When Dr. Joel Lanphear, Associate Dean of Undergraduate Medical Education at the Northern Ontario School of Medicine (NOSM), contemplates the number of milestones achieved since opening in 2005, he reflects upon his words carefully to summarize the School's distributed model of medical education, a teaching and learning framework enormous in its dimensions and complexity.
"We have to remember that the reason we exist is that our social accountability mandate is to improve access and quality of health care to all of the people of Northern Ontario. In order to do that, we have created an entirely new plan, drawing on the best research and education professionals we could get from around the world to develop this model," he said.
Dr. Lanphear works at NOSM's West Campus at Lakehead University in Thunder Bay, but at any time he may be in Sioux Lookout, Timmins, Bracebridge, or any one of a large number of communities spread across Northern Ontario, an area equal in size to France and Germany but with just 7% of the province's population thinly distributed over this vast region. His itinerary of meetings across the North is not atypical of the nine Associate Deans at the School, each charged with particular responsibilities in executing a model of education unique in the world.
Distributed education at NOSM is collaborative and inclusive. During the planning stages, while the School was still a pan-Northern dream, individuals, physicians, and community members from across Northern Ontario gathered to discuss an education system that would address the historical shortage of medical professionals in under-serviced communities.
NOSM Founding Dean, Dr. Roger Strasser, is the principal architect of the community-based learning model, and brings to the School an impressive list of accomplishments. His work encompasses expertise in rural education at the Monash University School of Rural Health in Australia, and a lifetime of related experience for which he has received international recognition. Much of the School's success, says Dr. Strasser, hinges on the participation of communities.
"The development of this School came about because of the groundswell of support from the communities. Right from the start we developed a relationship that would help us understand and meet their needs. Community-based medical education is a distinctive and essential hallmark of the NOSM model that the School, in consultation with the communities of the North, embraced to best address the shortage of health professionals."
The consensus was to build a made-in-the-North curriculum that would meet the demand for health practitioners as well as focus on leading-edge research directly relevant to Northern populations. Training and graduating resourceful physicians and health professionals with a particular understanding of, and affinity for, people in Northern and remote settings is key to responding to the cultural diversity of the region that NOSM serves.
The result of this mandate is a medical education model like no other.
Ninety per cent of undergraduate medical students are from Northern Ontario, and many are from remote and rural communities. Candidates need to be passionate about the North, able to work cooperatively with other team players, and demonstrate sensitivity to cultural and linguistic diversity. Learning is patient-centred, whereby students examine complex cases of real life scenarios in Northern communities.
NOSM medical students divide their time between classroom learning and hands-on clinical training in the many hospitals, clinics, and health centres across the North where they learn and interact with patients under the supervision of experienced physicians. At the end of their first academic year, for example, students benefit from cultural immersion in Aboriginal communities. During this integrated community experience, they are exposed to distinct lifestyles and world views, essential to their understanding of local health determinants. Second-year learners undertake two months of training in rural and remote communities, broadening their exposure to, and deepening their understanding of, medical care and lifestyle opportunities available in these diverse locales.
Third-year students make the transition from classroom learner to clinician in the Comprehensive Community Clerkship program. Here they advance their clinical training in one of 12 medium-sized communities, learning patient-centred care in real-life contexts. During this eight-month term, learners are engaged in a continuity-of-care cycle. They admit patients, chart their medical history, and assist in a health management plan--all unique features that prepare students for the practical challenges of daily practice in Northern communities.
In fourth year, students move on to the major hospitals in Thunder Bay and Sudbury where they complete core rotations in the specialties of Surgery, Medicine, Women's Health, Mental Health, and Children's Health. Upon completion of their four years of undergraduate medical education, NOSM students will have spent nearly 40% of their time living and learning in small, rural, remote, and urban communities across the North.
Charter Class member and Lakehead University graduate David Janhunen (HBK'03) knows well the practical benefits arising from clinical training in communities. Janhunen completed his Clerkship in Fort Frances where he learned to balance the pressing demands faced by a medical student with community involvement and physical exercise which, he says, are essential for the prevention of total burnout.
"I would spend one day with a gynaecologist, the next with a surgeon, and the following days in the emergency room or in a family medicine clinic," says Janhunen. "All these areas of medicine are coming at you all the time. Over the course of the year, this longitudinal program encouraged me to revisit many aspects of medicine, which I would not have been able to do in a traditional system."
It's an observation echoed by many participants involved in the Comprehensive Community Clerkship. "The Clerkship is a unique aspect of the NOSM program", says Dr. Christine Rossi, coordinator, family physician, and educator at the Sault Area Hospital. "Students are exposed to a range of specialists and are involved in a continuity-of-care experience with patients. NOSM students have a better understanding and appreciation of what a family doctor does after spending eight months in a hospital environment."
Now in their fourth and final year of undergraduate medical training, Charter Class students benefit by hindsight in reflecting on the significance of the intensive third-year clerkship. Adam Moir (BSc'00, BEd'03), a Lakehead University biology graduate (shown on cover), completed his fourth-year rotation at the Thunder Bay Regional Health Sciences Centre, immersing himself in one-month blocks of core medical specialties. It is here that the benefits of the Clerkship are revealed.
"When we started our fourth year, some people expected us to have only limited experience. Depending on where we were placed in our Clerkship, however, some of us were involved in as many as 25 surgeries, functioning as first assistants over the course of the year. Others came into their fourth year with a lot of emergency room shifts, so it was a real advantage that students from other medical schools did not have." Like many of his colleagues, Adam Moir will remain in the North, choosing to practice in his hometown of Thunder Bay upon completion of his studies.
Widespread research supports the notion that students will return to their places of learning as relationships develop, awareness of lifestyle opportunities increases, and comfort with work environments grows. Physician-teachers involved in training students in the communities, like Dr. Sean Moore at Lake of the Woods District Hospital in Kenora, concur.
"Working through an eight-month session enables students to grow personally by forming bonds with patients and families, and to develop professionally. In smaller hospitals, students have huge opportunities to be involved in medical procedures they would normally not have access to in large, tertiary centres." Kenora is one of many communities that enjoys a reputation for strong family physicians and specialists, another incentive for budding doctors to integrate into a cooperative and robust health network.
The Northern Ontario School of Medicine, which received full accreditation this year, will graduate its first cohort of medical students in May 2009. This is a precedent-setting accomplishment in the annals of Northern Ontario history as 55 new doctors educated in the North move on to complete residency training in the region and beyond.
Though monumental in its far-reaching effects, this is by no means a singular success. The Charter Class graduation stands alongside equally important achievements. Over 30 residents from NOSM's Family Medicine Residents of the Canadian Shield (RoCS) program will also complete training this year to pursue careers as family physicians or continue with additional specialty training. This two-year post graduate residency is the newest Family Medicine program in Canada. Students are drawn from undergraduate MD programs across Canada and beyond to train in Sudbury, Thunder Bay, North Bay, Timmins, and Sault Ste. Marie, as well as distributed rotations sites spanning the whole of Northern Ontario. While the focus of the program is to train doctors in rural settings, residents who complete their residency training with NOSM attain the necessary skills to practice medicine in any type of health delivery system.
Last summer, six family physicians with specialties in Emergency Medicine graduated from NOSM's Post Graduate Year 3 program. All remained to practice in the North. Approval for new programs in Pediatrics and General Surgery will result in more physicians pursuing these specialties at NOSM as well.
In August 2008, the first class of dietetic interns graduated from the Northern Ontario Dietetic Internship Program (NODIP), fully appreciative of the unique health-care needs of Northern Ontario and the cultural diversity of its population. The NODIP program is another example of NOSM's commitment to answering the shortage of all health-care professionals in Northern Ontario.
Paralleling NOSM's success in medical education is a strong commitment to research. This year marks the fourth Northern Health Research Conference (NHRC) in which students, researchers, and residents will share new knowledge arising from their research initiatives in community-based settings. This year's NHRC is May 29 and 30 at Lakehead University. Other milestones include the Partnership Opportunities in Research Gathering, an unprecedented occasion that brought together Aboriginal communities, the School, and research organizations to set a new course in establishing respectful, collaborative, and mutually beneficial relationships with Aboriginal research participants and communities.
A medical school that links communities, physician teachers, health centres, and two main locations into a seamless network of learning demands enormous resources in the fulfillment of a pan-Northern dream. But it is a dream visualized as an historically unprecedented accomplishment in which all Northerners will benefit.
"Most exciting in this process will be the time when our students are working in Northern communities and themselves functioning as physician-teachers for new students progressing through the NOSM curriculum. This will have an enormous impact on health care in the North", Dr. Lanphear concluded.
Marek Krasuski is a writer with the Northern Ontario School of Medicine.