Have you ever used a food bank? Were you raised by a single parent? What was your family income in the second decade of your life? And how should the answers to those questions influence who gets into medical school?

Medical schools used to say their job was to find the best and the brightest. But the selection method, based on grade-point averages, the Medical College Admission Test (MCAT) and a face-to-face interview, has resulted in classes that fall short of some universities’ goals for racial and socio-economic diversity.

Now some schools are asking if the process is truly fair, and if not, how it ought to change. Across Canada, medical schools are taking steps to shape incoming classes by offering advantages to applicants from certain demographic groups.

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In a given year, only 10 per cent to 20 per cent of applicants are admitted. Many schools could probably choose a similarly capable cohort from among the applicants they reject. But finding the right demographic mix is increasingly an important concern.

Medical schools in Canada exercise overwhelming influence over admission to the profession. About 75 per cent of physicians in this country are Canadian graduates, so the process by which admissions decisions are made is crucial not only to the applicants but to society as a whole. They shape the future of health care.

At the University of Manitoba, the admissions committee studied years of data and found a pretty clear pattern: Wealthy white students from big cities were more likely to be interviewed and more likely to get in, partly because of built-in advantages. As undergrads they don’t have to work part-time to pay for school, they’re able to pay for MCAT prep courses and, in interviews, they can cite an impressive range of travel and volunteer experiences.

The result is that a public university’s system seems to ensure opportunity for the already fortunate.

Bruce Martin, the U of M’s dean of admissions, set out to tinker with the crucial first stage of the admissions process so that more applicants from different backgrounds got through. He knew he could do so by systematically boosting scores based on certain attributes or experiences. But which attributes to target?

Open this photo in gallery Fatemeh Bakhtiari, a second-year medical student at the University of Manitoba, was born in Afghanistan but grew up in Winnipeg. Her mother worked as a grocery clerk, and her father was a truck driver. A strong student, she remembers answering questions on her medical school application about her family income and identity, but says she has no idea whether her answers had any role in her success. JOHN WOODS/The Globe and Mail

Sample questions appearing on University of Manitoba medical school applications: family history Were you raised by a single parent due to divorce, death of a parent, or a teen parent? Were you ever a child or youth in care? Are you a parent taking care of one or more children on your own? Did your parents or guardians graduate from college or university? Were you or your family admitted to Canada with refugee status? Source: Dr. Bruce Martin, University of Manitoba Admissions

He convened a panel of people from outside the university with experience in race relations and alleviating poverty and asked them to consider how the medical school could diversify its student body.

They decided to add a section to the application that would elicit the information they sought. They came up with more than 30 questions, many of them deeply personal and revealing, including factors such as visible minority status, sexual orientation, involvement with the child-welfare system and living with family members who suffer from addiction.

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The committee then ranked each question based on the perceived level of disadvantage suffered by the applicant. Should having a family member with a disability be a greater consideration than whether your parents graduated from university, or having a child-welfare file?

U of M sample questions: economic information Did you or your family ever have to use a food bank? During the second decade of your life, was the annual gross income in the household in which you lived between $40,000-$75,000? During the second decade of your life, did you have to work to contribute to family income? Will your parent(s) be paying for the tuition fees if you get accepted to our medical school? Do you currently receive student aid? Source: Dr. Bruce Martin, University of Manitoba Admissions

The numerical values assigned to each answer are combined to create an arithmetic modifier meant to reflect the degree to which the applicant’s background would put them at a disadvantage in the application, Dr. Martin said. (It turns out that a history of substance abuse moved the needle more than being a visible minority, while needing student aid rated well below using a food bank.)

The goal was relatively modest: a 5-per-cent increase in the number of medical students with diversity attributes.

“We didn’t want to have a quota system. But we want to increase the number of diverse individuals on an incremental basis,” Dr. Martin said.

U of M sample questions: other sociocultural determinants Do you consider yourself to be a member of a Visible Minority? Do you identify as First Nations, Metis, Inuit or other North American Indigenous ancestry? Is your primary language other than English or French? Do you have a participation or activity limitation that has an impact on your day-to-day life? Were you raised or are you living in a household in which there was/is a person living with substance abuse? Source: Dr. Bruce Martin, University of Manitoba Admissions

Other schools have set a similar goal but have taken a different approach. The University of Saskatchewan, for example, now reserves six of its 100 seats for applicants whose families earn less than $80,000 a year. At the University of Toronto, a special stream has been created for black applicants. At Dalhousie University, in Halifax, the medical school says it recognizes that affirmative action is required to increase admissions of African-Nova Scotians and Indigenous people. And at the University of Calgary, applicants from underrepresented groups are asked to “highlight their background and experiences.”

Many schools have the same goals as the University of Manitoba, Dr. Martin said, but are not as transparent about how they aim to achieve a diverse incoming class.

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At Newfoundland’s Memorial University, for example, acting dean of admissions Paul Dancey said the school takes a “holistic approach,” which is common at Canadian universities. He said it involves looking in great detail at all aspects of the candidate, not just their academic record, and paying particular attention to barriers that may have affected their grades or extracurricular activities. (Dr. Martin said Manitoba chose not to take the holistic approach because it relies on the judgment of individual evaluators and can be susceptible to bias.)

The drive to consider racial and socio-economic equality in admissions is also leading major changes in the U.S. college system. The College Board now includes what’s being called an adversity score in SAT test results based on demographic factors such as crime and poverty levels in a student’s neighbourhood and school district. The board said it could no longer ignore the extent to which differences in wealth and race were reflected in test scores, which are very influential in the admissions process. The method for calculating the score has not been released, but it’s based on public information, not answers submitted by students.

For students, the application process remains slightly mysterious, to prevent someone from gaming the system.

Fatemeh Bakhtiari, a second-year medical student at the U of M, was born in Afghanistan and came to Canada as a child. Growing up in Winnipeg, her family was not wealthy. Her mother worked as a grocery clerk and her father was a truck driver. Ms. Bakhtiari excelled in school and at university set her sights on medicine. But she didn’t have many of the advantages that other applicants could rely on, such as a family member who is a doctor. She also had to work part-time in restaurants and retail while studying.

“I had no idea where to start,” she said. “If it wasn’t for Google, I don’t where I would’ve been.”

She remembers answering questions on her application about her family income and whether she identifies as a visible minority or LGBTQ, but she didn’t understand why those questions were being asked. She said she has no idea whether her answers had any role in her success. She said her GPA was strong, she wrote her MCAT three times to improve her score and felt very confident about her interview performance.

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“I don’t know the scoring system or how it works,” Ms. Bakhtiari said. “I don’t know if it was my MCAT, my GPA or my interview that got me through. They don’t tell you.”

At the white coat ceremony where new medical students are welcomed and take the Hippocratic Oath, the U of M’s dean of the faculty of medicine, Brian Postl, said the school was proud of the diversity of Ms. Bakhtiari’s class. More than half are women, 10 per cent are Indigenous, 20 per cent are from rural areas and 50 per cent are from families with incomes of less than $75,000. Ms. Bakhtiari said she believes the diversity of her class is valuable for two reasons: Diverse groups have been shown to be more innovative, and physicians should reflect the population they serve.

Manitoba’s diversity initiatives started more than 30 years ago with attempts to get more Indigenous people into medicine. About a decade ago, the medical school also began to see rural candidates as particularly desirable. Canada was facing a staffing crisis in rural and remote hospitals and medical offices, and researchers began trying to identify what made a medical student more likely to stay and practise in a rural area. A key factor was having grown up in a small town or farming community. That’s when Manitoba began using an arithmetic modifier to place students with a rural background at an advantage.

The university was following a path laid by the Northern Ontario School of Medicine (NOSM), which opened in 2005 with a mandate to turn out doctors for the region – and made no bones about giving priority to students with a rural or remote upbringing.

Roger Strasser, until recently the dean and chief executive officer of the NOSM, said his program gets about 2,000 applications a year. It whittles those down to 320, who are invited for interviews based on a three-pronged score comprising a grade-point average, a personal statement and what’s called a context score, derived from answers about a person’s background and upbringing. The algorithm for deriving the context score is confidential, Dr. Strasser said, but he was transparent about its key implication.

“Applicants who’ve grown up in Northern Ontario or other remote, rural, Indigenous or francophone settings, they get the highest score. The people who are not Indigenous or francophone or come from big cities like Toronto get the lowest score,” Dr. Strasser said.

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Ninety-two per cent of NOSM students have grown up in Northern Ontario, and the other 8 per cent are from rural and remote parts of the rest of Canada. About 2 per cent of applicants are Indigenous, but in the past few years the selection system has been tweaked to increase the number of successful Indigenous applicants, including giving them training to succeed in the interview process. The class went from about 7-per-cent Indigenous over the school’s first decade to about 12 per cent for the past three years, Dr. Strasser said.

He said one of his biggest challenges as dean is the criticism from families in Toronto, who believe their children are excluded from his school.

“My response is, if you look at the numbers, this is just the reverse of the way it is for people from Northern Ontario applying to med school in Toronto or the other big cities. So in a sense, you could say it’s true, there is, let’s call it a bias, but what we’re doing is just countering the bias that’s built into the admissions process of other medical schools,” Dr. Strasser said.

It has become conventional wisdom, supported by research, to say medicine is done better when doctors come from diverse backgrounds, Dr. Martin said. A cohort of physicians with a broad range of life experiences are better able to understand the needs of the population.

The applicants selected under Manitoba’s diversity initiative all meet the school’s admissions criteria, but they might not otherwise have reached the top of the admissions heap. The flip side, however, is that some people who’ve worked hard and achieved a great deal won’t get in, Dr. Martin said. That’s difficult for some to reconcile.

Even his own colleagues, worried about their children’s prospects, have cornered him on this matter. The conversations were uncomfortable, he said.

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“We in medicine have generally been white, socio-economically advantaged and male. And that’s not who we serve,” he said.

“It’s my mission to pick people who are suited to the profession and can meet the needs of the population.”

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