Collective impact: A learner-led initiative to bridge silos and advance equity through a Canadian medical school application fee waiver program

Abstract

Canadian medical schools have a social accountability mandate to address the underrepresentation of students from low socioeconomic status (SES) backgrounds and have attempted to address prohibitively high medical school application fees. However, equity initiatives that are collaboratively developed between schools or with medical trainees are often not incentivized, which can hinder sustainability and large-scale impact.

In 2020, the Price of a Dream (POD, a learner-led team of medical trainees, staff and faculty from Canada and the United States) developed a novel, nation-wide medical school application fee waiver program using a learner-led collective impact approach. Through the collective impact approach, POD collaborated with 11 partnering national and provincial organizations to establish a pilot for the medical school application fee waiver program in Ontario in 2021. For applicants with demonstrated financial need, the pilot program waived the application fees (up to $600 value) for three of Ontario's six medical schools. The program was then expanded to institutions in two more provinces, Alberta and Saskatchewan, in 2022. The program has been accessed by over 700 applicants to date.

Collective impact efforts centre equity and emphasize that social change must be achieved through partnership across institutions and hierarchies. 1 The five core principles of a collective impact approach were key to this initiative's success.

(1) Define a common agenda and envision a collective solution: POD worked with the key collaborating organizations to establish a shared goal: addressing financial barriers for low SES applicants, with the long-term goal of improving representation. This was critical to our collective success, as it facilitated appropriate resource allocation. Sufficient resourcing through dedicated personnel with diverse skill sets, staffing hours and financing are necessary for starting and sustaining such equity initiatives.

(2) Dedicate a backbone team to coordinate the work: POD's medical trainees, many of whom are from low SES backgrounds themselves, led a core team of representatives from partnering organizations. Importantly, trainee leadership helped ensure that the program was learner-centred in its design and implementation. Furthermore, medical trainee members were provided honoraria for their work, which was intentionally budgeted for.

(3) Foster mutually reinforcing activities and (4) Encourage continuous communication: The backbone team met every 3 weeks, which ensured accountability. Tasks were delegated based on strengths. For example, POD members led applicant engagement efforts due to their personal experiences and proximity to applicants, while the Associated Faculties of Medicine of Canada received and assessed applicant eligibility for the program since they had an existing application portal with these capabilities.

(5) Establish shared measurement: Success was measured through number of applicants, waivers distributed and applied and impact on financial barriers. POD worked with collaborators to conduct a program evaluation.

Our application of the collective impact approach serves as an example of how medical schools and their student bodies may benefit from equity interventions that prioritize intentional collaboration and learner leadership.

Chantal Phillips: Conceptualization; writing−original draft; writing−review and editing; project administration; formal analysis. Amira Abdalla: Writing−review and editing; conceptualization. Oluwatobi R. Olaiya: Writing−review and editing; conceptualization. Mark D. Hanson: Conceptualization; writing−review and editing; resources; supervision. Justin Lam: Resources; supervision; writing−review and editing; writing−original draft; conceptualization.

Drs. Phillips, Abdalla, Olaiya and Lam each received stipends from the Council of Ontario Faculties of Medicine for their involvement with the Price of a Dream (POD) from 2020–2023, however, not specifically to develop this manuscript. All efforts were made to mitigate bias, such as mentorship by and co-authorship with a senior staff physician (Dr. Hanson) who was not directly financially compensated for their participation. Furthermore, financial compensation does not pose a conflict to the “collective impact” framework that is presented as the cornerstone concept of this paper, as this was not developed by the POD.