Medical schools play a significant role in shaping the physician workforce. The die cast by medical program admission processes has considerable influence, intended or otherwise, on the nature of the future medical workforce. Specifically, personal characteristics advantaged by admissions criteria affect the makeup of medical school classes, which, in turn, influences the composition of those in medical practice. Important equity concerns arise when the academic medicine community considers this influence in light of the critical underrepresentation of some minority groups at all levels of science and health education,1 of male minority students,2 and of science and health care professionals from diverse backgrounds.3 Although previous research has demonstrated that early exposure to science and health care professionals can increase the probability of students pursuing higher education,3,4 few role models are present,5 and significant barriers remain6 for persons from underrepresented groups to access MD training programs.
Discussions surrounding the social responsibility of medical education with respect to the obligations of the profession to society are in the midst of significant change. Recent reviews by the Association of Faculties of Medicine of Canada (AFMC) regarding the future of medical education7 and by the Macy Foundation8 address the issue of representativeness and inclusion in the selection process; specifically, they focus on the removal of barriers impeding underrepresented groups. Both reports call for enhancing the social diversity of the medical student population and identify the key principles of inclusiveness and representativeness. These principles constitute an effort not only to enhance diversity among medical trainees but also to increase and improve the medical services available to traditionally underrepresented groups.
Research demonstrates that minority physicians are more likely to work in underserved areas and are more likely to treat minority patients.9–12 Similarly, medical students from diverse backgrounds report increased desire to work in traditionally underserved areas with underserved patients.13 Minority patients tend both to seek care from minority physicians and to report greater satisfaction when they receive care from a minority physician.14,15
The benefits of a diverse medical class are not limited to workforce considerations or patient satisfaction. Prior researchers have demonstrated many significant and positive effects both on the curriculum (hidden, formal, and informal) and on learning outcomes in diversely constituted medical classes.16–18 Research shows that a diverse medical school class benefits most learners19 and creates an environment wherein stereotypes and cultural assumptions can be challenged.20
Although the AFMC7 and Macy Foundation8 support educational change related to social accountability, increased access to medical education, and increased diversity, little systematic documentation regarding what actually constitutes a diverse population is available, particularly in the Canadian context. In addition to the paucity of clear definitions of what constitutes a diverse medical student population, few systematic demographic data are available regarding current medical students in Canada. Compounding this problem, the data that are available are limited to gender,21,22 socioeconomic status,21,22 previous training,22 urban/rural status,22,23 age,22,23 and ethnicity.22,23 Also, notably, much of the available data were collected for only one year in an initiative headed by medical students.23 Data on gender identity, sexual identity, disability, and other dimensions of diversity are not available, even in a limited way.
Although research is limited, mounting political exigencies have given rise to multiple strategies aimed at promoting the entry of students from traditionally identified underrepresented groups in medicine. These exigencies place particular emphasis on three specific student groups: Indigenous Peoples of Canada* (identified as underrepresented),23,24 students from rural (and lower socioeconomic) backgrounds,25,26 and Francophone populations. For example, the AFMC and Indigenous Physicians Association of Canada have collaborated to enhance health care for Indigenous Peoples of Canada (First Nations, Inuit, and Métis) through a survey of Canada’s faculties of medicine regarding admissions and support programs for Indigenous students.27 Similarly, in an effort to address a lower-than-desirable proportion of medical students from rural backgrounds, a new medical school was created within the northern and rural regions of Ontario (the Northern Ontario School of Medicine [NOSM]) whose mission is to train physicians in northern and rural communities and to train physicians to be aware of and address those regions’ unique health care needs.28,29 Finally, several medical schools in Canada have removed the MCAT application requirement because no French-language version of the exam is available—even though French and English are both official national languages in Canada. Initial evidence suggests that the lack of a French version of the test is a potential barrier for admission for Francophones outside of Quebec.30
The additional support for Indigenous students, the creation of NOSM, and the local discontinuation of the MCAT admissions requirement all reflect admissions policies that are responsive to Canada’s unique history, geography, and politicolegal system. Although Indigenous students, rural students, and French-speaking students have been identified in the Canadian medical education context as underrepresented, relatively little is known regarding the breadth of diversity within Canadian medical schools. Because of this scarcity of nationally and regionally relevant data, Canadian schools and policy makers have relied heavily on research and policy generated by, and relevant to, the United States. Such research and policy may be a very helpful starting point, but directly importing and applying U.S. findings and guidelines to the Canadian context may be inappropriate, especially given the important political differences with respect to constructs of diversity and equity, and the different histories of marginalization and oppression for certain population groups in Canada and the United States. Even if basic conceptualizations of diversity, such as ethnicity and place of geographic origin, appear to be similar, the concepts of diversity and fair access can be broadened in both nations to include less visible forms of diversity such as religious beliefs or sexual orientation.5
To attain the goal of broadened diversity in student selection practices, the academic medicine community requires a comprehensive understanding of the current social diversity in the medical student population. Knowing the full range of diversity in current medical student classes can inform further investigations into the role of admissions processes and how they promote or hinder greater diversity in the medical student population. In comprehensively surveying the diversity of the medical students at four Canadian medical schools, the results of which we report in this paper, we propose a broadened conceptualization of diversity, including both surface (visible) and deep (less visible) diversity dimensions. We define surface diversity as characteristics that are typically discernible when meeting someone and/or that are divulged in census-taking efforts such as age, gender, self-identified ethnicity, languages spoken, and Aboriginal background. We define deep diversity as aspects of difference that may be less visible or hidden, including self-identified religious practices, rural background, sexual orientation, gender identity, personal and parental socioeconomic status, exposure to diverse groups prior to application, and diversity of experience and occupations prior to application to medical school. Such a conceptualization will allow for the analysis of the intersections of the dimensions of diversity, and for an investigation into how both surface and deep diversity may relate to barriers to entry into medical school that are experienced by groups underrepresented in medicine. In the context of supporting the creation, maintenance, and monitoring of Canadian-specific diversity data, and supporting a broadened conceptualization of diversity, we present (1) initial diversity data from nine medical student cohorts from four Canadian medical schools along both surface and deep diversity dimensions, and (2) suggestions regarding policies relevant to diversity—especially the creation of a national database of diversity—and the relevance of these policies within the Canadian context.
We invited all students (total n = 1,892) registered in nine cohorts across four participating Canadian medical schools (McGill University, McMaster University, University of Ottawa, and University of Toronto—all of which have unique admissions procedures and are in Central Canada) to participate in the Health Professions Student Diversity Survey (HPSDS). At two institutions, participants completed a paper-and-pencil version of the HPSDS; one of these schools invited participants on registration day, and the other invited participants during a full-class lecture. The remaining two institutions invited participants to complete an online version of the HPSDS via an e-mail from the local admissions or undergraduate medical education office. At one institution, the HPSDS was available online for four weeks, and students received two e-mail reminders; at the other institution, the HPSDS was available online for four weeks, and students received three e-mail reminders. Seven of the nine surveyed cohorts comprised first-year students, one cohort comprised second-year students, and the remaining cohort comprised students in their final (third) year. Each university’s local institutional research ethics board granted approval for this study. All participants gave informed consent.
The HPSDS was first developed and implemented at McGill University in 2009. The McGill University Faculty of Medicine Office of Admissions developed and piloted the survey tool through a process of stakeholder consultations. The major stakeholders included the Admissions Executive Group, Medical Student Governance, and the Social Equity and Diversity in Education Office at McGill University. The HPSDS was designed to assess the diversity of the medical student population with respect to visible diversity dimensions (age, gender, ethnicity, language[s] spoken, self-identified Aboriginal status), less visible diversity dimensions (gender identity, sexual identity, rural status, marital status, disabilities or limitations, religious beliefs, personal and parental income, work and education history, living situation), exposure to and experience with various minority groups, perspectives on diversity, and factors that influenced medical school selection. The survey tool presents a range of response options for each dimension of diversity (e.g., “less than 18,” “18 to 20,” etc., for age; and “heterosexual,” “gay,” “lesbian,” “bisexual,” etc., for sexual identity [see Table 1]). Wherever possible, specific items on the HPSDS, including wording and response options, were constructed to parallel relevant or similar items used in publicly available nationally representative data sources (2006 Canadian Census,31 2007 National Physician Survey,22 and the 2011 Canadian Medical School Graduation Questionnaire).32 A copy of the HPSDS is available on request.
For the purposes of this report, and because of length restrictions, we present only responses to the survey items regarding age, gender, gender identity, sexual identity, marital status, ethnicity, rural status, parental income, and self-reported disabilities. We will report our analysis of responses regarding religious beliefs, living situation, and exposures to, experience with, and perspectives on diversity and diverse populations in other upcoming reports upon completion of more in-depth qualitative analysis.
We invited students to participate either in person or via e-mail invitation between 2009 and 2011. The survey was available in both French and English at three institutions and in only English at the University of Toronto. Participants were free to answer only the survey items that they wished, and we imposed no penalty for either skipping questions or not completing the survey. We assured all participants of the confidentiality of their data and that their responses would have no bearing on their status at their institution.
At two institutions, no identifying information was collected, and anonymous data were shared with the lead researcher (M.E.Y.). Two institutions offered the possibility of a prize for survey participation, so at those schools survey administrators collected personal identifying information only for the purpose of selecting prizewinners. Subsequent to selecting and contacting the prizewinners, a research administrator removed all identifying data, and then only these deidentified data were shared with the lead researcher (M.E.Y.).
We collapsed data from all participating institutions for the purposes of analysis; however, we maintained the regional identity of the institutions in order to compare our data, where appropriate, with regional-specific data (i.e., metropolitan census data regarding ethnic composition). The majority of analyses were primarily descriptive; however, where possible, we made comparisons with nationally available data sources (see Discussion). Our comparisons with nationally relevant data sources were also primarily descriptive; the only exceptions were ethnicity and income data. We conducted the analyses for ethnicity and income using proportional over- or underrepresentation in order to contextualize our HPSDS results as comparisons with the overall population. We conducted all descriptive analyses and comparisons using Microsoft Excel (2007, Redmond, Washington).
Of the 1,892 medical students whom we invited to participate, a total of 1,552 (82.0%) completed the HPSDS. Response rates across cohorts and across institutions varied. Response rates varied from 63% to 100% across the cohorts at the two schools where students took the paper survey, and response rates varied from 61% to 87% across the cohorts at the two schools where students took the online survey.
We present highlights of our survey results below, and we provide the full results, including the numbers and percentages of students endorsing select response items, where available, in Table 1.
The most common response to the question regarding participants’ age was 21 to 25 years old (68.3%; 1,048/1,534).
Given the three response options—“female,” “male,” or “I do not identify as either male or female”—59.0% of the 1,529 students responding to this item identified themselves as female (n = 902), 40.9% (626) identified as male, and 1 student identified as neither male nor female (0.06%).
Nearly all of the students (99.8% 1,512/1,515) answered positively to the question “Does your gender identity correspond with the sex on your original birth document (e.g. birth certificate)?” Three participants (0.2%; 3/1,515) responded, “No.”
Most of the participants (94.6%; 1,422/1,503) responding to the question regarding sexual identity report identifying as uniquely heterosexual, meaning that 5.4% of respondents (81/1,503) identify as nonuniquely heterosexual.
In response to the question “What is your current marital status?” 90.1% of the participants (1,369/1,520) reported being single (never legally married).
In response to the question “With which of the following groups do you most strongly identify as (select all that apply)?” the majority of students (56.2%; 840/1,495) selected white/Caucasian, and 6.7% of respondents identified with more than one group (104/1,495).
About half of the 1,521 students responding to the item “Please select the word which best describes the area where you have lived for most of your life” selected “urban” (46.7%; 711). Less than half (42.8%; 652) reported spending most of their lives in suburban environments, and a smaller minority (10.4%; 158) reported spending most of their lives in rural environments.
The most common response to the item “Regardless of your dependency status, please select your parents’ or guardians’ combined gross income for last year” was a parental income of between $100,000 and $249,999 per year (38.7% of respondents; 531/1,373). A majority of the responding medical students (57.6%; 791/1,373) reported parental household incomes of over $100,000 per year.
Fifty-three students (3.50% of 1,516) answered “Yes” to the question “Do you have a participation or activity limitation that has an impact on your day-to-day life?” and 55 students identified a participation or activity limitation for the question “If Yes, what type(s) of condition(s) do you consider yourself to have (select all that apply).”
We found that the medical students who responded to our survey were variably representative of the Canadian population with respect to the diversity dimensions we examined. The group of medical students in our sample tended to be between the ages of 21 and 25 (68.3%), and most (59%) were female. The vast majority identified with the gender on their birth certificate (99.8%), were heterosexual (94.6%), and reported being single (90.1%). Most spent the majority of their lives in either an urban (46.7%) or suburban environment (42.8%), and a majority came from families with reported parental household incomes of over $100,000 per year (57.6%). A small minority (3.5%) reported any disability.
Comparison of survey findings to national Canadian data
Few relevant representative data are available for medical student age, marital status, or the proportion of the Canadian population who do (or do not) identify with the gender on their birth certificate. Therefore, we do not present an analysis of the data collected in the HPSDS compared with national sources for these diversity dimensions. However, below we examine how our survey results compare to those of other surveys of populations in Canada (and, in two cases, the United States).
Gender. The increased representation of female students is not unique to our sample, as the proportion of Canadian graduating medical students (as measured by the 2011 Canadian Medical School Graduation Questionnaire)32 is nearly identical (40.4% males and 59.6% females) to our results.
Sexual identity. To compare our respondents’ reported sexual identity with that of Canadians overall, we used the 2003 Statistics Canada “Canadian Community Health Survey,” which estimates that roughly 2% of the population of Canada is gay or bisexual33 (with typically higher concentrations in urban compared with rural areas)34; however, other estimates range as high as 8% of the 18- to 34-year-old population in the United States.35 We have no reason to believe that these estimates would differ significantly for the Canadian population. We have been unable to locate more specific or more recent nationally representative data regarding nonheterosexual sexual orientations. Despite this, in comparison with the available data sources, fewer than anticipated students are reporting nonuniquely heterosexual orientations, suggesting either that nonheterosexual orientations are underrepresented or that participants were not comfortable reporting a sexual orientation other than heterosexual on this institutionally conducted survey.
Ethnicity. Participants who responded to the HPSDS were less likely to report Aboriginal, black, and Filipino ethnicities than would be expected based on Canadian population share. Figure 1 shows the proportional underrepresentation of the responding medical students compared with Canadian census data for the relevant metropolitan, provincial, and national regions.31
Rural background. The Canadian census defines “rural” as towns of fewer than 1,000 people and having an urban density of less than 400 people per square kilometer.36 Using this definition, the Canadian census reports that 20% of individuals identify as living in rural environments.37 Considering this stringent definition, we believe that some of our participants who self-reported spending most of their lives in rural environments would not be considered “rural” by the census. Nonetheless, 10.4% of our respondents, using a self-defined concept of rural, did report spending most of their lives in rural environments, compared with 20% of the national population under the Canadian census definition. Rural students are clearly underrepresented, especially given the likelihood that our findings overestimate the number of medical students with rural backgrounds as defined by the Canadian census.
Parental income. We compared the distribution of our respondents’ parental (or household) income with nationally representative data. Figure 2 shows the proportional underrepresentation of respondents’ parental income (by income category) to relevant metropolitan, provincial, and national census data.38 The majority of participants (57.6%) report parental household incomes of over $100,000 per year—significantly more than the median after-tax income for a household in Canada, which is $56,584.39
Disability. We were unable to find nationally representative data regarding the relative and absolute frequency of disability within the Canadian population. Although data from another nation may not be directly comparable, previous U.S. Census Bureau data show that the national disability rate in the United States was 19.4% overall and 13.6% for adults between the ages of 18 and 44, an age range that may be more directly comparable to our medical student population.40 Because only about 3% of our respondents reported having a disability, persons with disabilities are also likely underrepresented in the medical school population.
Implications and recommendations
The Future of Medical Education in Canada Collective Vision7 posits that, to best serve the various health care needs of society, a diverse physician population is necessary. Further, research showing the positive influences of diversity on the educational environment and individuals’ intentions to serve traditionally underserved areas supports the Committee on Accreditation of Canadian Medical School’s and the Liaison Committee on Medical Education’s accreditation criteria aimed at fostering diversity. For example, research indicates that individuals from rural environments are more likely to return to practice in rural environments,41–45 that physicians who self-identify as Aboriginal are more involved in care of Aboriginal patients,46 and that physicians from low socioeconomic backgrounds are more likely to treat patients from lower socioeconomic areas.10 Notably, the underrepresented groups in our surveyed medical students, including Aboriginal peoples and those of lower socioeconomic backgrounds, represent the populations with typically worse health outcomes.47–49 Our findings show that, despite recommendations, proven benefits, and ongoing health care needs, Canadian medical schools may be falling short of preparing a workforce adequate for the diversity of its population.
Traditionally, Canada’s local political, historical, and cultural contexts have contributed significantly to the identification of underrepresented groups in Canada, and the findings reported here, especially those in relation to the age, gender, and socioeconomic status of medical students in Canada, do not differ dramatically from what has historically been reported.23,50 Although a range of strategies to improve representation of some populations (i.e., Indigenous peoples, francophone Canadians, and rural students) are in place, we believe that both a complementary, data-driven examination of the success of these strategies and an assessment of the current diversity of Canadian medical school classes would be relevant and add value in the context of equity. The careful examination of the dimensions of diversity (surface and deep) and of the intersection between these dimensions is relevant at the national level; however, this examination can be particularly relevant for individual medical schools as they form policy that reflects their individual political, historical, and local needs. As an example, prior to this survey, we had limited data to encourage the development of policies targeted at supporting applicants and students from lower socioeconomic strata at our schools. Our survey allowed us to realize that this population is clearly underrepresented and that, going forward, our schools should closely monitor the number and proportion of students with lower socioeconomic backgrounds.
Our findings suggest that the monitoring of not only surface—but also deep—dimensions of diversity may assist medical schools and policy makers in gaining a richer understanding of diversity issues relevant to their particular contexts. For instance, we were somewhat surprised to learn that Filipino Canadians are underrepresented at the medical schools included in this study. We believe that Filipino ethnicity can be seen as somewhat hidden, in that it may be subsumed into the Asian identity by less sophisticated applications of classification. Appreciating this reality has allowed us to speculate on the very different patterns of immigration for Filipino Canadians in comparison with those of other visible minority groups.51 As we follow this trend in the future, data may support the development of policy specifically targeted to this group.
Similarly, our data may support the development of policies to support people with disabilities and people with nontraditional gender and sexual identities. It is difficult to determine whether our survey respondents who provided nontraditional responses (i.e., those who do not identify with the gender on their birth certificates, who reported nonuniquely heterosexual identities, and who report a disability) are representative, as little information about this population in Canada is available at the national level. Nonetheless, those with nontraditional gender and sexual identities and those with disabilities may be underrepresented. Whether these populations are truly underrepresented, or whether respondents were uncomfortable reporting nontraditional responses on an institutionally administered survey, is unclear. What is important is that the responses, whether they point to underrepresentation or underreporting, can provide important insights into admissions procedures and institutional environments. These insights, in turn, provide the opportunity to reflect on whether the institution creates a safe environment—from application to graduation and beyond—for individuals to openly identify sensitive aspects of their identities.
Our data represent only those who volunteered to participate from 4 of 17 Canadian medical schools and are, thus, not generalizable to the entire population of medical students in Canada. Even so, we believe that these data support the need to create a National Student Diversity Database. A national database would facilitate the monitoring of traditionally underrepresented groups within undergraduate medicine, aid the evaluation of pipeline programs, enable school-specific community outreach, and allow for the investigation of how admissions procedures influence the inclusion of traditionally underrepresented groups within undergraduate medicine. We should reiterate that the data presented here represent only the initial collection of this kind of data in Canada, and we hope that this will form the base for a more nationally representative initiative. Additionally, such an initiative may highlight national needs, just as our findings showing the underrepresentation of students from rural backgrounds suggest that the shortage of physicians in Canadian rural areas52,53 is not likely to improve in the near future.41–45
Although we firmly support the ethical collection, maintenance, and interpretation of diversity-related data, we recognize that many issues surround the interpretation of these data and their use in the development of policy. For example, addressing underrepresentation through the initiation of quota-based class cohorts has been controversial.54,55 Seeking to address the representational diversity of our medical classes comprehensively will likely require a combination of approaches, all of which will need to be not only conducted in partnership with the communities they aim to help but also supported by nationally representative data.
Our research team recommends, in addition to the creation a national database of diversity-related data, that information similar to what we have presented here should be collected and interpreted within the local context of each individual medical school. We recognize that these data will remain politically fraught and that the underlying intersections of diversity (surface and deep dimensions) remain a difficult area to disentangle. Nonetheless, we recommend using data on both surface and deep dimensions of diversity for local policy development. Our HPSDS represents a survey model that can be adapted and adopted by other medical schools across Canada. Further, we encourage the sharing of diversity data among medical schools. The creation and maintenance both of a national database and of local depositories of diversity-related data will foster a national discourse regarding diversity as well as the analysis of school-specific policies and their ramifications.
Although we did not investigate whether diversity differs across institutions that employ a variety of admissions procedures, we believe that doing so is an important area for future research. Current application to medical training programs in Canada and the United States is a highly competitive, high-stakes process as large numbers of students apply and vie for a much smaller number of positions. The nature of this competition has intensified, and previous research suggests that this process has created a hidden curriculum56,57 wherein certain activities, occupations, and histories carry a different value or weight. Some of the expectations or biases may favor applicants from advantaged groups and limit the opportunities of applicants from less advantaged, or traditionally underrepresented, groups. For example, valuing volunteerism may inadvertently disadvantage applicants from lower socioeconomic strata for whom taking nonpaid employment is not possible.
Although selection practices for entry into medical school currently differ by institution, they often rely heavily on indices of academic achievement, including grade point average and MCAT scores, that are often praised for their reliability and validity.58 As such, some potential applicants resort to high-priced preparation courses, even with limited evidence of their efficacy.59,60 McGaghie59 has proposed that the test preparation industry has transformed the attainment of a medical education into a commodity for purchase instead of one of professional aspiration and success earned through work and study. Of course, only some applicants will have the financial resources to invest in a course or in some of the other commodities available, such as professional consultants who are available for hire to assist potential students through application preparation.61 Further activities emblematic of leadership and service are often sought for the building of resumes; these activities, as described by Karabel,62 attest to the social and financial capital expended by some families to influence the admissions process. Financial influence has clearly entered the medical school application process. The ability to harness available resources may give those who can afford them an advantage—unintended or not—which may lead to an unequal playing field for traditionally underrepresented groups. Yet, despite these challenges to diversity, admissions-related research has been dedicated to developing reliable and valid admissions tools with little attention to finding and eliminating the potential sources of subtle bias that may be present within and which may affect medical admissions processes.63 We therefore recommend that the national diversity database we have suggested herein also collect and maintain data related to the diversity of medical applicants, not solely matriculated medical students.
The academic medicine community should better understand and conduct research to illuminate the best procedures for (1) benchmarking and monitoring diversity and (2) identifying and eliminating potential barriers to both surface and deep diversity in regional, cultural, and historical contexts. These goals can be achieved only through the rigorous and nationally supported collection of relevant data.
Acknowledgments: The authors would like to thank all of the students who participated in this study. The authors would also like to thank Katharine Fischer and Maureen O’Connor for their help with data entry and preparation.
Other disclosures: None.
Ethical approval: Ethical approval for this study was granted by the McGill University research ethics board, the University of Toronto research ethics board, the University of Ottawa Hospital research ethics board, and the McMaster University research ethics board.
Previous presentations: Components of these data were previously presented at the 2011 Canadian Conference for Medical Education, the 2011 AIME Research Day, and the October 2011 meeting of the Canadian Council of Deans.
* Indigenous is the term preferred by the Indigenous Physicians Association of Canada (IPAC) and the term preferred by most Indigenous groups; however, Aboriginal is the Canadian Census terminology for Indigenous groups (as Native American is the census term in the United States). Please note that the authors have used both terms in this report. They have attempted to use Indigenous except when referring to a census category or to published materials that specifically used the term Aboriginal.
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