“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. 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.
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 underserved populations. Further, some research has shown that patients are best cared for by physicians from a background similar to their own.
“It comes back to our basic principle of social accountability,” says AFMC president, 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
Socio-economically disadvantaged students face many barriers to admission to medical school, and even to considering 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, outgoing director of admissions at the University of Calgary’s MD 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.”
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.
When asked whether deans of medicine are concerned about lowering their standards by recruiting for diversity, Postl, dean of medicine at the University of Manitoba, 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 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.” Some medical schools have introduced their own programs with a view to improving access to admission for low-socio-economic students.
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: “During the second decade of your life, was the annual gross income in the household in which you lived less than $20,000?” Answering yes to any question earns applicants “co-efficient” points, boosting their score and their chances of being accepted into the program.
The University of Calgary implemented the Pathway to Medicine program in 2015. The program offers an eight-year, high-school-through-medical-school admission for five underprivileged students from Alberta and provides academic support and mentorship.
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 families with an income below the poverty line.
But not everyone agrees with using quotas. “I perceive them to be a bit 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.”
But a nationwide strategy to specifically recruit low-income students into medical school is still lacking in Canada.
Altering the socio-economic diversity of Canadian medical students remains a persistent challenge. 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.”
Note: the following was republished with permission from Kate Peiyin Zhang from her article in healthydebate: https://healthydebate.ca/2019/06/topic/low-ses-medical-students