Innovative medical education in Northern Ontario
The Northern Ontario School of Medicine (NOSM) has developed a model of medical education to address the needs of people living in northern Ontario.
As the first NOSM graduates begin to enter practice, there are hopes that this school will both improve access to health care providers, as well as improve the health status of people living in northern Ontario.
Context: Undersupplied, Vast Regions
Research shows that rural, remote and northern communities in Ontario have fewer doctors caring for more patients. While there are 18.9 doctors per 10,000 people in Canada overall, there are only 14.9 doctors per 10,000 people in northern Ontario.
These communities not only have fewer doctors, they also have challenging environments that can influence health status, with higher rates of chronic diseases such as diabetes, more disability, and shorter life spans.
The area that NOSM serves has been described as economically, politically, socially and geographically distinct from the rest of Ontario. Northern Ontario is a vast land mass of 800,000 square kilometres, about the size of Germany and France combined, and makes up 90% of Ontario’s land area. However less than 10% of Ontario’s population lives in the region.
The 800,000 people who live in region include 104 of Ontario’s 140 First Nations groups, who live in cities, smaller centres and very remote, fly in reserves. The region also has a large Metis population and a sizable French-speaking population concentrated in the northeast. While about 30% of the population of this region lives in the two largest cities, Thunder Bay and Sudbury, these cities are located over 1000 km apart.
The chronic shortage of doctors, significant health care needs, and unique geographical challenges of providing health care services to people in the North have been recognized for decades. In 1999 the Ontario Ministry of Health and Long-Term Care commissioned a report that suggesting there would be benefits to establishing a medical training program in the North. In 2001, the Ontario government formally announced the decision to establish a medical school in Northern Ontario, with campuses at both Laurentian University in Sudbury and Lakehead University in Thunder Bay.
Watch the below video to learn more about NOSM, and the upcoming Rendez-Vous 2012 meeting being hosted by NOSM.
Reacting to the Needs of the North: The Structure of NOSM
The development of specific programs and policies to train doctors with the hopes that they would stay in the North was a new concept. The traditional model of medical education, where training is concentrated at large universities and in urban centres, was not resulting in many doctors keen to practice in northern Ontario.
Jeff Goodyear, Director of the Health Human Resources Policy Branch of the Ontario Ministry of Health says that “one of the pieces about setting up NOSM was creating a medical school in northern Ontario that would be able to address health services needs of the North.” Goodyear notes that the NOSM model was built in a way that was “relevant and accountable” to these communities. One way in which this has been done has been to have a specific focus on recruiting students from the region to NOSM.
Roger Strasser, Dean of NOSM, notes that NOSM works in partnership with schools and community leaders to “urge young people to see a future for themselves in health care.” NOSM also has an admissions process that favours applicants from northern Ontario.
In 2011, there were over 2000 applicants for 64 first year medical school positions, with 91% of ultimately successful applicants having grown up in rural or remote communities in Ontario, and the other 9% from rural and remote communities across Canada. Strasser notes that this is a “very different class profile” than the average Canadian medical school, with admission targets set to mirror the cultural and geographic diversity of the region. The class admitted in 2007 includes 27% from Francophone communities and 9% with an Aboriginal background.
Despite accepting a very different profile of students, the performance and scores of NOSM students is strong. The first class of medical students ranked fourth overall on the national licensing exam when compared to graduates from Canada’s 17 medical schools.
Kaylin Woods is entering her first year of medical school at NOSM in the fall of 2012, and grew up in Sault Ste Marie, Ontario. She says, “I want to live in northern Ontario when I graduate. To learn medicine, the health care system and build relationships with providers in the north during my training is what drove me to apply to NOSM.”
This strategy to recruit students from the north with the hope that the will stay there is based on evidence suggesting they are more likely to stay and practice in these settings.
The Broader Mandate of NOSM
NOSM has an explicit mandate of social accountability to improve the health of people and communities in the North. This means that the school focuses on addressing the “education, research and service activities towards the priority health concerns of the community.” This social accountability mandate is built into the curriculum. Given that the regions’ population is so spread out, students during the third year of medical school, known as clerkship, are trained in a clinical setting across 12 communities in the North.
Aaron Orkin, a recent graduate of the family medicine residency program at NOSM says “the region is huge, but the entire region, right down to the smallest communities, seem to be aware of the fact that there is a medical school that calls the North home and doesn’t make the north feel like an outpost of medical training.”
Roger Strasser describes this clerkship year as a time where students “make the transition from classroom learners to clinicians” and learn the core competencies of clinical medicine. This model means that students learn surgery, internal medicine, obstetrics, psychiatry family medicine and pediatrics primarily from rural family doctors, and not specialists within each of these fields.
Strasser notes that in the community setting, much of the learning takes place in family practices, and “the curriculum walks through the door with one patient being a child, the next pregnant, the next surgical” and that “in this environment, students learn from the community and family practice perspective.”
The majority of northern and rural Ontario communities are primarily served by family doctors, and because of this, the focus on family medicine as a career path is well established within NOSM.
The preliminary results of a tracking study established in 2005 to follow NOSM students from training to clinical practice are that 63% of NOSM medical school graduates choose a residency in family medicine, which is double the national average. In addition, about 65% of the doctors who do residency training through NOSM, practice in the region after completing their training.
Strasser notes that “students who have grown up here and have done medical school and training here, have deep roots and tend to stay in northern Ontario.”
However, despite NOSM’s strong social accountability mandate to address the concerns of the community, there remain major challenges to improving the health status of the people who live in the region. Whether a medical school can improve population health remains to be seen. Jeff Goodyear says “there is a logical program link to population health that NOSM will try to address and study.” Roger Strasser cautions that with just seven years since its founding, “it is too early for NOSM to demonstrate” these impacts on population health of the region.