Does every Canadian have equal opportunity to pursue a Medical Education?

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I’m not normally inclined to idle conversation at 4:30 in the morning, but the cab driver who picked me up for my early morning flight home was simply too engaging.  Obviously of African descent, he was possessed of that captivating quality that can only be described as charm.  Although he spoke with a heavy accent, his vocabulary and language hinted at a subdued intelligence, and his warmth suggested a genuine interest in learning about the people he encountered.  He drew me in with the usual questions:

“Where are you travelling today?”
“Have you enjoyed Victoria?”
“Must be nice to get away from the snow for a few days”. 

Finally, I succumbed:

“So when do you get off work?”  

Turned out, he gets out at noon, and would then be taking his youngest son, Grade 10, to basketball practice.  Crazy about basketball, that boy.

“Do you have other kids?”

And he was off.  Since immigrating from Ethiopia, he and his wife have had four children.  His eldest son has graduated from a college business program.  His second son is in his fourth year at university and contemplating law school.  Although obviously proud of all his children, there was a particular affection for his only daughter, now in her second year at university.  He was quick to point out that she had led her high school class academically and still excelling despite her part time job at a fast food establishment.

“What’s she thinking about doing?” 

“Something in healthcare, not sure what.”

“Has she thought about medical school?”

At this point he looked into the rear view mirror and, for the first time during our encounter, seemed sheepish and somewhat lost for words.  I felt like I’d crossed a line – asked something a little too personal, perhaps slightly embarrassing for him.  After a pause he responded that she was giving it some thought, but hadn’t decided.  Things went a little quiet at that point.  I had the strong sense that the idea of going to medical school and becoming a doctor seemed beyond her (and his) reach.

“You know”, I said finally, “you remind me of my father”.

This seemed to take him completely by surprise.

“Really?”

“Sure.  He immigrated with very little money, took on whatever work he could, and put six children through schooling, including sending me to medical school”.

We chatted for a while, even after arriving at the airport.  Certainly we left on very friendly terms, and I don’t think it was just the sizable tip I left.

Although I’ve known for some time about socioeconomic and cultural barriers to medical education, the abstract took on a sense of reality for me sometime during that early morning cab ride through the darkened streets of Victoria.

So what do we know about this?  What are the facts, and what do the studies tell us?

  • Applying to medical school is not only long and demanding, but also an expensive undertaking.  The application process itself, the MCAT examination, MCAT preparation and travel for interviews are all costs that applicants must bear.  The process also requires time, which favours those who are able to take time away from summer or part time jobs in order to study and travel.
  • The process favours students from urban settings.  This relates to the fact that students from rural areas must necessarily move away from home to attend university.  In addition, volunteer opportunities, MCAT preparation courses, the MCAT itself are much more available in urban centres.  All this is compounded by the fact that rural Canadians are known to have lower income than their urban counterparts (Rourke J. for the Task Force of the Society of Rural Physicians of Canada. Strategies to increase the enrolment of students of rural origin in medical school. CMAJ 2005;172:62).
  • Socioeconomic status has an influence on an individual’s perception of their suitability for medical school and a medical career.  This is partially because students from more advantaged backgrounds have more access to role models in medicine. (Greenlagh T et al. “Not a university type”: focus group study of social class, ethnic, and sex differences is school pupil’s perceptions about medical school. BMJ 2006;328:7455).
  • Students from higher income families receive more family and social encouragement to pursue medical education compared to those who self-identify as coming from “working class” families (Began B. Everyday classism in medical school: experiencing marginality and resistance. Medical Education 2005:39;777).
  • The Greenlagh study noted above also suggests that students from lower income families are more likely to over-estimate the costs of post secondary education, while simultaneously underestimating the financial benefits of post-secondary education.

It appears all this is having an effect.  An important study by Dhalla and colleagues (CMAJ 2002:166;1029) surveyed 1223 first year Canadian medical students and found that, compared to the general population, medical students were:

  • Less likely to be of Black (1.2% vs 2.5%) or Aboriginal (0.7% vs. 4.5%) heritage
  • Less likely to hail from rural areas (10.8% vs. 22.4%)
  • More likely to have parents with master’s or doctoral degrees (39.0% of fathers and 19.4% of mothers, compared to 6.6% and 3.0% respectively)
  • More likely to have parents who were professionals or high level managers (69.3% of fathers and 48.7% of mothers compared to 12.0% of Canadians), including 15.6% of medical students having physician parents.
  • Less likely to come from households with incomes under $40,000 annually (15.4% vs. 39.7%)
  • More likely to come from households with incomes over $150,000 (17.0% vs. 2.7%)

These findings have since been substantially confirmed by Steve Slade and and his colleagues, who compile the Canadian Post-MD Education Registry (CAPER). http://www.caper.ca/~assets/documents/CAPER_Poster_AAMC_Physician_Workforce_Conference_May-2012.pdf.

It appears, then, that the answer to the question posed in my title is a decided “no”, but do we accept this as an issue that should be addressed, and do we have the collective will to act?  To address this, I would turn to those perhaps most familiar with these issues, specifically our young colleagues who have successfully navigated the process and recently entered medical school.  None of this, of course, is lost on them, and they do not shy away from addressing the challenge.  The Canadian Federation of Medical Students has published a position paper entitled “Diversity in Medicine in Canada: Building a Representative and Responsive Medical Community.” http://www.cfms.org/attachments/article/163/diversity_in_medicine_-_updated_2010__cait_c_.pdf.  To quote their document:

“As medical students in a country that embraces diversity, we believe that our medical system should be representative of and responsive to the diversity within our communities.  Unfortunately, the medical school admissions process has traditionally favoured students from high-income, urban dwelling, majority groups, thereby limiting the diversity of medical students across Canada and further marginalizing underrepresented patients and communities…An increased emphasis on diversity in medicine would help ensure that medical students and physicians are in tune with the needs of the communities that they strive to serve and represent.”

Clearly, a strong case can be made to address this situation, based not only on the principle of simple fairness, but also the need to ensure our physician workforce appropriately reflects the cultural diversity and particular needs of the population they will ultimately serve.  Assuming we accept these points, what might be considered?  In seeking solutions, it’s important to recognize the fact that the financial barriers become much less an issue after students are accepted into medical school, at which point they qualify for various sources of private and university-based funding.  If the barriers to medical careers are to be truly addressed, mechanisms must be developed to help members of those underrepresented groups become more aware of medicine as a realistic career option, and provide practical assistance in working through the pre-medical educational and application processes.  Such initiatives might include:

  • High school programs to increase awareness of Medicine as a realistic career option, particularly targeting smaller, socioeconomically disadvantaged communities and underrepresented populations.  At Queen’s, our students have taken the first steps in this direction by developing the MedExplore program http://meds.queensu.ca/announcements?id=419.
  • Reconsideration of the MCAT as an admission criterion, and provision of viable alternatives
  • Reassessment of our admission processes to ensure they are equally accessible to all groups
  • Assistance programs for promising students to allow them to engage educational and community service options
  • Mentorship programs utilizing physicians and medical students from underrepresented populations
  • Programs whereby smaller and underserviced communities might identify promising students for mentoring and career assistance

Obviously, this is a complex issue that will require multiple and creative approaches, all of which seems rather daunting, but perhaps less so when viewed from the perspective of that daughter of a hardworking and devoted Ethiopian-Canadian cab driver.

As always, your perspectives are welcome.

Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library for her valuable assistance in the compilation of information for this article.

12 Responses to Does every Canadian have equal opportunity to pursue a Medical Education?

  1. Dr. Sanfilippo,

    Thank you for addressing yet another important issue.

    I had a similar experience when I was in Saskatoon. A few of us went to a pub post evening shift and the server was a second year sciences student hoping to go to medical school. She was working until 0230 because she had to pay for tuition and support her family back home….she had her midterm organic chemistry exam at 0800 the next day.

    I wanted to let you know that twitter world was on fire last night with discussion about the topic, all ignited by your post. Queen’s folk, educators from around the world and organizations that might be able to help were engaged. Since you aren’t on twitter (which we could change!) I will summarize a few of the points that came up here for you and other readers. Many were touched on in the future directions part of your post.

    1. Admissions Criteria: The non-academic admission criteria put low SES students at a distinct disadvantage. As you mention in the article the cab driver’s daughter was working at a fast food establishment in an effort to support her own education and her family. That is time away from volunteer, research and other activities that are traditionally valued by admissions criteria. She is less likely to have letters of reference from medical types because she doesn’t have access to those connections. Once at an interview, such candidates may not rank as highly because they don’t have the ‘relevant’ experience to answer questions the way that interviewers are expecting them to. For example, I grew up in an environment where euthanasia was a concept discussed around our dinner table for as long as I can remember, some candidates don’t sit around a dinner table debating because both parents were working two jobs. Its reasonable to believe then that I might be more comfortable discussing the topic in an MMI. The bias against low SES backgrounds permeates every stage of the admissions process. There is no one quick fix but we need to start somewhere.

    2. Outreach: If changing the admissions criteria is going to take time (which it will) then in the mean time we need to find promising candidates early and help them navigate the system for free. MedExplore is an awesome program that Queen’s should invest in to grow. Last night Pathways to Education http://www.pathwaystoeducation.ca/en/kingston said they would be up for a collaboration. Medical students should be going into elementary schools, junior high science classes and high schools to work and inspire young students.

    3. QuARMs: We have a huge opportunity here. This is an opportunity to shorten years of school and help young talent get where they need and want to be. The problem with the current system is that most students who qualify either a Loran scholarship or the Chancellor’s scholarship (and are therefore eligible to apply to QuARMs) are more often than not from higher SES backgrounds. The admissions criteria that are prohibitive for medical school are the same ones that are prohibitive for this program. Since this is a new program with no other in Canada like it, let’s really innovate. I don’t have any fixes off the top of my head to make this program appropriately target candidates but I would be VERY willing to help come up with them. Again since a big overhaul wouldn’t happen immediately in the mean time we need to do outreach to rural and lower SES schools. Every guidance counsellor in this country should know about it (and I mean really know about it). Let’s get medical students to call them up and explain the type of candidates were looking for and why it’s important that they let their students know.

    There was more to the twitter conversation, but that was the gist.

    And, a few radical ideas of my own:

    -As you mentioned money is available to students once in medical school. So, perhaps our fundraising efforts and any new money that comes from donors should be redirected from current medical students to medical school applicants. Let’s increase the amount of scholarships available to fund travel to and from medical school, application processing fees etc. Let’s be the first medical school to make our admissions process free (I know that’s probably not feasible but shoot for the moon right). It wouldn’t fix the problem but it would be a big statement.
    -I’m not sure how, but maybe a google hangout MMI is possible…eventually.
    -Every medical student is expected to get paired up with a grade 9 student at the beginning of medical school. They go through the next four years together. Similar to first patient program but mentoring high school students. Let’s partner with local high schools.

    Thanks for starting the conversation!

    • Thanks Eve. The student perspective, so well articulated, is particularly relevant to this conversation. We need to pursue all the points you raise. Thanks also, for keeping me up to date on the Twitter-verse. I’ll take you up on the offer to get me connected.

  2. Sophie Palmer says:

    Dear Dr. Sanfillippo,

    I applied to medical in the states as well as in Canada last year and noted that AMCAS, the American equivalent of OMSAS (that also administrates the MCAT worldwide), has a bursary program for both the MCAT and their application cost.
    https://www.aamc.org/students/applying/fap/
    As far as I am aware, OMSAS has no such resource in place. It would be great if eligible students could apply to have their application fees covered or substantially subsidized, and could also apply to have their interview expenses at Queen’s covered through a bursary. The School of Medicine would be a real leader in Canada if it developed a policy stating that the cost of the admissions process should not be prohibitive to any potential applicant. I would suspect current students and alumni would be interested in contributing funds towards / fundraising for such a bursary program.
    Sincerely,

    Sophie Palmer, Meds 2017

  3. Jemy Joseph says:

    Article hits right on the nail
    http://www.cmaj.ca/content/186/3/177.full?etoc
    CMAJ article on rural pre-med program that has helped encourage more rural students to apply

  4. Anonymous says:

    Dear Dr. Sanfilippo,

    Thank you for bringing up these points and giving them some consideration. To add to the points discussed above, many medical schools are appreciative of students who take Piano for years, or who compete in sports, who participate in Scouts etc. clubs for years. While these all show tremendous dedication, determination, and hard work, it is important to note that the success and long-time enrollment in these types of formalized/registered activities largely rests on parents being able to afford them. If one piano lesson starts at $30/hour, it would be incredibly difficult to convince a parent that that is worth spending money on, when the parent themself is earning $10.50/hour and there are 3-4 children in the family that need providing for. Affording these activities means not just paying for lessons, but also for the instrument, or for sports equipment, for club membership fees, travel expenses for tournaments, car expenses for multiple cars in household, time-off-work for someone to accompany the child, babysitting/daycare expenses to take care of other children, etc.)

    It is also important to realize that immigrant communities are also at significant disadvantages, in that even if their parents come to Canada with higher education (graduate – PhD, Masters) credentials, many are working in minimum wage fast-food restaurants, in food/automobile production factories, on farms picking vegetables for significant periods of time (5-6 years or more)- circumstances my parents found themselves in, upon arriving in Canada. At that time the concept of applying to Medical School was not even on the ‘radar’. The outcome of my medical school interviews will be released this spring May 14, however today, I am happy I explored activities that allowed me to develop myself, and made the decision to at the very least apply to medical school, even with what most would consider an underwhelming application.

    I am highly supportive of suggestions highlighted by Eve, especially the one to pair medical students with grade 9 high school students who show an interest in sciences, in working with others, in helping others, in medicine really, to give them the opportunity to realize that it is not impossible to at the least, try for it. Pathways to Education is an excellent program to partner up with – especially since 1), they are a Canada-wide program and this type of mentorship could be encouraged at other Canadian medical schools, and 2) they have a focus on working with disadvantaged, inner-city youth. Having volunteered (and worked) with Pathways at Rexdale (Toronto) I have first hand experience and satisfaction in really making efforts to encourage students and youth to strive for what they want and work hard in school, explore work experiences and volunteer opportunities to get where they want to be in the future.

  5. Amro says:

    Hi Dr. Sanfilippo,

    Thank you for writing about this important issue.

    My opinion is that medical schools in general put a lot of emphasis on diversity and achievement in making their admissions selections. While this is something that I think is important, I also think that it contributes to the issue being raised here. As you recognize in your writing, the disadvantaged candidates do not necessarily have the time or resources to pursue long-term activities that medical schools value (eg: piano, competitive sports, gymnastics, singing, research, scholarly achievements, advocacy, etc). As you mention, more often than not, these candidates have to take on part-time jobs or deal with personal issues that collectively make it much more difficult to engage in the aforementioned activities. Since there are a limited number of seats in any Canadian medical school, one of the ways around this is to place a quota on the number of seats based on accepted and standardized criteria. However, I am not sure if that is entirely fair either. Firstly, I would imagine that placing quotas on certain categories is a restrictive approach for students pursuing medical school. It is not something that I am entirely comfortable with, and I think (or perhaps hope) that others also share my view. Secondly, having the resources and time to pursue certain activities does not guarantee anything. There are a lot of struggles and obstacles on the way even for those with the appropriate time and resources; most achievements still require a lot of perseverance, discipline, and commitment. Placing a quota would somewhat undermine the effort and dedication it takes these students to fulfill their achievements.

    As you note, this is a complex issue that cannot be resolved by any one approach. I was just wondering about your view on the above, and if there is anything currently in the works to help address it, whether in the dialogue or action phase. Many thanks for your input, and I look forward to reading your response.

    • Developing differential admissions criteria for any subgroup of candidates introduces a number of troubling issues. Firstly, there would be a need to define different but equivalent processes for the “alternative” group. Secondly, and perhaps more troubling, is the issue of developing criteria to identify students who could engage the alternative stream. I’ve learned in the admissions world there exists an almost Newtonian reaction of unintended consequences to any change one wishes to make, no matter how well intentioned. However, I very much like the spirit of your suggestion and I’m sure it lead to fruitful discussion among admissions committees.

  6. Gina E says:

    Dr. Sanfilippo,

    The US Bureau of Labor Statistics has just released a demographic breakdown of individuals’ household income childhood and their subsequent vocation (choice?). While it is purely US centric, some parallel may be drawn to Canada as well.

    http://www.npr.org/blogs/money/2014/03/18/289013884/who-had-richer-parents-doctors-or-arists?utm_medium=facebook&utm_source=npr&utm_campaign=nprnews&utm_content=03182014

    http://www.bls.gov/nls/nlsy79.htm

    The statistics seem to be surprisingly modest in that physicians grew up in the 50th and 60th income percentile, however this may be misconstrued from parents in different training stages in their careers. The statistics are also lacking standard deviation, and I would suspect that there is a large variation in our vocation in particular.

    Interesting statistics nonetheless and hoping that someone will reproduce such a report for Canada, as I am currently unaware of any.

    • Hello Gina,

      Thanks for sending along this interesting information. The studies I referenced in the article reflect similar fundamental messages. I agree it would be very interesting to develop more contemporary Canadian data. Sounds like a great student project!

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