Addressing the income gap in medical school

Kate Peiyin Zhang is a medical resident at University of Toronto.


“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:

3 thoughts on “Addressing the income gap in medical school

  1. Roodal Ramchandar M.D. (retired)

    This is a well-written, original paper on a complex subject not previously researched. The writer is perceptive and thoughtful and has the makings of a good primary health practitioner. Congratulations and best wishes in your career.

  2. S French

    Although I believe these sociocultural diversity initiatives are helpful for some, I agree they are a bandaid solution. I experience first hand how these kind of things fail struggling students. I come from a family of 5 with an annual income of 70-80k per year. To say a family of 3 vs 5 vs 7 making the same amount of money would face the same challenges is ridiculous. In addition to this I am an independent student, not by choice. I have been homeless and faced homelessness in my undergrad. Yet my access to aid is continuously based on my (estranged) parents income. What would have helped me would be reduced fees for the MCAT and prep resources as well as applications. And the addition of tests like CASPer which have little research backing just adds an additional financial barrier. Not only do students like me often lack the social connections that make finding extracurricular activites easier, we are often passed by on financial aspects due to not fitting the cookie-cutter mold of a "low socioeconomic status student" while still facing very real challenges.

  3. Anjali

    I am an international student came to Canada by borrowing money from someone back home and by spending the very last penny of saving my mom had for old age, just to be able to stand on feet for family expenses as I don't have my father. Just 19 and started undergraduate on as Associate degree , however it's Arts instead of science because of agents mistake and my own also. Everyone and even government consider international student to be rich enough. Government is imposing three to four tumes more fees than domestic students for same education. Ignorant behavior is shown toward increase rate of international student's suicides. They don't do anything because they know that main problems are too high tuition fee for even very less valuable programs of study, cultural shock, loneliness, food and health imbalance, high pressure for high grades, collecting tuition fee whole year, work permit and permanent residence for which every low income student comes in Canada.Now college don't have pre med courses and can't afford to change college. My aim from childhood was to be doctor. I am ready to do all hardships to be at a place I once dreamed and it's not about only 'doctor' but want to work in research field ,find more better ways as well as providing resources of treatment and settlement for poor families who lose someone they love and need most. I lost my father because of cancer and because of money , he died just in one month of its known existence. He died in front of me every single moment in that month and left my mom, brother and me devastated. My mom had to start work, even she had no education and work experience. The average income of my family is less than $4000 per year from that day. From that day till now nothing has gone better and now she spent everything over me.
    I want to enter med school but in this regional area of Dawson Creek ,Canada with no resources no pre med and have to work part time constantly during the studies to collect tuition fee, medical insurance and other expenses for next year admission .Then have to work more to get work permit, Permanent
    Residence to first earn for family and debt and then enter university for Bachelors. Have to do pre med also which I don't know how. Can't waste another two years for pre med. My aim or maybe dream is to be in the position one day when can provide all help mentally, most importantly financially to all the families facing such situations. Not only for just a part but to settle them. It's too much that I want but I cannot constraint my wants as every other thing is. I still have hope that maybe I could enter some free tuition med school with scholarship and financial aid to some university as NYU, I really want to go there but have to remind myself of duties toward my mom and her sacrifices.
    Really need some support financially, for admission requirements and process, access and real devoted help of med school and government also.As have no one to help me or support us is present.
    Have to earny food ,rent and fees,books, internet and phone calls as needed by assignmenta of college and employer. Family back home with no source of income, debt from last helping belonging.
    And where to get money for MCAT, application fee, resources for preparation.Don't have own laptop.
    If anyone reads this please just even advice me , that would also be valuable.Maybe a hope ad I am losing and getting depressed day by day. Couldn't find even advice in college or anywhere, no consolation here. When I tell them about my aim , they don't take seriously and give no attention.
    Getting no hours of work here and want to go big city for work but again turion is paid to college and can't waste as Boone to provide in future and can't earn so much in part time less hours.
    Hope to something.


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