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.    

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.  

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  

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.    

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.  

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  

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  

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.  

Executive  Summary  

The  Problem:  Inadequate  Diversity  in  Canadian  Medical  Schools  

Implications  for  the  Canadian  Healthcare  System  

Existing  Efforts  to  Address  This  Problem  

Existing  Programs  on  Which  the  Canadian  Solution  Could  be  Based  

10.80%  

46.70%  

12.80%  

22.40%  

19.40%  

36.70%  

0%   10%   20%   30%   40%   50%  

Rural  Origin  

Parental  Income  >  $100,000/year  

Parental  Income  <  $40,000/year  

Canadian  Population   Medical  Student  Population  

Comparison  of  Average  Family  Income  and  Rural  Origin    in  Medical  Student  and  Canadian  populations  

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.  

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    

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.  

February  7,  2011  

References  

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

www.cfms.org