Is Canada Ready for Nationwide Collaboration on Medical School Admissions Practices and Policies?

A survey of medical school aspirant perceptions of an unexpected lottery-facilitated admissions adaptation

INTRODUCTION

Due to the COVID-19 pandemic, the Undergraduate Medical Doctor (MD) Programme at McMaster University (Hamilton, Canada) was unable to run in-person medical school interviews in March 2020, prompting an alternate solution that maximised admission opportunities for Indigenous applicants, prioritised admission for those rated most highly in the interview determination process, and allocated subsequent offers via lottery.

METHODS

A short survey was administered to applicants who had been offered an admissions interview and were subsequently impacted by the admissions adaptations. The survey elicited perceptions of the adaptation through Likert scale ratings and free-text responses. Survey data were analysed via a sequential (quantitative to qualitative) mixed-methods design.

RESULTS

196 of 552 potential participants completed the survey. Across quantitative and qualitative analyses, respondents reported that the adaptation had a negative impact on their professional development and personal life. Ratings of negative perception were greater for those who did not receive an offer than for those who accepted or declined an offer. Free text responses emphasised considerable criticism for the lottery portion of the adaptation and displeasure that efforts made in constructing applications were less relevant than anticipated.

DISCUSSION

The negative responses to this unexpected change highlight the profound upstream impact admission policies have on the preapplication behaviours of aspiring medical students. The outcomes support a refined understanding of the value candidates place on the interview in appraising their own suitability for a career as a physician.

Applicant and Match Trends to Geriatric-Focused Postgraduate Medical Training in Canada: A Descriptive Analysis

Physicians with postgraduate training in caring for older adults-geriatricians, geriatric psychiatrists, and Care of the Elderly family physicians (FM-COE)-have expertise in managing complex care needs. Deficits in the geriatric-focused physician workforce coupled with the aging demographic necessitate an increase in training and clinical positions. Descriptive analyses of data from established matching systems have not occurred to understand the preferences and outcomes of applicants to geriatric-focused postgraduate training. This study describes applicant and match trends for geriatric-focused postgraduate training in Canada. In this retrospective cohort study, data from the Canadian Resident Matching Service and FM-COE program directors were analysed to examine program quotas, applicants' preferences, and match outcomes by medical school and over time. Based on their first-choice specialty ranking, applicants to geriatric medicine and FM-COE signalled a preference to pursue these programs and tended to match successfully. The proportion of unfilled training positions has increased in recent years, and the number of applicants has not increased consistently over time. There is a disparity between applicants to geriatric-focused training and the health human resources to meet population-level needs. Garnering interest among medical trainees is essential to address access and equity gaps.

The Allocation of Medical School Spaces in Canada by Province and Territory: The Need for Evidence-Based Health Workforce Policy

BACKGROUND

Most Canadian medical schools allocate admission based on province or territory of residence. This may result in inequities in access to medical school, disadvantaging highly qualified students from particular provinces.

METHOD

The number of medical school spaces available to applicants from each province and territory was compared to the total number of available spaces in Canada, the regional application pressure and enrolment in 2017/2018.

RESULTS

There is differential access to medical schools based on the absolute numbers of available spaces and application pressure. Applicants from Prince Edward Island are afforded the greatest number of spaces per 100,000 population aged 20 to 29 (5,568.8). Applicants from Ontario experience the lowest ratio of available spaces to relevant population (54.3).

DISCUSSION

Health workforce policy must balance equity and regional social accountability. Privileging regional residence over academic aptitude and personal characteristics may be justified by strong evidence that these applicants are likely to serve populations that would otherwise be underserved.

CONCLUSION

The availability of medical school spaces in Canada differs as a function of the province or territory from which applicants apply. Determining whether this differential is justified requires appraisal of the consequences of the policies with respect to their goals.

Assessment of Diversity Outcomes in American Medical School Admissions: Applying the Grutter Legitimacy Principles

In the last 30 years, except for female participation, the enrollment of Latinx, African Americans, Native Americans, Alaskan natives, and disadvantaged students in medical school has been constant; however, increasing enrollment of these minority populations is feasible, if admissions committees make two changes in approach. First, the traditional belief that matriculation merit is a linear function of past academic performance must be rejected. Second, once the threshold needed to complete medical school in four years and to pass licensing examinations at the first attempt has been met, all candidates are equally qualified, and matriculation decisions must be based, in part, on societal interests. In Grutter vs. Bollinger, the United States Supreme Court determined that graduate admission committees can and should consider societal interests. Each admission decision represents a substantial government investment in each student, as the Medicare Act directly subsidizes much of the cost of medical education. As Grutter explained, there is a societal interest in the public having confidence in, and access to, the medical school training that will prepare tomorrow’s medical, professional, and political leaders. Our analysis suggests that medical school admissions are biased towards academic achievement in matriculants, beyond acceptable thresholds for graduation and licensure. We believe medical schools must shift their admissions strategies and consider noncognitive factors in all candidates as determinative once minimum acceptable academic standards have been met.

Demographic and socioeconomic characteristics of Canadian medical students: a cross-sectional study

BACKGROUND

While the importance of medical students' demographic characteristics in influencing the scope and location of their future practice is recognized, these data are not systematically collected in Canada. This study aimed to characterize and compare the demographics of Canadian medical students with the Canadian population.

METHODS

Through an online survey, delivered in 2018, medical students at 14 English-speaking Canadian medical schools provided their age, sex, gender identity, ethnicity, educational background, and rurality of the area they grew up in. Respondents also provided information on parental income, occupation, and education as markers of socioeconomic status. Data were compared to the 2016 Canadian Census.

RESULTS

A total of 1388 students responded to the survey, representing a response rate of 16.6%. Most respondents identified as women (63.1%) and were born after 1989 (82.1%). Respondents were less likely, compared to the Canadian Census population, to identify as black (1.7% vs 6.4%) (P < 0.001) or Aboriginal (3.5% vs. 7.4%) (P < 0.001), and have grown up in a rural area (6.4% vs. 18.7%) (P < 0.001). Respondents had higher socioeconomic status, indicated by parental education (29.0% of respondents' parents had a master's or doctoral degree, compared to 6.6% of Canadians aged 45-64), occupation (59.7% of respondents' parents were high-level managers or professionals, compared to 19.2% of Canadians aged 45-64), and income (62.9% of respondents grew up in households with income >$100,000/year, compared to 32.4% of Canadians). Assessment of non-response bias showed that our sample was representative of all students at English-speaking Canadian medical schools with respect to age, though a higher proportion of respondents were female. Additionally, there were no differences between early and late respondents with respect to ethnicity, rurality, and parental income, occupation, and education.

CONCLUSIONS

Canadian medical students have different socioeconomic characteristics compared to the Canadian population. Collecting and analyzing these characteristics can inform evidence-based admissions policies.

Thinking of selection and widening access as complex and wicked problems

OBJECTIVES

'Wicked problems' are complex in nature, have innumerable causes associated with multiple social environments and actors with unpredictable behaviour and outcomes, and are difficult to define or even resolve. This paper considers why and how the frameworks of complexity theory and wicked problems can help medical educators consider selection and widening access (WA) to medicine through fresh eyes to guide future policy and practice. We illustrate how 'wickedity' can frame the key issues in this area, and then address steps that education stakeholders might take to respond to and act on these issues.

METHODS

We used the 10 properties of a wicked problem to frame common issues in the broad field of selection and WA in medicine. We drew heavily on literature from different disciplines, particularly education, and, through debate and reflection, agreed on the applicability of the theory for illuminating and potentially addressing outstanding issues in selection and WA.

RESULTS

Framing medical school selection using the 10 properties of wicked problems is a means of shifting thinking from erroneous 'simple' solutions to thinking more contextually and receptively. The wicked problem framework positions selection as a multi-causal, complex, dynamic, social problem and foregrounds stakeholders' views and context as being highly relevant in medical school selection.

CONCLUSIONS

The wicked problem lens shifts thinking and action from seeking one elusive, objective truth to recognising the complexity of medical school selection, managing uncertainty, questioning and considering 'issues' associated with medical school selection more productively. Although there are criticisms of this framework, labelling medical selection as 'wicked' provides original insights and genuine reframing of the challenges of this important, and high profile, aspect of medical education. Doing so, in turn, opens the door to different responses than would be the case if selection and WA were simple and readily tamed.

Building worldly insights

This article offers health leaders in Canada an opportunity to build a more worldly understanding of healthcare challenges. The focus is on post-conflict countries and island/small countries. Small and island countries often depend on other countries for their workforce and for specialist healthcare services. Conflict usually undermines if it doesn't destroy a country's healthcare system. Small and island countries offer opportunities for the majority of Canadian provinces and territories to develop new approaches from novel comparator countries, with which they may have more in common. Post-conflict countries offer an opportunity to consider the applicability of the determinants of policy and institutional failure to Aboriginal healthcare in Canada.