Years ago, while working at my university’s booth at the Ontario Universities’ Fair, I wandered over to the medical school representatives at another booth. As I gathered information in my blue Hilroy notebook, a doctor on faculty said, “It doesn’t matter whether a candidate worked at McDonald’s or did volunteer work overseas. It only matters that he learned from the experience.”
As an academic and the parent of a student at a Canadian medical school, I’ve recently watched the admissions process unfold with some dismay. Medical schools bend over backwards to be fair. They talk about holistic admissions criteria and introduce innovations every year to address the sense that they’re not quite getting it right.
Admissions are extraordinarily competitive. In Ontario, the success rate for getting an offer is lower than 10 percent for applicants to many schools. Last year, for example, McMaster University had 5,270 applicants for 206 places. Queen’s University had 4,686 candidates for 100 places. These admissions rates are not unusual.
the process favours students with money
At the medical school my son eventually attended, his classmates had demonstrated skill and initiative to get in. They’d started international charities, competed in sports at the national level, won prestigious academic awards and published prolifically.
All this points to something that the admissions process overlooks, and it’s an uncomfortable elephant in the room: the process favours students with money.
Strong candidates all over North America have the kind of profile the University of Pennsylvania included in promotional materials they sent out with a picture of a pre-med student:
“I am currently a research assistant in the neuroscience lab, where I am analyzing the neural circuits underlying the development of empathy in young children. Over the summer I volunteered at Children’s Hospital where I shadowed a pediatric neurosurgeon and attended my first brain surgery! This year I am President of Student Affairs so I’ll be organizing all the fun large-scale events on campus. Currently I am on the dance team and I love it! My biggest project right now is working with a mobile clinic in Peru. Being able to shadow local doctors, dentists, and gynecologists, build sanitary bathrooms, and educate the people on basic hygiene was a great experience for me …”
– (from “Is medical school just for rich kids?”, a 2014 blog post by Pamela Wible).
This is almost a parody of the classic profile of a successful medical school applicant, exclamation marks and all. Many students take unpaid research assistant positions as a route to co-authorships on papers. Extracurricular activities are just as important as straight A’s and sterling results on standardized tests. Many students are applying with 4.0 averages, typically only attainable when all grades are over 90 percent. For the would-be applicant working at McDonald’s, time on the job and pressure to show up to assigned shifts are not conducive to exceptional academic accomplishment.
Then there’s the Medical College Admission Test, or MCAT. The newest version is seven and a half hours long, including breaks. Students who can afford to do so take entire summers off to study for this brutal standardized test. Preparation courses for the test offered by numerous companies can be very helpful but can cost thousands of dollars. Students who don’t have to work and have access to that kind of money are again at an advantage.
An insistence on holistic assessment
Some medical schools still use traditional panel interviews but most are now using a series of mini-interviews, where applicants move from station to station reacting to scenarios. Again, training companies offer workshops to help applicants prepare. In fact, there’s no aspect of the admissions process for which companies don’t provide guidance, at a price.
But it is medical schools’ insistence on holistic assessment that might put students who need to work at the biggest disadvantage.
The University of Toronto spells out what it’s looking for in applicants. Typical of most schools, it rewards commitment to advocacy as expressed through community service. It looks for evidence of leadership and of outstanding achievement in scholarship, including publications.
How much easier is it to devote time to community initiatives when you don’t have to worry about paying the rent? Or to take on leadership roles, which are in short supply at most minimum wage jobs? The extensive unpaid labour that goes into research associated with publication takes time too, but so do shifts at a fast food or retail outlet.
And it doesn’t stop there. The price of applying to all medical schools in Ontario alone is nearly $900. Then there’s the cost of submitting applications and ordering transcripts. Candidates who are lucky enough to get interviews have to pay to travel across the province or the country for those interviews.
The last time academic researchers assessed the socio-economic profile of medical students in Canada was over a decade ago. Irfan Dhalla and co-authors found that students came from families with high socio-economic status (“Characteristics of first-year students in Canadian medical schools,” CMAJ, 2002). Many of their parents – 39 percent of fathers and 19.4 percent of mothers – had a master’s or doctoral degree, compared with 6.6 percent and 3 percent, respectively, for the Canadian population as a whole. More than 69 percent of fathers and more than 48 percent of mothers were professionals or high-level managers, compared with 12 percent of the general population. Most tellingly, 17 percent of households had incomes exceeding $160,000, while just 2.7 of Canadian households at that time had incomes over $150,000. More than 15 percent of participants had a physician parent.
My son is lucky. Even though he comes from a one-income family with a father on disability, I have a good job as a professor and was able to lend him the money he needed. Yet even for students who don’t have overt financial challenges, it’s a tough journey. My son says getting one of the few coveted seats in a Canadian medical school is one of the hardest things he’s ever done.
Why become a doctor?
He knew he wanted to be a doctor from the age of 11. That was the year his father had multiple heart attacks. My son spent more time around hospitals than any child should. At an impressionable age, he watched as doctors saved his father’s life. When he grew older and qualified as a lifeguard, he kept his first aid kit in the car, in case he encountered an accident on the highway.
In university, my son did everything right. He achieved the highest grades in his faculty. He published. He filled out the application form effortlessly with long-standing volunteer and work activities. And his references were glowing.
Even so, it took him three tries to get a spot. The first year he applied he didn’t even get an interview. The second year, he was waitlisted at the two schools where he interviewed, tantamount to rejections. The third year he was offered spots in two provinces. But the relentless process took a toll. When he was waitlisted that second year, away in Asia, he wrote about checking his email for the message that had the potential to change his life:
I woke up early and walked briskly to the little Internet café. I was doing a course on a beautiful little island but it didn’t matter. Not compared to this. It was painfully slow to log onto my email. My heart was racing. I quickly said a silent prayer as I opened the first email. The prayer intensified as I opened the second. Two rejections. For the second year. I stared up at the ceiling. I’d wanted this so much for so long. So much sacrifice and hard work and emotion. For nothing. I still wasn’t good enough. At that moment, it felt like the end.
Although he was heartbroken, my son came to realize it was a marathon, not a sprint. On average, it takes a candidate approximately three tries to get a place.
The sometimes random nature of the application process
The sometimes random nature of the application process was brought home at another universities’ fair. I was working at the Ryerson University booth across the hall and, maybe out of professional courtesy, the faculty doctor I spoke to was unusually frank: “We could take the first couple of hundred students on the admissions list. Or the next couple of hundred. Or the next. And we’d still end up with good doctors. It probably doesn’t make much difference.” I scratched this into my notebook and I remember how discouraged I felt on my son’s behalf.
However, in a system where subjective measures come into play, it’s hard to know how to proceed. The University of Calgary, with one of the most transparent medical schools in the country, addresses this head on. In the MD admissions blog on the university’s website, Ian Walker writes that once you rule out top and bottom candidates, “In the middle is a very large group of applicants who are good, and somewhat difficult to distinguish from each other. Our scoring systems try, but it is a blunt instrument at best.” In response, one of the students commenting on the blog refers to admissions as a “lottery.”
Many of those in my son’s class also applied several times. Several did a pricey second undergraduate degree to boost grades. Others did master’s degrees with their eye on the med school prize. If my son had added a precarious financial situation to the equation, would it all have been possible for him?
In Ontario, the medical school application form asks candidates to fill in a 48-item list of activities and accomplishments since the age of 16 and to include “all experiences, both structured and non-structured, that demonstrate an ability to determine needs in their community and a willingness to play a part in filling those needs.” As much as a medical faculty member might protest, a minimum-wage job that consumes most of a candidate’s free time doesn’t allow for a very impressive showing in those 48 boxes.
schools have an obligation to cultivate prospective medical school applicants at the high school level and even earlier.
Senior administrators at medical schools agree this is an important issue. “It’s a multi-headed beast,” says Dr. Walker, “and we’re just starting to chip away at some of the heads.” He believes the problem may start much earlier than the application process and that schools have an obligation to cultivate prospective medical school applicants at the high school level and even earlier.
An added concern is that more-affluent applicants have additional social capital. “They are well connected, they know the system, if they want to go away and shadow a physician or work in a research lab their parents know people,” says Dr. Walker. “They have access to opportunities and mentorship that are perhaps not available to all applicants.”
One of the many ways U of Calgary is addressing this is with a new Pathways to Medicine program. Five students from low socio-economic backgrounds are selected straight from high school. They are mentored and subsidized as undergraduates and, if they successfully complete the program, will have a guaranteed spot in medical school.
Anthony Sanfilippo from Queen’s University’s school of medicine agrees that high school programs have the potential to promote medicine as an option for disadvantaged and underrepresented students. Queen’s invites such students to visit the school to meet medical students and see what the curriculum is like. In his thoughtful blog that addresses medical school issues, Dr. Sanfilippo calls for reassessment of admissions processes to ensure they’re “equally accessible to all groups.” He wonders whether the MCAT should be reconsidered as an admissions criterion, especially when affluent students can purchase expensive prep programs. He supports mentorship and assistance programs for promising students who wouldn’t normally have a crack at medical school.
Virtually all schools hold spots for students from underrepresented groups and mentor and support them. U of T, for example, offers generous bursaries, a support program for Black students and a targeted application program for Indigenous students. And schools grapple with admissions criteria, trying to find fairer measures of assessment.
But the perks of affluence can’t be understated. To broaden their chances of admission, candidates who can afford it can apply to schools in the United States, where the route back to Canada is reasonably straightforward. Tuition fees in the U.S. average more than US$50,000, compared with less than a third of that at some Canadian universities. Ireland is also a popular destination for Canadian students, with tuition similar to U.S. fees. Caribbean schools are cheaper, but more of a gamble for students who want to practice in Canada one day.
Is it the same for other competitive programs?
Maybe it’s the same for other competitive programs. I’m sure there’s an advantage to taking the summer off to study for the LSAT, the standardized test for law school applicants, for example. But somehow it’s more personal when universities are choosing future doctors, the people who will be handling the most intimate aspects of our personal care and making life-and-death decisions on our behalves. When I’m going through the biggest health struggle of my life, I’d appreciate having a doctor who might know a thing or two about struggle herself.
My son can expect other major expenses. During his final year of medical school, he’ll be travelling to do electives in hospitals across Canada for a few weeks at a time. That’s not cheap, but now that he’s in medical school, he doesn’t worry as much about money.
However, my concern is for those who are applying for a spot in first year. I have to wonder what the real price is when, in spite of steps to change the system, those who have money can more easily secure a golden ticket.
Marsha Barber is a professor in Ryerson University’s school of journalism. She thanks her son, who co-authored this article.
A very interesting article. The next question is how well MD graduates are serving the needs of the health care system in Canada. I live in central Halifax. A friend who is a family physician in a nearby practice with four or five other physicians cannot find anyone willing to take over from her as she retires. My partner, a healthy middle-aged man, had a very tough time finding a new family physician in the same area. If we are not producing young doctors who will accept work in an established practice in the middle of one of Canada’s nicest cities, then one has to wonder what medical students have in mind as they compete for these scarce places in medical schools.
Unfortunately, med students have little say in where they will practice. The provincial governments, with it’s ill conceived organization of medical service provision, has continued to under fund health care which makes it almost impossible for a young med student to buy an established practice. Also, retirement aged docs have so little retirement funds, they often do not retire. This further limits wheer a young doctor can set up.
Great article. The fundamental issue you are dealing with here is far broader than just admission to competitive higher education programs. It is really a problem of socioeconomic mobility (see http://www.statcan.gc.ca/pub/11-626-x/11-626-x2016059-eng.htm ). While Canada fares better than most countries in this respect, we cannot be complacent. We do need to find ways to break down economic and other arbitrary barriers to all forms of higher education. We are not immune to this at veterinary colleges, and in trying to resolve this issue we will be looking to best practices from other institutions like the University of Calgary.
Thanks for the well considered and well written article. There is no question that economics and socioeconomic status interact with the med school admissions process in all sorts of ways that those of us who are intimately involved are distressed about. The concern about it is not limited to one or two institutions by any means, and I think good faith efforts are being made to understand where specifically within our processes these unwanted advantages occur and to correct for them.
My only area of disagreement with you would be on the role of “holistic review” in perpetuating the problem. Depending on how the term is used, there is no doubt that it has the potential to worsen the situation. If it is code for “looking at all of an applicant’s life accomplishments” then certainly it will favour the privledged, since as you rightly point out, the ability to accomplish many of these impressive things we see in applicants is predicated on financial and circumstantial opportunity. If, however, holistic review is understood to mean thinking much more broadly about an applicants total life experience, and the relevance of that experience to a career in medicine, I think it can have entirely the opposite effect. What if we look at someone’s part time job at McDonalds during university as an asset, not just an obstacle. Does that job not teach an applicant about time management, prioritization, and most importantly give them a deeper appreciation for the everyday existence of average citizens (i.e. their future patients)? If you accept that logic, then working part time at McDonalds might actually make you a better doctor. I would argue, in fact, that it does, and medical school admissions processes need to at least consider that possibility. I think it is to our credit, collectively, that we are starting to do exactly that.
We have long considered the process of med school admissions to be a meritocracy where we select the “best and the brightest”, but as we begin to consider the mounting evidence that wealth and privilege are confabulating factors in assessing merit, we need to also take a careful look and reconsider what we mean by “merit” and “best.” As one of the other commentators implied, thinking about those terms through the lens of a patient, and the needs of the patients we are ultimately going to serve, might radically change the underlying processes for how we select medical students.
I appreciate you speaking out publicly about this issue. As a process that is ultimately beholden to the public even more so than our applicants, it is important that these conversations be had as openly and publicly as possible.
I would agree that the “holistic review” can be interpreted in different ways depending on if its defined by life accomplishments or life experience. However, I do not think that the experience view is as appreciated or as understood compared to the accomplishment view. The current application process does not allow for evaluation of experiences and the subsequent soft skills gained from them. The 48 item sketch is inherently biased towards those who have the advantages of being able to take on extra curricular that lead to accomplishments without being burdened by a heavy work schedule. The interview seems to be the only part of the application process where relevant soft skills learned from work experience can be evaluated and by that point thousands of applicants have already been eliminated. The long standing and ever increasing GPA and MCAT requirements are another step in the process that leave students who have had to work at a disadvantage as they also overlook soft skills learned from work experience. The CASPer test has helped somewhat to evaluate soft skills however it has not been heavily adopted and its weighting is variable. Overall, I think that a far better way to get a holistic assessment of a candidate would be a more involved application process that was more interactive. This could be as simple as granting more interviews or case by case interviews for a candidate that shows more experience than accomplishments.
My real worry with the current system is that it has become incredibly cold and although It selects for students who demonstrate academic excellence and strong extra curricular involvement will these students be able to relate to the average patient. Medicine is at the end of the day a service and being able to meaningfully connect with patients is vital to a high quality of care and impacts both patient adherence to treatment and patient satisfaction. A physician that can openly and respectfully explain the merits of vaccines to a patient who is considering not vaccinating their child is more likely to have a favorable resolution to the situation than a physician that is unempathetic and dismissive. Medicine is a human science and selecting future physicians so heavily based on criteria that favor the privileged and accomplishments that are out of touch with the general public could have further reaching negative effects than we can fully understand/quantify.
This article makes several very cogent points and deserves to be taken very seriously.
I would like to add a remark about the whole focus on “Med School” (or Dentistry or whatever). I teach Organic Chemistry and I see that students for the most part have been focused on getting into Med School at least partly because that is the only way they can imagine being involved in human health issues. But I think of my own trajectory towards science, which started in the early 1970s. In those days medicine was just another job – well paid and respected but not the be-all and end-all it is today.
I knew I wanted to try to make a difference, and I was inspired by the “War on Cancer” and learning that a relative was diagnosed with cancer. But I knew that it was not going to be an MD who “cured cancer”. The MD would give the pill that was invented by a scientist – in fact, a team of scientists. So I knew I wanted to get involved in science, and I chose organic chemistry because I knew that this was the tool that could build the molecule that was going to “cure cancer”.
Well, I was naive as a teenager. Of course we know that cancer is much more complex and a simple “magic bullet” cure is not going to happen. But I still think that most students would be better advised to think beyond the MD – to pursue the fundamental biology, biochemistry, and chemistry that will drive us towards understanding human disease. Only a few will be MDs, but many hundreds more will make enormous contributions as scientists. I think a lot of students would be much more relaxed if they were not given misguided advice that tells them that if they don’t get the MD then they can’t make a positive difference in the world, or have a rewarding career.
This is truly a great piece on the current medical school application in Ontario. It is such an unfortunate situation when you have hard working and thoughtful students who are genuinely interested in a medical career but unfortunately are faced with huge economic burdens. Currently, there is no financial assistance or mentorship that students from low income families can benefit from when applying to medical school or preparing for the MCAT. And if the average time it takes to get into medical school is at least 3 times, that’s a serious cost that these students will have to consider and stress over. It would be great if we could look at the current LSAT free prep course and mentorship that UofT offers students from low income families. A great article!
I agree with Dr. Hultin’s assessment. At the high school and university level, students are presented with limited career options rather than the full gamut of options. What I also find interesting, is that there is such a sharp focus and interest on the small minority of prospective applicants who successfully enter medical school that we lose sight of the vast majority who never get in. What happens to those thousands of students? What do they end up pursuing? Shouldn’t we serve those students better?Currently no Canadian medical school is tracking those students or statistics.
Publicly funded medical schools need to take far more responsibility for their applicant pool. The system seems incredibly inefficient and wasteful; they need to sift through thousands of applicants and interviews to identify 100-200 students for an entering class. Realistically, they should have stricter and higher GPA cut offs to reduce the number of applicants; they’re rarely selecting for prospective applicants with lower GPAs so there is no reason to include them in their assessment. This would help reduce the work load of admissions staff, while also ensuring thousands of students wouldn’t waste their time, money and effort on needless applications. These students could focus their efforts on other careers like business or sciences.
While the author makes a number of points that point to economic advantage of children from well-to-do families, one must be very careful with this type of analysis. The same applicant whose parents are well educated and highly paid may also be the beneficiary of life-time experiences that also prove advantageous during medical essay preparation or medical school interviews. As an example, these parents may value literacy more than the Canadian norm, and thus spend more time reading to their young children.
My daughter entered medical school this past September. Her profile was very similar to Dr. Barber’s son. While I could afford to pay for preparatory courses for her, I did not; rather, she bought some relatively inexpensive preparatory manuals.
Many of the issues highlighted in the article will apply equally to anyone attending university versus the general population. The university population tends to come from better educated, more affluent backgrounds than the overall population.
Finally, the comment that students who have faced financial hardship know a thing or two about struggles implies that students from more affluent backgrounds do not. I would offer that any student that makes it into medical school – affluent or not – has struggled mightily to get where they are.
Thank you for this reply! It contains insights that are generally overlooked. Other posts have been laden with assumptions that are not necessarily true.
It is now 2024, and with these sentiments, the admissions systems at some universities have actively shunned hardworking and talented students, who by no fault of their own, might have parent(s) with a good income. The admission application asks whether their relatives are involved in the healthcare field, as well as their parents salary bracket. (Note that this is not an application for financial assistance.) These kids should not be left to pay entirely for inequalities that need to be dealt with in many different societal ways.
Furthermore, because a student’s parent is a good income earner, or a health care professional, does not necessarily mean the student “had an easy life without struggle”, nor does it mean their parents paid for extra training, or were “connected” enough with the medical world to arrange hospital experiences or work terms. Also, the student might have been required to hold down a job – please don’t assume they are not required to work. They might experience certain obligations and do not necessarily “have more time on their hands” as indicated in previous posts.
Just as you indicated, this discussion should be done with more care and fewer assumptions. We do not need to swing the pendulum fully in the opposite direction.