Our study confirmed that applicants from areas with higher total neighborhood incomes were more likely to apply and to be offered admission to medical school. We found that the median neighborhood income of all applicants was 33.67% percent higher than the Canadian median total household income. Applicants that were offered admission had a 40.43% higher neighborhood income than the national median [14]. Furthermore, 48.3% of all applicants had a median total neighborhood income bracket greater than or equal to $100,000. We demonstrated that applicants from greater than or equal to $100,000 form most successful applicants, with 56.4% coming from areas with median neighborhood incomes greater than or equal to $100,000. In addition, we showed that our analysis is not biased by our large Ontario cohort.
Although neighborhood income in our binary regression model was not significant when correcting for MCAT, CASPer, MMI and GPA, this is to be expected, as McMaster’s pre-interview score is generated as a function 33% for each component and therefore leaves no discretion. Similarly, the MMI is weighted at 70% post-interview score, with MCAT and GPA accounting for 15% each. Interestingly, our first and second model, summarized in Table 3a and b, show contradictory results. We believe this to be an important finding. The first model represents the phase of the application process where academic scores such as MCAT, GPA and CASPer determine an offer of interview. This group of applicants had a median neighborhood income of $98,816. Interestingly, the second model, which is a smaller cohort of successful applicants from the first model, had a significantly higher income of $104,960, which is approximately the income of applicants offered admission. This suggest that the applicants of lower socioeconomic background are disadvantaged from the first round of the application process. In the second round, the interpretation is unclear. Either income is less of a factor, perhaps from the MMI having so much weight (70% of the total score) or because the applicant cohort is now of significantly higher incomes, and therefore there is no variability for the model to test. Although it has been previously established that medical school applicants tend to be from higher neighborhood income households [2, 11], our study is significant because, despite institutional calls to action and knowledge of these facts for decades, we show that there been little improvement in the socioeconomic diversity of medical school admissions. It also points to a particular aspect of the application process, namely the pre-interview process, that may be disadvantageous to lower socioeconomic applicants.
We found that applicants from areas with a greater median neighborhood income tend to be accepted into medical school. Measures used to rank students such as the MCAT can have significant financial barriers, with a large financial market for preparation courses. This is in keeping with literature suggesting that MCAT, MMI, and application fees correlate significantly with applicant’s income [15, 16, 18, 21, 22]. Importantly, neighborhood income remains a predictor of success despite the significant skew in all applicants who already are disproportionately from neighborhood incomes of above $100,000.
To our knowledge, we are the first to demonstrate that applicants from areas with a greater median neighborhood income are more likely to apply to medical school in the first place. These results remain significant even when dispensing with our large Ontario cohort. These findings suggest that there are critical advantages in higher income area that result in an over-representation in medical school applicants. Some advantages may directly relate to the measures used in admission, as they are often associated with expensive preparatory courses that can deter many low-income applicants from applying. Furthermore, application fees are expensive and have been identified as a potential limiting factor for persons of lower socioeconomic status [17]. Taken together, these factors can aggregate and can form a perception that many potential applicants have regarding their chances of being offered admission. For example, rural students in Newfoundland reported feeling they would have a harder time being accepted to medical school and that medicine was not promoted as a potential career [18]. In addition, high school applicants in Southwestern Ontario reported feeling that finances were a potential barrier to being accepted into medical school. Interestingly, these feelings correlated with parental neighborhood income and circumstance [19]. These examples exemplify self-selection, which are the preconceived notions that act to limit potential applicants from applying in the first place.
Interestingly, our Pearson coefficient analysis reveals an important correlate with neighborhood income, namely that an offer of an interview correlates strongly with an offer of admission. We found that on an individual basis, an offer of interview correlated more an offer of admission than any of the academic scores or neighborhood income. Interestingly, based on our models in Table 3, this also represents a significant change in the neighborhood income distribution of applicants. Although this may not be surprising, to our knowledge, we are the first report this particular finding.
Our study contributes to the broader debate on the importance of medical school diversity and quantifies the magnitude of the problem. Specifically, we are the first to report on the direct relationship neighborhood income plays in medical admissions as well as characterizing applicants to medical school. First, at our institution, this study provides an in-depth analysis of the current status of our socioeconomic diversity and will direct focus on further study to inform policy changes. Second, this study can galvanize medical programs across Ontario and Canada to characterize their respective economic diversity profile and continue to address this issue. Importantly, it should spur a discussion around the concept of hidden biases. There is no direct measure of socioeconomic status in medical admissions, but the assessments used in determining success in medical admissions have positive correlations with ascending affluence. Although this study is at one institution, our data set includes approximately 74.6% of all Ontario medical school applicants and 21.4% of all admitted registrants to an Ontario medical school [7].
Limitations
Our study has many strengths but several notable limitations. Although our data set is large, our study includes only a single institution and therefore our findings may not generalize to all medical schools in Canada. However, our study includes relatively large contributions from every province and territory and is larger than any other study on the subject to date. Furthermore, McMaster is recognized as a leader in inclusive medical admissions. They are the developers of the MMI and CASPer, as well as research on equity in medical school [23, 24, 25, 26, 27]. In addition, our socioeconomic proxy measure of median neighborhood income is based on postal codes and may not be reflective of the income of all medical applicant households. Furthermore, the neighborhood income of rural households is difficult to estimate in this manner [28]. However, we suspect that this would only make our findings more conservative. Finally, although our report identifies important associations, we cannot determine with certainty the causative mechanism(s) behind our findings, although we have postulated reasonable theories.