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.
“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.