How the medical school admissions process is skewed

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.