Implications for the Canadian Healthcare System
Survey data indicates that the medical student population inadequately represents the Canadian population, given the signi8icant underrepresentation of students from lower income and rural backgrounds. The reasons for this are complex and multi-‐factorial, including lower rates of application from these groups, prohibitive costs, and application biases. Because low-‐income and rural students are more likely to serve their communities of origin, this problem has a negative impact on access to physician care in underserviced areas.
This inequity of access means that medical students are disproportionately derived from af8luent and highly educated backgrounds, resulting in limited access to one of the most highly regarded social-‐capital professions and likely maintaining a cycle of elitism within the medical community. Inadequate admission of low-income and rural students is reducing physician accessibility in underserviced areas.
Over the past year, this issue has become an important area of focus for many national medical organizations, including the Association of Faculties of Medicine of Canada (AFMC). While medical schools are working towards solutions, there is a need for government involvement. Notably, there is precedent for federal intervention in this problem. Therefore, the CFMS is asking the government to take action to foster a physician workforce that serves the needs of all Canadians. We are proposing 1. the establishment of a bursary to cover the signi6icant costs of application to medical school for students in 8inancial needs, and 2. the creation of a fund to support mentorship and outreach programs aimed at recruiting and supporting low income and rural background students in a career in medicine.
The Problem: Inadequate Diversity in Canadian Medical Schools Survey data from 2007 suggests that medical school is not accessible to rural and low-‐income students.1 This research shows that the disparity has grown since the previous survey was conducted in 2001.2 Comparison of Average Family Income and Rural Origin in Medical Student and Canadian populations Parental Income < $40,000/year
Existing Efforts to Address This Problem Canadian Medical schools are aware of the problem of unrepresentative medical student populations: • The accreditation standards have been recently revised to require that every Canadian medical school show proof of initiatives to increase diversity, including economic and geographic. 12 • The Association of Faculties of Medicine of Canada (AFMC) recommended in a report funded by Health Canada that every Canadian medical school enhance admission processes to foster increased diversity and the creation of a representative physician workforce. 13 • At the 2010 AFMC Deans on the Hill Lobbying event, deans from medical schools across the country proposed that the federal government should make increased enrollment of low income and rural background students a priority. They proposed the creation of application grants and funding for pipelines projects. 14
Existing Programs on Which the Canadian Solution Could be Based
Parental Income > $100,000/year Rural Origin
1. Students with rural backgrounds are 2.5 times more likely to practice in a rural community. 9 2. Students with low-‐income backgrounds are more likely to serve low-‐income patients. 10 3. Students with rural or lower income backgrounds are also more likely to practice as family physicians , a discipline in which Canada is experiencing signi8icant shortages.11
19.40% 46.70% 22.40% 10.80%
Medical Student Population
While the reasons for this disproportionate representation are complex, the following are known barriers at the medical school level: 1. Students from low income backgrounds are less likely to have the opportunities necessary to meet application requirements. • Signi8icant emphasis is placed on academic achievement and extracurricular activities, however, economically disadvantaged students who must work part or full-‐time to 8inance their education may have less time to dedicate towards these activities. • Applicants from lower income backgrounds have decreased opportunity for attaining the same levels of academic achievement and extracurricular involvement, relative to other applicants. 3, 4 2. Students from low income and rural backgrounds are less likely to consider medicine as a viable career option. • Students from underserviced communities lack the exposure to medicine during the critical high school years in which they are making decisions about potential future careers. • Students from the poorest neighbourhoods are 7 times less likely to enter medical school than students from richer neighbourhoods.5 • The rates of medical school application are much lower among rural students than among their urban counterparts.6,7 2. Costs associated with medical school negatively impact students from low income and rural backgrounds. • The rising costs of medical training. o When medical school tuition in Ontario tripled to $17,407 in 1997, the proportion of medical students from low-‐ income families dropped from 22.6% to 15.0% in 2000.8 • The costs associated with applying to medical school. o Such costs can be $1000 or more, when expenses such as entry exam (MCAT) registration, application fees, and travel costs of interviewing are tallied. o Students of rural origin have even greater expenses, such as travel and relocation.
United States: Association of American Medical College’s (AAMC’s) Fee Assistance Program • Subsidizes prohibitive costs of applying to medical school by decreasing MCAT examination fees and waiving medical school application fees. • Targets students with family income below 300% of the poverty line. 15 Australia: Rural Undergraduate Support and Coordination (RUSC) Incentives Program • Administered by the Australian Government, a part of the RUSC program awards monetary incentives to medical schools based on increased admission of students from rural and remote communities. • Major focus of the program is the creation of pipelines that aim to recruit and assist high school and undergraduate students from underrepresented and disadvantaged communities in the pursuit of a career in medicine. These pipelines include outreach programs to high schools in underserviced communities, longitudinal mentorships for students with expressed interest in medicine, summer employment and research opportunities in the health sciences, and 8inancial assistance to cover the costs of undergraduate education and preparation for medical school. • Since the program’s creation in 1994, the proportion of medical students of rural origin has increased from 10% in 1989 to 25% in 2000. 16
Our Proposal The underrepresentation of low-‐income and rural background students in medical schools is producing a population of physicians that is unlikely to fully meet the needs of underserviced communities. The Federal Government must take action to support medical schools in seeking strategies to increase enrolment of students from these groups. Therefore, the CFMS is calling on the Government of Canada to: 1. Establish an application bursary program to cover the signi8icant cost of applying to medical school for students in 8inancial need. 2. Create a fund to support mentorship and outreach programs aimed at recruiting and supporting low income and rural students in a career in medicine.
References 1Merani S, Abdulla S, Kwong JC, Rosella L, Streiner DL, Johnson IL, Dhalla IA. Increasing tuition fees in a country with two different
models of medical education. Medical Education 2010 44: 577–586. 2Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Characteristics of 8irst-‐year students in Canadian medical schools. CMAJ. 2002 166; 1029-‐35. 3Sirin, SR. Socioeconomic Status and Academic Achievement: A Meta-‐Analytic Review of Research Review of Educational Research. 2005 75(3): 417-‐53 4Betts, JR and Morrel, D. The Determinants of Undergraduate Grade Point Average The Relative Importance of Family Background, High School Resources, and Peer Group Effects. Journal of Human Resources. 1998 34(2):268-‐92 5Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Characteristics of 8irst-‐year students in Canadian medical schools. CMAJ. 2002 166; 1029-‐35. 6Wright B, Woloschuk W. Have rural background students been disadvantaged by the medical school admission process? Medical Education 2008 42: 476–479. 7Hutten-‐Czapski P, Pitblado R, Rourke J. Who gets into medical school? Comparison of students from rural and urban backgrounds. Can Fam Physician 2005 51: 124 -‐1241. 8Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Effects of rising tuition fees on medical school class composition and 8inancial outlook. CMAJ. 2002 16;166(8):1023-‐8. 9Rourke J, Dewar D, Harris K, Hutten-‐Czapski P, Johnston M, Klassen D, Konkin J, Morwood C, Rowntree C, Stobbe K, Young T; Task Force of the Society of Rural Physicians of Canada. Strategies to increase the enrolment of students of rural origin in medical school: recommendations from the Society of Rural Physicians of Canada. CMAJ. 2005 4;172(1):62-‐5. 10Woo JK, Ghorayeb SH, Lee CK, Sangha H, Richter S. Effect of patient socioeconomic status on perceptions of 8irst-‐ and second-‐ year medical students. CMAJ. 2004 22;170(13):1915-‐9. 11Senf JH, Campos-‐Outcalt D, Kutob R. Factors related to the choice of family medicine: A reassessment and literature review. J Am Board Fam Pract. 2003 Nov-‐Dec;16(6):502-‐12. 12Liaison Committee on Medical Education (LCME) document: “Functions and Structure of a Medical School” Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree, June 2008. 13The Association of Faculties of Medicine of Canada (AFMC) document: “The Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education.” 2010. 14The Association of Faculties of Medicine of Canada (AFMC) Deans on the Hill document: “Fostering a Diverse Physician Workforce.” 2010. 15AAMC: About the Fee Assistance Program. Available from: http://www.aamc.org/students/applying/fap/, Accessed: January 30, 2011. 16Dunbabin JS, Levitt L. Rural origin and rural medical exposure: their impact on the rural and remote medical workforce in Australia . Rural and Remote Health 3 (online), 2003: 212. Available from: http://www.rrh.org.au, Accessed: January 30, 2011.
Fostering a Physician Workforce that Serves the Needs of Canadians A plan to increase access to Canadian medical schools for students from low income and rural backgrounds.
Canadian Federation of Medical Students/ Fédération des étudiants et des étudiantes en médicine du Canada 324 Somerset Street West, Suite 300 Ottawa, ON K2P 0J9 Phone: 613-‐565-‐7740 Fax: 613-‐288-‐0524 www.cfms.org
February 7, 2011
Canadian Federation of Medical Students/ Fédération des étudiants et des étudiantes en médicine du Canada www.cfms.org