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Executive Summary  

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  

36.70% 12.80%  

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%  


Canadian Population  





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:,  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:,  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    

February 7,  2011  

Canadian Federation  of  Medical  Students/   Fédération  des  étudiants  et  des  étudiantes  en  médicine  du  Canada      


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