Indigenous peoples (First Nations people, Inuit, and Métis) represent approximately 4.3% of the Canadian population, with one in five Indigenous persons residing in the province of Ontario.1 Indigenous peoples typically have poorer access to health care and poorer health status than non-Indigenous peoples in Canada.2,3 Increasing the number of Indigenous physicians may address these gaps and improve access to culturally appropriate health care.4–6 The number of Indigenous medical students in Canada, however, is six times below what would be expected based on the size of the country’s Indigenous population.7 A 2009–2011 survey of medical students from four Canadian medical schools reported that 0.9% self-identified as Indigenous.8 Some of the known barriers to increasing the number of medical students (and ultimately physicians) of Indigenous background in Canada are the small number of Indigenous applicants to medical schools and Indigenous applicants’ lower academic grades and rates of university degree attainment.6,9,10
The underrepresentation of Indigenous peoples in medical education is of particular concern for the northern and rural regions of Canada, which have a higher percentage of Indigenous peoples than other areas of the country.1 Northern Ontario School of Medicine (NOSM), which admitted its first cohort of students in 2005, was created as part of the Ontario provincial government’s efforts to respond to the need for doctors in northern, rural, francophone, and Indigenous communities.11 NOSM’s admissions goals are to select the applicants most suited to the medical profession, who will be most likely to practice family medicine in the region, and who, as an incoming class, reflect the overall demographics of Northern Ontario,12,13 including Indigenous peoples, who represented more than 12% of the Northern Ontario population in 201114 (and about 17% in 2016).15
The development of socially accountable admissions policies that are “open, transparent, and fair”16 was achieved at NOSM through a consultative process that engaged admissions faculty and personnel from all six of the already-existing Ontario medical schools; human rights professionals; public representatives of Northern Ontario’s rural, Indigenous, and francophone communities; and rural physicians. The key admissions innovations at the time of the school’s development (e.g., multiple mini-interview [MMI], a rurality index, graduated weighting of grade point averages [GPAs]) and other admissions requirements (e.g., Medical College Admission Test [MCAT], premedical course work, demographics) were carefully considered in light of their potential impact on the selection of candidates from the school’s service region.16How the NOSM’s admissions elements emerged in that process, as well as the challenges faced and lessons learned, have been described in detail elsewhere.16
In this Research Report, we examine NOSM’s admissions process as it relates to the fulfillment of the school’s social accountability mandate with regard to Indigenous peoples. In 2006–2015, publicly available data had showed that the representation for admitted applicants was achieved for northern, rural, and francophone populations in all NOSM incoming classes, but was not fully achieved for the Indigenous population.17 Only 6.7% (41/610) of admitted students were self-identified Indigenous in 2006–2015.17 This percentage was 1.8 times below what would be expected based on the estimated size of the region’s Indigenous population in that period. In this study, we describe the admissions process and outcomes for Indigenous applicants to NOSM, using data on their demographic characteristics, academic (e.g., GPA) and nonacademic (e.g., MMI) scores, and progression through major stages of the admissions process.
There is little empirical research on admission of Indigenous applicants to Canadian medical schools, particularly schools that serve specific geographic and cultural minority populations and seek to address the underrepresentation of these populations in medicine.9,18–21 The role of medical school admissions in overcoming barriers for Indigenous applicants is also not well documented in the literature.22 According to a recently published scoping review, the literature that connects medical school admissions and their social mission outcomes is more aspirational than evidence based.23 This study seeks to address this gap in the literature with an empirical analysis of how NOSM, the first Canadian medical school with an explicit social accountability mandate, improved its admissions process and outcomes for Indigenous students so that their representation in incoming classes reflected the demographics of the school’s service region.
The NOSM admission requirements are the same for Indigenous and non-Indigenous applicants. The minimum GPA is a 3.0 on the 4.0 scale.24 The MCAT is not required for any applicant because of potential concerns about the validity of the test for Indigenous or francophone applicants and the cost and additional expenses to access testing sites for applicants from northern and rural communities.16 The admissions process is enhanced with an Indigenous stream (see below) to facilitate applications from Indigenous candidates. About 90% of self-identified Indigenous applicants apply through the Indigenous stream, which requires a personal letter declaring Indigenous ancestry and a recommendation from the applicant’s First Nation, Band Council, Tribal Council, Treaty Community, or organizational affiliation. The Indigenous Admissions Subcommittee—chaired by an NOSM Indigenous faculty member and composed of Indigenous practicing physicians, students, and community representatives—reviews these documents.25 NOSM also has an Indigenous Affairs Unit, which is responsible for relationships with Indigenous peoples and communities.26 This unit coordinates pipeline activities with Indigenous youth to increase the number of Indigenous qualified applicants and provides interview (i.e., MMI) preparation support to Indigenous applicants.
To promote selection of applicants from specific population groups for interviews, NOSM developed context scoring,27 a point system based on each of the following geographic or cultural criteria: (1) rural background based on years lived in rural community that is defined using the Statistics Canada classification of communities by population size and degree of influence from metropolitan areas28; (2) northern background based on years lived in Northern Ontario or another Canadian northern region; and (3) self-identified Indigenous or francophone background. An automated system calculates the score for each applicant. The scoring algorithm may undergo changes between admissions cycles (e.g., to adjust the threshold for rural or northern exposure according to the Statistics Canada Census); however, the individual applicant’s context score is not altered during the admission cycle (excluding cases where, for example, the Indigenous Admissions Subcommittee is unable to confirm the applicant’s self-identified Indigenous status).
In addition to the context score described above, a preinterview score also consists of the applicant’s GPA and a community involvement score based on the autobiographical essay. The total preinterview score is the sum of these three scores, each weighted at about one-third.27 NOSM uses the MMI, developed at McMaster University,29 for interviews to assess applicants’ communication skills, critical thinking, ethical decision making, and suitability for the medical profession.30 The MMI format, in which trained raters evaluate applicants’ performances on a series of 10 brief, timed, structured stations,31 was chosen because of its potential ability “to level the playing field for applicants with varying abilities for self-promotion.”16 The choice of applicants who will receive an admission offer is based on the final score (the sum of the preinterview and MMI scores, which are equally weighted) and a complete file review by the Indigenous Admissions Subcommittee.
Description of data
Researchers from the Centre for Rural and Northern Health Research (J.C.H., O.M.) obtained 10 years (2006–2015) of deidentified person-level admissions data from NOSM through a comprehensive agreement ensuring confidential and secure use of the data. Data included applicants’ admission scores (i.e., GPA, preinterview, MMI, and final scores), demographic characteristics (i.e., age, sex, rural and northern backgrounds, and Indigenous status), and final application status (i.e., disqualified, qualified, declined interview, interviewed, declined admission offer, or admitted to NOSM). Indigenous self-identified status was assigned upon confirmation from the Indigenous Admissions Subcommittee. Following NOSM’s practice, we categorized age as young (less than 25 years old) or mature (25 years or older). Rural and northern backgrounds were defined according to NOSM’s context scoring system. We assigned rural background (yes or no) based on living the defined number of years in communities with a population below a certain size (per the most recent Statistics Canada Census). We assigned northern background (yes or no) based on living the defined number of years in communities within the 12 Northern Ontario census districts (see Table 1 for a list of these districts) or in the Canadian Northwest Territories, Nunavut, or Yukon.
We examined 10-year trends in admission rates, calculated as the percentage of qualified applicants admitted to the program, and percentage of Indigenous applicants among all applicants at the following admissions stages: qualified, interviewed, received admission offer, and admitted to NOSM. We compared age, sex, and northern and rural backgrounds of Indigenous and non-Indigenous applicants using Pearson chi-square tests. For each applicant, we computed ranks according to each admission score (the highest rank in each cohort was 1 and the lowest rank was equal to the total number of applicants in that cohort). We used Mann–Whitney tests to compare the applicants’ admission-score-based ranks. We used binary logistic regression to assess the relationship between Indigenous status and the likelihood of interview, receiving an admission offer, and being admitted to NOSM, controlling for age, sex, northern and rural backgrounds, and standardized (i.e., z score) preinterview and, when appropriate, MMI scores calculated by cohort year. We used SPSS Statistics for Windows (version 20.0, IBM Corp., Armonk, New York) for all analyses.
This study was approved by the Laurentian University and Lakehead University Research Ethics Boards and was compliant with the Tri-Council policy statement guidelines on conducting research involving Indigenous peoples. The chair of NOSM’s Indigenous Admissions Subcommittee reviewed this manuscript for the relevant Indigenous content.
Of the 19,720 total applicants to NOSM in 2006–2015, 438 (2.2%) were Indigenous. Among all applicants, a total of 17,060 (86.5%) were qualified for admission; 1,622 (8.2%) were disqualified because of a GPA lower than 3.0, and 1,038 (5.3%) were disqualified because of incomplete documentation (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A640). The percentage of those disqualified because of low GPA was 16.2% (71/438) among Indigenous applicants, which was significantly greater (P < .01) than the percentage (8.0%; 1,551/19,282) among non-Indigenous applicants. Incomplete documentation disqualified 6.6% (29/438) Indigenous and 5.2% (1,009/19,282) non-Indigenous applicants.
Of the 17,060 total qualified applicants, 338 (2.0%) were self-identified Indigenous. Indigenous qualified applicants were more likely to be mature (25 years or older), female, or of northern or rural background than non-Indigenous qualified applicants (P ≤ .01, Table 1). A higher percentage of Indigenous mature applicants persisted among applicants who were interviewed and admitted to NOSM. The percentage of Indigenous applicants with a northern background increased 1.5 times from the qualified pool (48.2%; 163/338) to the admitted (incoming classes) pool (70.7%; 29/41), and for non-Indigenous northern applicants the percentage increased 5.2 times (qualified pool: 17.4% [2,908/16,722] vs. admitted pool: 91.0% [518/569]). Thus, Indigenous admitted students were less likely to be from the north than non-Indigenous admitted students (P < .001). The percentage of Indigenous rural applicants changed very little between admission stages, with 44.4% (150/338) in the qualified pool and 41.5% (17/41) in the incoming classes. In contrast, the percentage of non-Indigenous rural applicants increased almost twofold from 20.4% (3,419/16,722) in the qualified pool to 36.9% (210/569) in the incoming classes. The percentage of females was not significantly different between Indigenous and non-Indigenous admitted students.
Admission trends: 2006–2015
From 2006 to 2015, a total of 41/338 (12.1%) Indigenous and 569/16,722 (3.4%) non-Indigenous qualified applicants were admitted to NOSM (Figure 1). The annual admission rate fluctuated between 8.7% and 15.6% for Indigenous applicants (except as noted below) and between 2.6% and 4.0% for non-Indigenous applicants. In 2010, there was a high admission rate of 5/19 (26.3%) among Indigenous applicants because of the lower number of Indigenous qualified applicants that year.
The percentage of self-identified Indigenous applicants at each major admission stage showed yearly fluctuations (Figure 2). The smallest fluctuation of 1.2 percentage points was found among qualified applicants (between 2.5% in 2015 and 1.3% in 2010). The largest fluctuation of 9.7 percentage points was among those who received an admission offer (between 14.8% in 2014 and 5.1% in 2006). Among students admitted to NOSM in 2006–2015, 6.7% were Indigenous students (minimum of three and maximum of five students). This was similar to what was known previously via publicly available data.17
Indigenous applicants at major admission stages
Of the 17,060 total qualified applicants, 3,809 (22.3%) were invited to an interview; of these, 290 were Indigenous applicants. The percentage of applicants invited to interview was higher among Indigenous (85.8%; 290/338) than non-Indigenous applicants (21.0%; 3,519/16,722). We found no significant difference between Indigenous and non-Indigenous applicants in the rate of declining an interview (overall rate: 104/3,809 [2.7%], P = .44). Overall, the percentage of Indigenous qualified applicants who were interviewed (82.8%; 280/338) was 4 times greater than the percentage for their non-Indigenous peers (20.5% [3,425/16,722], P < .001). Percentages of those who received an admission offer after being interviewed were closer, but still significantly different: 28.6% (80/280) of Indigenous versus 20.1% (689/3,425) of non-Indigenous applicants (P = .001). The pattern was reversed at the next stage, with only 51.3% (41/80) of Indigenous applicants accepting the admission offer compared with 82.6% (569/689) of non-Indigenous applicants (P < .001).
Indigenous applicants had lower GPA-based ranks than non-Indigenous applicants throughout all major admission stages (P < .001, Table 2). They ranked significantly higher on preinterview scores at the initial qualified stage (P < .001) but not at other admission stages (P ≥ .20). We did not find any statistically significant differences in MMI-score-based ranks between Indigenous and non-Indigenous applicants (P ≥ .16). Final-score-based ranks of Indigenous and non-Indigenous applicants were not different among those who were interviewed (P = .45) but were higher for non-Indigenous than Indigenous applicants who received an admission offer (P = .03) or were admitted (P = .06).
Likelihood of interview, admission offer, and final admission for Indigenous applicants
After adjusting for age, sex, northern and rural backgrounds, and preinterview- and MMI-score-based ranks, Indigenous applicants were 2.4 times more likely to be interviewed and 2.5 times more likely to receive an admission offer than non-Indigenous applicants (Table 3, model 1 and 2). However, Indigenous applicants were 3 times less likely to accept an admission offer than non-Indigenous applicants (adjusted odds ratio [OR] = 0.3, P < .001) (Table 3, model 3). Northern background was a strong factor throughout all admission stages. For example, northern applicants were 3.5 times more likely to be interviewed and 5 times more likely to accept an admission offer than their non-northern peers. Additional analysis also indicated that northern applicants were more likely to accept an admission offer than non-northern applicants. For example, among non-Indigenous applicants, 518/612 (84.6%) northerners accepted the admission offer compared with 51/77 (66.2%) non-northerners (P < .001). This difference was larger among Indigenous applicants, with 29/40 (72.5%) northerners versus 12/40 (30.0%) non-northerners accepting an admission offer (P < .001). Rural applicants were 2 times less likely to be interviewed than urban applicants (adjusted OR = 0.5, P < .001) and 1.4 times less likely to receive an admission offer than urban applicants (adjusted OR = 0.7, P < .01). Mature applicants were less likely to receive an admission offer (adjusted OR = 0.6, P < .01) but almost 2 times more likely to accept it (adjusted OR = 1.8, P = .01) than younger applicants. Sex was not significantly associated with the likelihood of interview, admission offer, or acceptance of offer.
Our analysis showed that in 2006–2015, NOSM was admitting higher percentages of Indigenous qualified applicants than non-Indigenous qualified applicants and has achieved a higher representation of Indigenous students (6.7%) than other Canadian medical schools (less than 1%).6,7 These results may be attributable to a combination of factors, including NOSM’s admissions selection criteria (e.g., the use of context scoring and MMI), outreach programs for Indigenous high school students applying to medical school, and involvement of the Indigenous Admissions Subcommittee throughout the admissions process. All other characteristics being equal, Indigenous applicants were 2.4 times more likely to be interviewed; we believe this was a direct outcome of NOSM’s context scoring ensuring that as many qualified applicants from this underrepresented population as possible were selected for interview.
After interviews (again with all other characteristics being equal), Indigenous applicants were 2.5 times more likely to be offered admission than non-Indigenous applicants. Considering our study findings, we suggest that this was possible because of comparable MMI scores between Indigenous and non-Indigenous applicants as well as the continuing effect of context scoring.
The percentage of Indigenous students in 2006–2015 was almost two times below the NOSM’s admissions target of 12% based on the size of the Indigenous population in Northern Ontario. Our study also showed that Indigenous applicants were 3 times less likely to accept the admission offer than non-Indigenous applicants and that 70% of admission offers to Indigenous non-northern applicants were declined. On the basis of these findings, NOSM has adjusted the context scoring points for northern background for Indigenous applicants; this has resulted in further increases in the representation of Indigenous students in 2016 and 2018 (12.5%; 8/64) and 2017 (10.9%; 7/64).32 Our findings of a lower likelihood of rural applicants being interviewed and receiving an admission offer warrant further study to determine whether there are barriers that impede admission of Indigenous rural applicants to NOSM.33
Compared with non-Indigenous applicants, a higher percentage of Indigenous applicants were not qualified for admission because their GPA was below 3.0. Further, mean GPA-based ranks of Indigenous applicants were statistically significantly lower than that of non-Indigenous applicants at all admission stages. This may be due to educational barriers, institutionalized discrimination, and dominant-society biases in the assessment of educational performance of Indigenous peoples.34 In contrast, mean MMI- and final-score-based ranks of Indigenous applicants were not significantly different from those of non-Indigenous applicants. This finding agrees with other studies showing that MMI scores did not correlate negatively with minority status and that the MMI format did not create an additional barrier to applicants from underrepresented in medicine populations.35–37 Among Indigenous applicants, there was a higher percentage of mature or female applicants, who tend to perform better on MMIs than younger or male applicants, and this may, in part, explain why MMI scores of Indigenous applicants were competitive with non-Indigenous applicants.9,38
Our results suggest that the MMI may be useful in counteracting lower GPA scores of minority applicants and promoting diversity in undergraduate medical education. In addition, there is evidence that strong MMI performance is related to strong academic performance during medical school.39 However, we agree with some researchers who have concluded that the use of MMI can only go so far to increase the diversity of medical school matriculants because of the paucity of applicants from lower incomes or smaller communities.9 This is also true for Indigenous applicants. Further development of pipeline programs and efforts to reduce gaps in educational attainment between Indigenous and non-Indigenous peoples are needed to increase the pool of Indigenous qualified applicants.
One of the challenges of the medical school admissions process is to determine which applicants “who faced educational and socio-economic disadvantages” during their premedical education would achieve the “academic competency expected of medical students.”40 An Australian study found that poorer academic performance in students with a rural or remote hometown versus those in metropolitan areas correlates with poorer performance in the early years of medical school but not during later years.41 These findings support the use of context scoring to overcome potential disadvantages in preadmission academic achievements for rural applicants.
Our findings indicate that at NOSM, representation of Indigenous applicants increased 3.4 times from the qualified pool (2.0%) to the incoming classes (6.7%) in 2006–2015. For a comparison, data for the same time period from the University of Manitoba, a Canadian university with an explicit goal to attract and retain Indigenous students,42 indicated a 1.8-fold increase in representation of Indigenous applicants in the incoming classes, compared with the qualified pool, from 3.4% (156/4,556) to 6% (66/1,076).43 These numbers provide evidence for the role of medical school admissions in increasing the representation of Indigenous peoples among admitted applicants. Future research based on comparable data and standard definitions across medical schools would help to assess the success of different admissions processes. This area represents an important focus for future study, given the paucity of published research about admissions outcomes for Indigenous applicants to Canadian or U.S. medical schools.8,23
Our research was based on data from one Canadian medical school, which currently accepts 64 students per year. Using a 10-year span of data, standardized scores, and score-based ranks, we adjusted for year-by-year fluctuations to make meaningful comparison over the years. The relatively small number of Indigenous northern or rural applicants restricted our analysis of the interaction among factors that may influence admissions rates for these subgroups. Nonetheless, our research provides evidence of how a focused admissions initiative has had a positive impact on the representation of Indigenous peoples at one medical school. Some may consider the support given to Indigenous applicants to NOSM unfair to non-Indigenous applicants.16,19 However, when assessed from the lens of society’s needs and the medical profession’s and medical education’s core values of social responsibility and accountability, the benefits of socially accountable admissions processes (such as the one at NOSM) are recognized as consistent with social justice.4,44
Importantly, NOSM does not have a separate admissions process for applicants from underrepresented populations such as quotas or affirmative action programs. The support of Indigenous applicants at early admission stages (e.g., via the use of context scoring) explicitly adjusts for known systemic bias (e.g., lower GPAs) by leveling the playing field for these applicants so that they can compete with peers in all other aspects relevant to the medical profession. There is strong evidence that medical students from disadvantaged backgrounds tend to practice in underserved communities22,45,46 and that medical student diversity and health care access for underserved communities are “inextricably” connected.5 Thus, reflecting the demographics of NOSM’s service region in incoming classes is important not only as an ethical and fair goal but also as a long-term policy for improving access to health care and, ultimately, the health of Indigenous peoples. Further tracking of Indigenous students through medical education and practice may help assess the effectiveness of NOSM’s social accountability admissions process. For example, research is under way on how NOSM students perform throughout undergraduate medical education and certification exams. Future research on Indigenous graduates’ practice locations is also needed to fully assess the effectiveness of NOSM’s admissions process with regard to the school’s social accountability goals.
Our study demonstrates that representation of minority population groups, such as Indigenous peoples, among applicants admitted to medical school can be increased through the use of socially accountable admissions processes. The outcomes of NOSM’s socially accountable admissions for Indigenous applicants can provide insights to medical schools in Canada and other countries that are aiming to increase the number of medical students from populations that are underrepresented in medicine.
The authors wish to thank Dr. Joyce Helmer, chair of Northern Ontario School of Medicine’s (NOSM’s) Indigenous admissions subcommittee, for reviewing this manuscript for the relevant Indigenous content.
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