Increasing Diversity in Medicine: The ‘BSAP’ Approach at the University of Toronto

This is a guest post by Seana Adams and Nelson Saddler.

In 2016, there was only one Black incoming medical student at the University of Toronto among a class of 259. In a city such as Toronto, one of the most multicultural cities in the world and home to a population in which 10% self-identify as Black, this is simply unacceptable and fails to serve as a representation of the population at large. Failing to train physicians from marginalized communities will only exacerbate the current health inequities faced by those communities. Unfortunately, we have no data on how many Black individuals applied that year, or in any of the previous years, so it is difficult to properly assess the systemic barriers that prevent a Black student from successfully entering the University of Toronto medical program.

Although inexcusable, the presence of only a single Black student should not surprise anyone familiar with the literature on implicit bias. Implicit bias refers to unconsciously held biases, stereotypes, and associations that exist outside of our conscious awareness and impact our actions and decisions (1). The role of implicit bias in society is pervasive, influencing decisions as far ranging as success in job applications to individuals’ access to care and therefore health outcomes (1).

These anti-Black biases exist directly within the hiring process; in the 2014 General Social Survey by Statistics Canada, it was indicated that 13% of Black individuals had experienced discrimination in the hiring processes, as compared to 6% of non-Black people (2). This survey also showed that racialized candidates with the same qualifications and experience were significantly less likely to be called for an interview (2). 

Implicit bias has also been clearly demonstrated in the medical school admissions process. One of the methods in which implicit bias can be assessed is through the completion of the implicit association test (IAT) – a computer-based reaction time test that has been validated in numerous contexts (3). This test measures unconscious attitudes toward different social groups and can be tailored to focus on multiple determinants including race, gender, and social class (3). An investigation by Capers and colleagues (2017) utilized the IAT to assess implicit racial bias, specifically Black-White preferences, in medical school admissions at Ohio State University  (4). The cohort displayed significant levels of implicit White preference; a finding still present when controlling for sex (men/women) and education (medical student/faculty) (4). However, after making all 140 admission raters aware of their preferences through disclosure of their respective results, the class that matriculated following this study was the most diverse in the history of the institution at the time (4). Similar findings of health care providers having some level of pro-White, anti-Black racial bias have been demonstrated using the IAT, as noted in systematic reviews by Fitzgerald et. al (2017) and Maina et. al (2018) (5, 6). We know that marginalized communities are negatively impacted by implicit bias and racialized assumptions within healthcare, which in turn precipitate poor health outcomes. Addressing these health inequities begins at the admission process in which representation within medicine matters. 

Thankfully, discriminatory admission practices can be changed. There are now approximately thirty Black medical students entering their second and third years of medical school at the University of Toronto. The incoming class of 2024 will introduce more than 20 self-identified Black students, the largest cohort in the university’s history, and an astounding increase from just 4 years ago.

This achievement was spearheaded by the implementation of the Black Student Application Program (BSAP) in 2017. This program aims to support students that self-identify as Black African, Black Caribbean, Black North American, and multi-racial students who identify with their Black ancestry, and serves to limit the degree of explicit and implicit bias in the application process. The BSAP incorporates members of the Black community – including physicians, healthcare workers, and community members – and facilitates their involvement in the admission process for these students. For students who choose to participate in this program, at least one self-identified Black individual is involved in reviewing their application, and if an interview is granted, it is conducted by at least one self-identified Black interviewer. 

Applicants are not treated preferentially. They must still meet the exact same admission requirements (e.g. Medical College Admissions Test (MCAT) scores, GPA scores, autobiographical sketch, and supplementary essays) and undergo the same rigorous application process as students who apply through the general stream. Additionally, there are no quotas for students who apply through BSAP, nor any race-related quotas that apply to the incoming class of medical students. Therefore, this program does not lead to the preferential or mandated acceptance of Black applicants regardless of merit. It simply aims to level the playing field. 

Health equity is essential for the health of our patients and a cornerstone for optimal outcomes. 10% of the population of Toronto self-identifies as Black, and the proportion is growing. Although we are aware that the health outcomes in this community are notoriously poor, evidence-based research is limited due to the lack of systematic collection of race-based data in Canada. However, one need look no further for racial disparities than to how the Black community has been disproportionately impacted during COVID-19. In an analysis of Toronto’s demographic data, there was a strong association between COVID-19 cases and factors such as low income and conditions of work (7). However, there is a significantly stronger association between COVID-19 cases and communities with a high proportion of Black people (7). Dr. Nnorom, President of the Black Physicians Association of Ontario and Black Health Theme Lead at the University of Toronto, said to Global News, “It’s not because people who are racialized enjoy living in a densely populated context; it’s because poverty in this country is racialized.” (7). Perceived discrimination has been linked with decreased utilization of health care and social services, delays in seeking treatment, and decreased adherence to medication regimens (8). 

Moreover, in a 2017 report by the Ontario Ministry of Health and Long-Term Care, a quotation by a young Black male highlights his experience with institutional racism: “I’ve been to the ED and been told I wasn’t having a crisis. They didn’t believe me until I threw up on myself. It turns out I had a blood clot and the vein was twice the normal size.” (9). These are not isolated incidents and are most certainly not uncommon experiences for Black individuals who interact with the healthcare system. 

The reality of health inequalities in Canada has been highlighted in work by Veenstra & Patterson (2016) (10).  They found that compared to White Canadians, Black Canadians suffer from worse cardiovascular health (higher rates of hypertension and diabetes), that cannot be explained by several other determinants of health including income, education, smoking, frequency of physical activity, and BMI (10). The authors note other research conducted in the United States that has discussed the internalization of anti-Black racism by Black individuals and its link to chronic stress as well as the chronic physiological response manifesting as insulin resistance and other precursors to Type II diabetes (10). However, due to the insufficient collection of race-based data in Canada, more thorough analysis is necessary to properly demonstrate racial identity and poor health. 

Increasing the representation of Black physicians is an obligatory and crucial first step towards improving the health outcomes for Black and other marginalized communities. Even within the first two cohorts of the program, the Black Medical Students Association (BMSA) has already started making an impact in communities, from hosting Black Mental Health forums which bring out hundreds of community members, to hosting mentorship sessions for underprivileged highschool and undergraduate students interested in STEM. (The transformative work of the BMSA will be explored in a subsequent blog post. )

Of course, we did not do this alone. We stand on the shoulders of giants. This was all made possible due to the Black community working in concert with the university, through the Black Physicians Association of Ontario to authentically design and implement this program. Additionally, leaders within the medical community have provided us with the opportunity to not just endure, but thrive, and in line with this, we specifically want to highlight the impact of allyship. Dr. David Latter, Vice Dean of Admissions at the University of Toronto has been an instrumental ally in ensuring  Toronto’s medical school class reflects the communities of which it serves. “He is our champion as Director of Admissions within the Faculty,” says Ike Okafor, Senior Officer of Service Learning and Diversity Outreach and BSAP liaison. “He fully stepped up to the challenge and oversaw implementation. If more people with roles in public-serving institutions were as serious about service for communities they don’t resemble, most organizations, and society as a whole, would be further ahead.” We rely on those with recognized social privilege to leverage their positions in institutions in our cause for increased representation. 

The single Black medical student who entered the University of Toronto in 2016 recently graduated and was the first Black woman to be chosen sole valedictorian, proudly representing the class of 2020. Dr. Chika Oriuwa is a stellar example of what just one student can accomplish and how one student can motivate all those that come after her.

The BSAP initiative, in our eyes and in the eyes of the broader Black community, is a pillar to follow, admire, and emulate. The University of Toronto has taken the initiative in Canada to be a leader for this cause and is a shining example for other universities. For this, we are extremely proud.

We would like to specifically thank those who had a vital role in establishing the BSAP: 

• Dr. Lisa Robinson, Associate Dean of the Office of Inclusion and Diversity 
• Dr. Mark Hanson, former Admissions Director 
• Ike Okafor, Senior Officer of Service Learning and Diversity Outreach
• Dr. Onye Nnorom, President of the Black Physicians Association of Ontario
• Dr. David Latter, Vice Dean of Admissions 
• Chika Oriuwa, MD and Class of 2020 

References 

1. Sukhera J, Watling C. A Framework for Integrating Implicit Bias Recognition Into Health Professions Education. Academic Medicine. 2018;93(1):35-40.

2. Results from the 2016 Census: Education and labour market integration of Black youth in Canada [Internet]. Www150.statcan.gc.ca. 2020 [cited 3 July 2020]. Available from: https://www150.statcan.gc.ca/n1/pub/75-006-x/2020001/article/00002-eng.htm

3. Greenwald A, Poehlman T, Uhlmann E, Banaji M. Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity. Journal of Personality and Social Psychology. 2009;97(1):17-41.

4. Capers Q, Clinchot D, McDougle L, Greenwald A. Implicit Racial Bias in Medical School Admissions. Academic Medicine. 2017;92(3):365-369.

5. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 2017;18(1):19.

6. Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med 2018;199:219–29.

7. Black neighbourhoods in Toronto are hit hardest by COVID-19 — and it’s ‘anchored in racism’: experts [Internet]. Global News. 2020 [cited 3 July 2020]. Available from: https://globalnews.ca/news/7015522/black-neighbourhoods-toronto-coronavirus-racism/

8. Schnierle J, Christian-Brathwaite N, Louisias M. Implicit Bias: What Every Pediatrician Should Know About the Effect of Bias on Health and Future Directions. Current Problems in Pediatric and Adolescent Health Care. 2019;49(2):34-44.

9. Provincial Council for Maternal and Child Health & Ministry of Health and Long-Term Care. Clinical Handbook for Sickle Cell Disease Vaso-occlusive Crisis. Toronto; 2017.

10. Veenstra G, Patterson A. Black–White Health Inequalities in Canada. Journal of Immigrant and Minority Health. 2015;18(1):51-57.

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