Gabby Schoettle, a first-year medical student at Western University, was 8 years old when she lost her mother to breast cancer. In high school, when her father’s health started deteriorating, she took on the role of making meals for her younger brother and caring for her father. In her final year of high school, her father passed away. She and her brother had to work to pay the mortgage. “We had to learn a lot of things on the fly,” says Ms. Schoettle.
The experience of losing both her parents far too early was one of the reasons that drove Ms. Schoettle to want to be a doctor, to prevent and relieve suffering. During her undergraduate years, she took a research position at a lab at Victoria Hospital and waited tables at a pub evenings and weekends. She wrote the Medical College Admissions Test (MCAT) with little time to study, nor the money to spend on an MCAT preparatory course.
She applied to every medical school in Ontario and was accepted at one – Western’s Schulich School of Medicine & Dentistry. In 2018, the year before Ms. Schoettle applied, the school lowered its threshold for MCAT scores and introduced an autobiography section into the application process, giving students like Ms. Schoettle an opportunity to highlight aspects of her life that a CV doesn’t normally reveal – like her experience caregiving, her resiliency and her maturity. She’d made it this far without many of the family supports taken as a given by other candidates.
Many medical schools across Canada have changed their admissions processes in the last few years in hopes of attracting students like Ms. Schoettle. That medical students largely hail from privileged households is widely recognized. A 2018 survey conducted by the Association of Faculties of Medicine of Canada (AFMC) found that 63 percent of students come from families making above $100,000 a year and only seven percent were from families making less than $40,000. In 2018, the AFMC launched the Future of Admissions in Canada Think Tank (FACTT) to provide guidance to medical schools on how to structure admissions to improve diversity.
While medical schools have taken steps to improve racial and gender diversity, and to attract more students from Indigenous backgrounds, socioeconomic status is one aspect that medical schools “haven’t perhaps been putting specific focus on up until recently,” says Geneviève Moineau, president and CEO of the AFMC. This comes in light of numerous analyses in recent years that medical schools’ admissions processes are biased in favour of people with economic privilege – those who can take extra tutoring and can afford to volunteer or take low-paying medicine-related jobs that will look good on their CV.
The importance of tackling this bias is obvious. “Almost all of the diseases that we treat in medicine have a very important social determination,” says Saleem Razack, chair of the AFMC Network on Equity, Diversity and Gender, and a member of the FACTT. “We’re not going to achieve as good of outcomes unless we’re in a situation of having the inside [of the medical profession] reflect better the outside.”
Tisha Joy, the associate dean of admissions at Western’s medical school, adds that people from non-typical backgrounds improve the learning for everyone. “We know from the business and technology world, the more diverse a team is, the more likely they can solve innovative problems and be empathetic to their customer’s needs. The same principle holds for medicine,” says Dr. Joy. “Non-academic traits can be equally important or maybe sometimes more important than academic strengths,” she says.
By changing the admissions process through widening the MCAT threshold and considering autobiographical sketches, Western was able to consider an additional 280 applicants. The new autobiographical sketch component was reviewed by physicians and members of the community who represented diverse perspectives, such as those from rural and urban areas, recent immigrants, single parents and retirees. The sketch allowed candidates to describe how they’ve been affected by their experiences, rather than simply providing a laundry list of their activities, “like volunteering in an African country,” says Dr. Joy.
The University of Manitoba’s Max Rady College of Medicine, meanwhile, has been adapting its admissions process incrementally over the years and is now considered a leader in diversity. Out of 110 students in this year’s entering class, 15 are Indigenous, 42 are among the first generation of their family attending postsecondary education, 41 students were raised in households with incomes below the Canadian median and 36 students are members of a visible minority group. To get there, the school introduced a comprehensive questionnaire, which includes asking whether a student has received welfare or is a refugee. Each question gets a score, and these scores are ultimately factored into the admission decision. While the school doesn’t “send in investigators” to verify answers, “we make very clear you would probably be thrown out of medical school if any answer wasn’t honest,” explains Brian Postl, the college of medicine’s dean.
The growing diversity has been “a game-changer in how students approach issues of diversity and social equity,” says Dr. Postl. The tolerance of microaggressions towards groups such as Indigenous people or sexual minorities “is not acceptable now, so people expose it quickly,” he says. And the academic rigour remains untouched. “Initially, there was concern these changes would preclude us from getting the best and the brightest, but the pool of applicants is so large that … the students do as well as they’ve ever done.”
Other medical schools are taking a different approach. Rather than changing the admissions criteria for everyone, they’re creating a separate stream. The University of Saskatchewan’s college of medicine launched its Diversity and Social Accountability Admissions Program (DSAAP) in 2018, which reserves six spots for those who come from a lower socioeconomic background. Applicants who wish to be considered for the program must demonstrate that their average family income over the last five years is below $80,000. Then, they answer questions about their parental education, whether or not they’ve received social assistance, if they were ever a refugee, if they have a disability, and whether or not they completed high school in a rural setting. Their score based on these questions is factored into their application, explains Trustin Domes, director of the admissions program at the medical school.
Only those who don’t make it under the regular admissions process are considered for the DSAAP, to ensure the program is doing as it should – admitting students who wouldn’t otherwise get in. Afterward, the records are destroyed so students don’t know if they got in through the regular or DSAAP stream. “We didn’t want to make people feel they have to prove themselves in some way,” says Dr. Domes, who stresses that the DSAAP program isn’t about lowering academic standards. Instead, he says, “for those who have historically been disadvantaged due to things that they cannot control, we’re trying to level the playing field.”
Lucas King was raised primarily by a single mother who supported him and his older brother with multiple jobs. She worked seasonally at a local arena and campground and also assisted kids with special needs in school. When he was 19, Mr. King had a son and worked for a year before deciding to pursue postsecondary education. He’s now attending his second year at the University of Saskatchewan’s medical school and living with his partner and their son, with another child on the way. (Though Mr. King applied to the DSAAP, he doesn’t know if he was admitted through that stream or the regular one.)
Already, Mr. King says he can see how his perspective is different from that of many of his fellow students. During a clinical placement, he and some of his classmates were consulting with a single mother who didn’t have family in the country. His instructor and classmates recommended that she put her son in activities, like soccer, to help him lose weight. But, upon asking questions about her circumstances, Mr. King says he knew it was unlikely that she had the time or the means to sign her kid up for organized sports. “I didn’t think the reality of her situation was considered, and that bothered me,” he says.
After he graduates, Mr. King says he wants to work in family medicine. “We have a bit of a revolving door in terms of physicians in rural Saskatchewan, in that doctors sign a contract for a couple years and then move elsewhere. I’ve seen within my family how much of an impact that can have.”
Of course, for programs like the DSAAP to attract students who come from rural, remote and low-income communities, these students have to be considering a career in medicine in the first place. As Victor Do, president of the Canadian Federation of Medical Students (CFMS) and a fourth-year medical student at the University of Alberta, puts it, “we need to identify people five or 10 years earlier and make sure they have that understanding that they fit in to medicine.”
Université de Montréal is working to send this message through its Accès médecine (Access to Medicine) program. U de M medical students visit Montreal high schools and CEGEPs in underserved communities once a month to talk about what it’s like to be a medical student and answer students’ questions. High school students are invited to workshops, where they learn skills like how to take vital signs. The teenagers also get to visit hospitals and clinics and meet health-care professionals. The program lets students imagine themselves in the role of a physician, says Jean-Michel Leduc, head of the equity and diversity committee at the university’s medical school.
On the admissions side, since 2017, the university has two fully funded spots reserved for people with demonstrated financial need, which is verified by the university’s financial office. These students go through the same admissions process, but they’re given slightly more leeway on academic performance. “It’s a small step, but you need to put your foot in the door to start,” says Dr. Leduc. One of the concerns of other stakeholders at the university was that academic standards were being lowered; but, so far, the four students’ grades are comparable to their peers, and Dr. Leduc says he hopes the number of reserved spots will be expanded. “Is somebody who gets an R score of 36 going to make a better doctor than someone who gets 35.5? I don’t think so,” he says, referring to Quebec’s version of the GPA. “Communication, collaboration, resilience, empathy, all of the traits that are so important to practise medicine, are perhaps not well captured by school records,” he says.
The University of Calgary is putting students on the road to medicine in a more formal way. Once they’re accepted into an undergraduate program, students who are Alberta residents and from lower socioeconomic backgrounds can apply to the school’s Pathways to Medicine Scholarship program. Up to five are accepted each year. They’re provided with financial assistance, as well as tutoring, mentorship and mental-health supports.
“We wanted the opportunity to catch the bright ones early to make sure that they had the tools that they needed to succeed,” says James Fewell, program lead of the Pathways program. Dr. Fewell and Barb Cowley, the program coordinator, check in with the students weekly and sometimes daily. “It’s a big transition from high school to university, especially for our rural students, so we keep a really close eye on the first-year students particularly,” says Dr. Fewell. So long as the Pathways students meet the requirements, which include an overall GPA of 3.4, the students are guaranteed admission to the medical school.
Mathieu Chin is a final-year Pathways student who will transition to medical school next year. He’s the first in his family to go to university. He credits the financial support of the program with allowing him to forgo more lucrative summer jobs and instead work for minimum wage as a research assistant. And, he describes the mentorship of the program in a way that someone who has parents who attended university might describe the help they receive at home. For example, when he was disappointed with his MCAT score – even though it was still high enough for admittance to med school – he remembers neurologist Lara Cooke, his faculty mentor at the medical school, telling him to just take a deep breath, that everything’s going to be OK and that he should be proud of himself. And, he should be: he’s presented his research on the effects of bodychecking policies on injury rates in hockey at prestigious conferences, he volunteers to help cancer patients with exercise rehabilitation and, in 2019, he was one of ten 3M National Student Fellows recognized for his leadership.
“One of the things I love about medicine is the human aspect, interacting with people,” says Mr. Chin. “I think having grown up without luxury things and exciting vacations, I’ll be able to make that connection with people on a wider spectrum.”
While these efforts to create more holistic admissions processes are heartening, Mr. Do at the CFMS points out that they benefit only a very small fraction of all medical students. In general, admissions processes at medical schools “are still very outdated,” he says, focusing on “who has done the most volunteering and who has won the most awards.” Mr. Do says he would like to see more schools adopt essays and narrative questions like Western has done, so that people with less privilege can discuss the challenges they’ve overcome and the skills they’ve developed outside of formal programs. The CFMS 2016 position paper outlines other actions to improve diversity, including waving application fees, removing the MCAT requirement, increasing needs-based financial assistance and supporting student-run diversity-awareness interest groups.
The methods for improving diversity in medicine are already there, says Mr. Do. What often stands in the way is “resistance from those with power and privilege who say things like, ‘You’re lowering standards.’” To continue to improve diversity, he says, faculty at medical schools will have to prioritize diversity over status-quo arguments. “People with privilege will have to be a little uncomfortable. For health outcomes as a whole, this needs to be the future of medicine.”