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How Should Canada Select New Medical Doctors?

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The field of medicine is one of the most sought after professions in this country, with admission rates around 26 - 28% of domestic applicants in a given year gaining acceptance to a Canadian medical school. Factors included in admissions decisions for medical schools include a combination of grade point average (GPA), Medical School Admissions Test (MCAT) score, extracurricular involvement, autobiographical sketch, and reference letters and interview.

Many Canadian medical schools have official quotas based on applicants' home province, area within a given province and/ or size of hometown. Competition is especially high for international applicants, for which many medical schools reserve only a handful of entry positions.

Given such a low admissions rate, there are far fewer positions than qualified applicants. How, then, should we choose those who are admitted to medical school?

One group of individuals believes that the opportunity to study medicine in Canada should be given to those who have demonstrated academic ability and display evidence of a track record of dedication. This includes MCAT score, GPA and scholarships, awards and bursaries and extra-curricular activities. In an article published in the Montréal Gazette in August 2013, Montréal-based family physician Dr. Barry Slapcoff states "the admissions process should be blind to any quality except excellence."

Those in this camp believe that students who excel in academics and other fields, regardless of demographics, will be most likely to become physicians who possess the diligence, innovation, and intelligence to propel the profession forward. They are dismayed that many students who display their dedication by earning extremely high grade point averages and prove unsuccessful in gaining entry into medicine. They will be known as the Meritocracy School of Thought on Medical Admissions.

Clearly, a plethora of factors beyond academic achievement has been recognized by those in the admissions process for several years. These people are hesitant to incorporate immutable factors such as an applicant's ethnicity (visible minority or aboriginal status) into admissions decisions.

Those of the Meritocracy School believe that diversity should not trump excellence and merit. Approximately 85% of Canadian Universities are large, publicly-funded, non-profit institutions, while the remaining private post-secondary institutions have less than 15% of Canadian university students as attendees.

A divergent point of view from the Meritocracy School of Thought holds that the fundamental goal of training physicians in Canada is to effectively deliver quality healthcare and improve the health of Canadians who need it the most. It has been well-documented that Canadians living in rural and remote communities are least likely to receive adequate medical care.

Putting this together, it makes sense, according to those of this Social Accountability School of Thought on Medical Admissions to select physicians that are most likely to practice in these in these relatively under-served populations.

The approximately 30% of Canadians living in rural areas suffer from higher rates of injury and premature death than their urban counterparts and have higher rates of chronic cardiovascular and respiratory illnesses. Medical school candidates from rural backgrounds are more likely to be prepared for both clinical and cultural aspects of rural practice.

The Future of Medical Education in Canada (FMEC) report continues attests that "little progress has been made in attracting applicants from First Nations, Inuit, and Métis communities and rural areas. Other socio-cultural and economic groups are also underrepresented.

"Many Canadian medical schools have formal quotas reserved for Inuit and First Nations applicants. Further, the Schulich School of Medicine and Dentistry at Western University has explicitly-stated lower academic requirements for applicants from rural and underserved regions. Many subscribers to the Social Accountability School of Thought may find viewing through this holistic lens appropriate.

It is clear that there is a physician shortage throughout Canada and especially in rural and remote regions. It has been documented that exposure to rural practice settings during medical schools will increase likelihood that students will be comfortable to work in these settings.

As proportionally fewer applicants come from rural and aboriginal backgrounds compared to their urban and non-aboriginal counterparts, one way to provide for a diverse pool of qualified applicants is to continue to support measures to increase the proportion of applicants from these backgrounds that apply to medical school in the first place.

Community-based, grassroots measures aimed at recruiting applicants under-represented among physicians and increasing exposure to students after they have began medical training are worthwhile practices that should be acceptable to individuals from either school of thought.

A second way to move forward harmoniously is by increasing exposure to medical practice with rural and aboriginal populations among students that have already been accepted into medical school. Many medical schools have adopted elements of their curriculum to highlight rural medical practice including mandatory rotations in rural settings but there remains room for improvement.

Merit and social accountability should both be considered in medical admissions. I think that being willing and able to see things from two starkly different perspectives is useful in several domains and certainly for those who have the privilege to be involved in the process of selecting future Canadian-trained physicians.

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