“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.”