her possession of the requisite social, cultural, and economic capital, is going to be best placed to contribute to the perpetuation of a particular university’s excellence,” wrote Saleem Razack and colleagues in their 2012 review of Canadian medical schools websites.
When asked whether deans of medicine are concerned about lowering their standards by recruiting for diversity, Postl says they needn’t be. “The panel of candidates is so large that you don’t compromise the horsepower by trying to improve diversity.”
What is being done to improve access for low SES students?
In 2010, the AFMC created the Future of Medical Education in Canada project which recommended that medical schools “enhance admission processes” and “recruit, select, and support a representative mix of medical students.” In 2018, the AFMC struck the Future Admissions of Canada Think Tank (FACTT) to look at how to improve “diversity and inclusion in medical school admissions.” In an interview with Healthy Debate, Moineau shared that, “FACTT is currently drafting a national position paper on diversity, where socio-economic diversity is one of the main priorities.”
In its 2015 policy report, the Committee of Accreditation of Canadian Medical Schools, emphasized that medical schools should engage in “ongoing, systematic, and focused recruitment and retention activities, to achieve mission-appropriate diversity outcomes among its students, faculty, senior academic and educational leadership, and other relevant members of its academic community.”
In 2016, the University of Manitoba began implementing a supplemental questionnaire which asks about an applicant’s family history, socio-economic information and other socio-cultural determinants. Examples of questions include: “Were you ever a child or youth in care?” “During the second decade of your life, was the annual gross income in the household in which you lived less than $20,000?” “Do you have a participation or activity limitation that has an impact on your day-to-day life?” Answering yes to any question earns applicants “co-efficient” points, boosting their score and their chances of being accepted into the program.
Since the University of Manitoba introduced this questionnaire, the profile of its entering class has changed dramatically. According to Postl, 37 percent of the graduating class of 2021 comes from a family with an income below the Canadian median. Students are culturally, racially, ethnically, and socio-economically more diverse than previous classes.
The University of Calgary implemented the Pathway to Medicine program in 2015, modelled on similar programs in the United States. The program offers an eight-year, high-school-through-medical-school admission for five underprivileged students from Alberta, and provides academic support and mentorship, a rigorous undergraduate curriculum, enrichment experiences, undergraduate scholarships and conditional acceptance to the MD program based on successful completion of a four-year undergrad degree. “I always say to the mentors, ‘Treat these kids as if they were your second cousin, your niece or nephew,” says Walker, who established the Pathway program at Calgary. “Advocate for them and connect them with people.”
In 2018, the University of Saskatchewan created a program which reserves six spots for applicants who come from families with an income of less than $80,000 per year and who otherwise would not have been admitted. University of Montreal has similarly reserved two spots for CEGEP applicants who come from families with an income below the poverty line.
But not everyone agrees with using quotas. “I perceive them to be a bit of a band-aid solution to a broken system,” says Walker. “We should value the lived experiences of low-income applicants, saying that it is important for medical school. We need a system that reflects the belief that some low-income applicants are actually our best applicants. It has to be integrated into the core admission process itself.”
Many medical schools have developed partnerships with communities to strengthen the education pipeline and recruit more diverse applicants. These efforts include the Community of Support and summer enrichment programs at the University of Toronto, and at McMaster through its MacMEDucation program. To try to help break down barriers for Black students to apply to medical school, the University of Toronto launched the Black Students Application Program (BSAP) in 2017. And nationwide recruitment strategies exist for Indigenous, rural and French-speaking minority applicants.
In the U.S., the American Association of Medical Colleges (AAMC) administers a centralized online application system through which applicants who grew up in poverty can have their fees for applications to up to 15 schools waived. Furthermore, the AAMC’s system includes an opportunity for applicants to indicate that they come from a low SES background and provide additional application material so that their candidacy might be considered “holistically.”
Altering the socio-economic diversity of Canadian medical students remains a persistent challenge. Every medical school faces funding and infrastructure constraints which make changing the administration of admissions processes cumbersome. And, as Moineau points out, one size does not necessarily fit all when it comes to admissions processes. “Every school has to feel that they are doing it the right way for them.”
In the end, the question that medical schools need to ask themselves is, “Have we created empathetic, caring and committed physicians who understand their social accountabilities?” says Postl. “That doesn’t come from the current selection process that favours the ‘best and the brightest,’ frankly.”
The comments section is closed.
I am a visible minority in a Canadian medical school. It really sucks to be a minority in medicine. Having faced significant challenges in my life (homelessness, divorce, death of family etc.) being in medicine is easily the most painful experience and I am not exaggerating in any way. The culture is extremely toxic if you stand out in any way, whether it is looking different or being introvert, medicine is terrible. I am seriously contemplating dropping out.
If you’ve had a tough life and are unique in anyway consider it a favour if they are not allowing you to enter this field.
I am Metis and my goal is to serve in an isolated, underserved, high risk Aboriginal community. I have the prerequisite courses, and will be writing the MCAT in 2020. However, I am an ex-nurse who was on the Student Loans Repayment Assistance Plan for too long; because I took lower paying jobs to avoid the bullying that is the cause of the nursing shortage. Because of this, I cannot qualify for more student loans. So, I want to serve where the need is greatest, but I cannot see a way to pay for medical school and living expenses.
I too had an inconsistent education that was unsupported throughout my life.
I would be willing to do anything that is not immoral to make this happen. But the opportunities just don’t seem to be there.
I so desperately want to go to medical school as trying to heal people mainly with psychiatry is what ive done since i was a kid but i grew up poor and alone with only my mother, father and sisters, eating macaroni and hotdogs for luch and dinner and plain oatmeal for breakfast while my parents fought all day long especially with my mentally ill older sister who was a demon incarnate and still is, i never had the chance to play sports of any kind, join clubs or anything extracurricular at all minus a few times and only because it was given as a gift, i later found out in many of my Christmas memories my parents had to get things donated to us because they were too poor, because of all this i never had the chance to interact with others much i spent my entire junior high and highschool years without a single friend while taking care of my mother whom lived off welfare, while trying to take care of her alcohol addiction since i was 11 and still am, taking care of her because she was almost murdered with a pint glass to the temple, and i am almost 20, i just barely passed school, never done anything extracurricular in a decade, not a single friend, a job that i have worked since i was 12 and has been so rough ive got minor PTSD from it and i have 0 connections to anything , i basically have nothing going for me at the moment besides the fact that im quite intelligent and that i am a hell of alot wiser than most people, since i was 15 i have been a “marriage counselor” to my mothers friends and ive never even had a real relationship of any kind outside of my family relationship because my whole life ive been looked at as the sane, calm and logical person of the family that offers better and wiser advice than anyone they know, despite the fact ive been dealing with pretty bad depression silently, thats where my passion for medicine comes from and why i want to.go though medical school to psychiatry. Reading your article assured me that i still do have a chance and that im not totally being denied the chance to earn my success because of things out of my control. It puts me at ease that these people running these things are willing to listen and consider me.
I am the proud father of a child (16) who is interested in simply giving back through a career in medicine. He is a highly empathetic person who has a rare emotional intelligence in reading and helping others. Although my wife and I are fortunate enough to have high incomes, we are both disabled and have had chronic health issues his entire life. No doubt his growing up in our family which has these special needs and requires lots of medical support, as well as his many hours in hospitals and clinics with us, may have inspired his choice. Income is only one of the factors that make up minority populations and would increase doctor’s diversity. Perhaps there needs to be a broad process for med school admission that considers both personal motivation and experience more broadly.
Excellent article. Thank you for helping to bring more attention to these issues. As a medical student with a disability from a poor, remote community, I can relate to some of the challenges and speak to the power ‘alternative’ or ‘non-traditional’ applicants bring to their medical practice. Thanks again!
Dear Rebecca,
Thank you so much for reading my article, I am so humbled to hear your story in medicine and so impressed with your journey. I am hoping to write an article in the future about physicians with disability, as I believe that it improves the healthcare system to have physicians undergoing the same challenges as their patients. It’s tough to get into medicine coming from a low SES background, let along with disability and chronic health conditions. Let’s hope that our message gets heard and can make a difference.
I really feel that there are not enough spots available in Canadian Universities for medicine. Giving spots to people who are dedicated to helping rather than interested in prestige would improve our medical system. Also I feel strongly that students trained in Canadian Universities should give back to the country in recognition of the education subsidy they have received. This is particularly true for medicine. I hate it when I see Canadian trained doctors, particularly specialists going to the US or other countries for more money. There is a shortage of doctors and specialists in Canada and what are we doing about it?
Given that Cuba’s potential for exports is very limited, that nation has concentrated on tourism and education as means to obtain foreign currency or goods. Education, primarily training doctors and engineers in great numbers, allows Cuba to provide professionals on a contractual basis to many countries. As well, Cuban universities invite nationals from other nations to train in Cuba. Though sometimes poorly resourced (owing to the U.S. economic embargo “war” against Cuba), Cuban-trained doctors have no problem meeting international proficiency standards, even in the U.S. Canada, meanwhile, not only discriminates against lower income Canadians entering medical schools and other disciplines; we also happily entice (steal?) trained doctors from poorer countries, taking advantage of public education investments by those countries instead of increasing medical training in Canada and making it more accessible.
The last paragraph sums it up beautifully. After all since science has few answers….a good doctor is not one who has one side of his brain engaged to be able to remember and regurgitate chemistry, and the ability to study and retain information. A good doctor is not one that comes from a home where it ‘runs’ in the family to become ‘something’, and where money and support or being pushed along is the norm. A good doctor does not become created from money.
Dear Sam,
Thank you for reading my article. A good doctor is someone who cares about his/her patients, committed to their well-being and advocate for their care, who stands by his/her patients through difficult moments. Research has shown that increasing diversity in medical school improves the quality of medical education and healthcare. I sincerely hope that there will be changes in the near future!
The above article was very informative and well written. In addition to low income individuals, persons with disabilities also face a lot of barriers and difficulties in pursuing a career in medicine. I have Duchenne Muscular Dystrophy, it is a progressive condition and as a result of the condition I use a power chair. I always wanted to be a physician. Unfortunately I was advised in high school that because of the progressive nature of my condition I could not be a doctor as it would not be possible for me to practice. I also tried to speak with the various medical schools to find out if someone in my position could be a doctor. I didn’t want any special consideration, I just needed to make sure that I would be able to continue in the medical field if my health were to deteriorate. It takes many years of hard work and dedication to be a doctor, therefore I had to be sure that I would be able to work as a doctor. Unfortunately the schools indicated that they would not be able to help. I would just have to apply and see what happens. In light of this I became a Chartered Accountant. The problem is that after all the years I still think about whether I should have done medicine or not. From this experience I feel that medical schools should do more to help people with disabilities to pursue a career in medicine. For example internships geared to high school students or undergraduate students with disabilities, could provide students a chance to make a more informed decision.
Thank You
Dear Amar,
Thank you for your reply. Research has shown that there are less physicians with disabilities compared to the general population. I have found the following two articles: https://www.macleans.ca/education/post-graduate/breaking-down-barriers-for-med-students-with-disabilities/ ; 2) https://cmajnews.com/2017/04/20/physicians-with-disabilities-often-undervalued-cmaj-109-5402/
As quoted in the MaClean’s article by Dr Lewis: “Any candidate who comes from an extraordinary background with a unique perspective, they often do make extraordinary physicians.” There is much work needed to be done to recruit students from low SES background and students with disabilities. I wholeheartedly believe that having diverse physicians that is reflective of our population, benefits ultimately our healthcare system.
This is such a great article. This is my heart’s voice. The requirements of medical schools here in canada are too much challenging to afford for students from low income families. Shadowing a physician, volunteering in a hospital and research is itself not a big deal but finding out these oppurtunities itself killed them. The high fees of MCAT preparation and fees to apply is such a stressfull process for them that most competitive and brilliant low income students endup not getting admissionin any medical school.
Thumbsup for your article
Dear Mehnaz,
Thank you so much for reading my article. The daily challenges are real and I hope that medical schools could value the lived experience of an applicant from disadvantaged background. The “valuable” non-academic attributes are largely mitigated by social and financial gains. For MCAT, the AFMC has launched a new MCAT Fee Assistance Program: https://afmc.ca/medical-education/mcat-fee-assistance-program-canadians
I remain hopeful that our medical admission system will change, so the bright kids from poor background can aspire and pursue a career in medicine.
I am a practicing specialist who grew up poor in a poor town. I funded my way through university through scholarships and student loans.
I found it incredibly unfair that throughout medical school I was singled out as one of the low-SES admissions who should pursue primary care or other ‘needed’ field because I come from that demographic. Meanwhile the affluent majority of my class had no intentions of being anything but urban specialists, and nobody expected anything else of them. I resented this presumption and pursued an urban based specialty myself.
Diversity admissions for diversity’s sake is a fool’s errand. It will merely tarnish the credibility of those students who earned their place working from poverty. Expecting them to pursue primary care in ‘needed’ areas is presumptuous and frankly classist. The real solution to increasing primary care access is to pay it more and make it actually desirable to practice.
If socioeconomic diversity is desired for medical school classes, the admission criteria should not value the inclusion of volunteer work or other such activities believed to prove one is ‘well-rounded’, whatever that means, as these activities are accessible only to the wealthy and connected. I would go as far as to say that only standardized criteria like the MCAT should be used.
Thank you for reading my article. Being a family medicine resident myself, I don’t think pushing low SES medical students to pursue primary care is fair, as once you get admitted into medical school, you should pursue the specialty that you love the most. In order to attract more family physicians in inner city and rural areas, the government needs to intervene and makes the primary care practice more desirable among graduating medical students. This is another topic itself.
I personally find that students from disadvantaged backgrounds had to work harder than their peers to secure a place in Canadian medical schools; our background taught us resilience and empathy which are invaluable traits for a physician. If anything, low SES applicants credibility should not be tarnished. I don’t think any medical schools mentioned above reveal the low SES medical students identity to protect them from being targeted.
I agree for a more inclusive admission process itself, where they look more holistically at an appplicant’s life experiences and attributes, rather than value experiences which are largely mitigated by social and financial capitals. I agree that volunteering and other ECs valued by admission committees are mostly accessible to the wealthy and well connected. Changes need to be made in the admission process itself to recruit more low SES applicants.
Thank you for your comments!
your article hits home. Our women’s group hosted a lady recently who has lived with Rheumatoid Arthritis for 25 years. Even after several surgeries her body is quite crippled but not so her spirit. She is an amazing advocate!
At the onset when sore feet were the first sign she was told, repeatedly, that she should simply take Ibuprofen and put up her feet. After six weeks her malaise was full-blown. She still mourns the lack of understanding in the beginning of her condition where she felt further exploration would have been appropriate.
She is often asked to speak to fledgling physicians and gives one important advice: have empathy. Although you may not have walked with her crippled feet or tried to use her deformed hands, nor may you have ready answers, her pain and frustrations are real and need to addressed. Yes, physicians are busy, but please, don’t dismiss! We are thankful for everyone who chooses this vocation for their life goal. Let your heart show…
Thank you very much for your comment Renate, I am glad that you enjoyed my article! Please feel free to share to reach a broader audience to make a difference.
I have a disease, it is a killer disease. What I have endured at the pencils of doctors is common and should be considered unethical. To be denied your symptoms, to not be heard is simply soul destroying, not only that, it destroys families. I’m going to die anyways, so what does it matter correct? I should not let it affect me, because after all it only hurts me, but it did and does. But here’s the deal, in the end we all must die and in the meantime I can only work on my deepest sense of self NOT to accept being a victim, deep with my own psyche. I applaud those doctors who hear their patients. Thank you for the doctors who do not become a cog in a wheel.
You are a great person Sam with a brave heart! It s terrible that some doctors are allowed to practice medicine when they don’t deserve the title to be called healers or doctors.,when they’ve lost empathy and understanding due to different reasons .I hope you don’t give up hope.Ive heard true stories of recoveries for people even at stage 4 with cancer etc illness to totally recover.Spontaneous recoveries are what the medical people call it.This can happen.I read Love ,medicine and miracles by Dr.Bernie Segal years ago.Its a good book .
All the best to you Sam, don’t give up in your battle fighting your disease.
Great article, and very true from what my friends in med school tell me. Income helps, but the “connections” and expensive preparation from childhood are the game changers.
Also, a $20,000 cutoff for the med school questionnaire is too low I think. You will only be helping the very very poor. Stats Can says “low income” is just under $40K/year after tax for a family of 4 in Ontario for example, which is probably $50k before tax. Maybe raising that number to 40K or considering a case by case situation would be better.
Thank you for your reply, I hope that you could share this piece to reach a broader audience to ultimately make a difference in our current medical school admission process!
I totally agree with u regarding $20,000 cutoff low income threshold.
It will not help most of the people who are under $40,000 who are still under low income families
Dear A guy & Mehnaz,
Here is the link to the University of Manitoba’s supplemental questionnaire: https://www.winnipegfreepress.com/local/U-of-M-looking-to-make-changes-to-medical-school-admission-in-2016-303522391.html
They do give “co-efficient points” to applicants with family income <40,000 and < 75,000 (questions 5& 6).
I don’t necessarily agree entirely. I know many people, myself included, who’s parents are not in the health industry, have virtually no connections as we are immigrants, and are able to excel academically and find extracurricular opportunities. I do, however, know that it is much eaiser to obtain the said “edge” if you do have connections. Nevertheless, although things are harder for us, it is by no means impossible. The world is not fair, but that’s just how it is. Only you can break the wheel for yourself, and just yourself.
I do not agree with you completely. I think that having financial capital to have access to resources such as mentoring or communication building opportunities is essential. I came here as a immigrant just like you. The 12 year old me really did not see myself affording summer camps or mentoring and coaching sessions because my parents did not have a job. My father was a student and so basically the house was running on $30,000 through his grant. I too was able to excel academically thanks to the constant support that my family was able to provide but also the public system in Canada that was and is government subsidized. Life is filled with challenges but having inaccessibility to beneficial resources cannot be given a pass by saying that life is not fair and one should break free.