Innovative approach to medical training meant to address growing gaps in primary care
A visionary Canadian physician believes three new medical schools opening in Canada will flip the country's medical training model on its head to focus more on family medicine.
"It takes a community to raise a physician," said Dr. Roger Strasser, interim dean of the new Simon Fraser University Medical School and founding dean of the Northern Ontario School of Medicine (NOSM).
"The carrot is positive role models and mentors and a sense of excitement that a career as a family physician is really the way to go because it's a rewarding and satisfying career," he said. "It's hard to learn that if your main clinical learning is in a big acute teaching hospital."
Just over a century ago, a major shift in medical school education in North America moved the teaching and training of new doctors from communities into universities, where they learned basic sciences; and hospitals, where they got hands-on experience in patient care and research.
Those big university-affiliated teaching hospitals are where students now spend much of their time, but most Canadians get their health care through a family doctor or walk-in clinic, which sees a much wider range of problems. About six million Canadians, or one in five, don't have a family physician.
Strasser sees medical education returning to the community — something he says is a crucial piece in training and retaining more family doctors — and he can point to the only Canadian medical school established so far in the 21st century as an example of success.
The Northern Ontario School of Medicine (NOSM) accepted its first class of 56 students in September 2005. It became Canada's first independent medical university, now known as NOSM University, in April 2022, and it was the first one established with a social accountability mandate — a commitment to improve the health of the people in the communities of northern Ontario.
It pioneered an approach in which medical students learned their core clinical medicine in family practice clinics, community health centres, elder care facilities and community mental health services, seeing patients early in their training, in locations where it's hoped they'll serve after they complete their degrees.
"You could say the curriculum walks through the door," Strasser explained.
"The first patient might be pediatrics, the next patient might be pregnant. That's obstetrics. The next patient might have a surgical problem."
So while the students' learning objectives are the same, instead of learning them in separate blocks in teaching hospitals, they learn by seeing patients who come to their family doctor.
School and community partnerships
NOSM puts students into 90 sites, supported by high-quality broadband internet and an extensive digital library service so they have access to the same resources as any big city teaching hospital environment. Because the priority is serving the community, it involves a partnership between the school and the community in the development and delivery of curriculum.
"We evolved to the point of describing the entire geography of northern Ontario as the campus of the Northern Ontario School of Medicine. So if you're in northern Ontario, you're on the campus of Northern University," Strasser explained.
"The students themselves, within a couple of months, they change the way they think. They talk about going to work rather than going to study," he said. "You have the students and then the residents contributing to clinical services and then ultimately contributing to the health system transformation."
NOSM also developed a recruitment and university admissions process for groups most in need of family physicians — Indigenous people, rural residents and recent arrivals to Canada — and encourages students to see themselves as physicians working in their communities.
"That's what I call a cradle to grave approach," Strasser said. "Seeing them from starting in their own community, to serving their own community, to retiring in their own community."
In the first 10 years since the first doctors graduated from NOSM, 77 per cent remained in family medicine and 92 per cent practiced in northern Ontario.
New Canadian medical schools
Canada currently has 17 medical schools, but three more are being established between now and fall 2026.
Strasser is taking what he learned with NOSM to shape the new medical school at Simon Fraser University in Surrey, B.C.
The first class of 48 students is expected to start in September 2026, with family practice residency starting soon after. Enrolment will grow to 120 students per year within a decade.
Strasser has also consulted with groups establishing new faculties of medicine at Toronto Metropolitan University (TMU) and the University of Prince Edward Island (UPEI), which will begin as a joint program with Memorial University of Newfoundland (MUN), but has already started the accreditation process to become its own entity.
Halifax-based Dalhousie University is expanding to include a third campus at Cape Breton University (CBU), which will admit 30 new physicians every year, starting in 2025. It is not considered a new medical school because physicians will graduate from Dalhousie, not CBU.
New approach decentralizes health care
The new medical school at TMU will have 94 undergraduate seats and 95 postgraduate positions when it opens in September 2025. The school will be housed in a renovated Bramalea Civic Centre complex in Brampton-Peel and will work in partnership with the William Osler Health System and clinics in the community.
It's being founded and designed from the ground up on the principles of social accountability, equity, diversity and inclusion and reconciliation — an innovative approach to health education meant to address the growing gaps in primary care — especially in a diverse and fast-growing region, said Mohamed Lachemi, TMU's president and vice-chancellor.
"Doctors trained at this medical school would be prepared to work with diverse and under-served communities, allowing them to provide health care that is culturally respectful," he said.
The volume of patients in Canada going to hospitals is a problem for the overtaxed system, according to Lachemi, who says establishing this kind of integrated network of clinics could provide support within communities, prevent unnecessary ER visits and decentralize health care, instead "providing support within communities."
UPEI's new Faculty of Medicine will begin as a remote site under the accreditation of Memorial University of Newfoundland, with the first intake of 20 students in Fall 2025. One of those spots is reserved for an Indigenous student.
Students will receive a joint UPEI-MUN medical degree once the program has been accredited, said Dr. Greg Keefe, interim president of UPEI.
The first two years of the MUN curriculum will be delivered at UPEI, with video lectures from St. John's, Nfld, and will include state-of-the-art simulation labs built to mimic emergency rooms, operating theatres and labour and delivery rooms to immerse students in the clinical experience without risking harm to actual patients.
More senior students and residents will work with nurses and other health-care professionals in an on-site community clinic, an interdisciplinary program Keefe says will have patients from the university and the broader community.
The province has long struggled to provide family physicians and specialists to residents who often have to leave the island to get care.
Though he says they know they won't change things overnight, Keefe says it's a "once in a generation opportunity" to build a better future for health care in the province.
"We're looking seven to 10 years down the road before we really see the impact of it. But I think when we look back, we'll be very glad we made the decision to do what we did in 2023."
Who will teach?
However, there are concerns that there aren't enough physicians to teach and supervise medical students and residents, particularly on P.E.I., because they're already stretched thin caring for patients.
"It's not really a question of whether or not the medical school is a good idea. It's a question of whether we're ready for it," said Dr. Krista Cassell, an obstetrician and gynecologist who is also president of the Medical Society of P.E.I.
"The crux of burnout for physicians is trying to do everything, and we know there's just not that much wiggle room left in our system," she said. "So we do have to be very careful when we roll out a medical school that we're not impacting the health care of the patients that we already have."
Dr. Michael Gardam supports the idea of a new medical school on the island — in theory. He's the CEO of Health P.E.I., an infectious disease physician and an associate professor at the University of Toronto.
"My worries start when I try to figure out, how do we bring this number of trainees into a system which is, frankly, just scrambling to keep the lights on every day and we don't have enough doctors to do the clinical work that we need to do."
New med school will face challenges, P.E.I. health official says
Dr. Michael Gardam, Health P.E.I. CEO, says a new medical school in the province could help recruit doctors interested in more than just clinical work, but he isn't sure how it will work with the system that exists.
Gardam has been teaching his whole medical career and knows from experience that he doesn't see as many patients when he's teaching.
He's heard from P.E.I. physicians who are concerned they'll be told to teach on top of maintaining their patient load, which they worry will lead to burnout for them, a poorer learning experience for students and a lower level of care for patients.
He believes it would have been less expensive and more efficient for UPEI to buy more seats in an existing medical school, or become a satellite campus for MUN or Dalhousie University.
The incoming CEO and president of the Association of Faculties of Medicine of Canada concedes it will take a lot of work for new medical schools to meet rigorous accreditation standards, but said this is an exciting time for medical education in the country.
"It's a huge deal," said Dr. Constance LeBlanc, who will head the group representing Canada's Faculties of Medicine as of July 1.
"As a physician, it's really encouraging to see that our provincial governments are interested in investing in training more physicians."
LeBlanc points to 2021 statistics showing Canada had 2.77 doctors per 1,000 people, compared to the world average based on 11 countries, of 3.88 doctors per 1,000 people.
"We need practitioners who are interested in rural, who are interested in their communities," she said. "And I think we'll be able to train physicians with a broad understanding of equity, diversity, inclusion and justice."
Medical schools rooted in communities help focus on local needs: doctor
Dr. Constance LeBlanc, incoming CEO and president of the Association of Faculties of Medicine of Canada, says it's encouraging to see provincial governments investing in training physicians who can 'breathe new life into the system.'
Learning teams can reduce strain
Simon Fraser's Strasser knows the system is under pressure and that health-care professionals are tired and might not be able to imagine taking on students, but his experience in Ontario showed him how teaching medical students can enrich the entire team.
"When we started talking about this, physicians said, 'It's an extra burden having a student or a resident attached to me.' Well, as soon as there are two students, then they start teaching each other and then we expand the learning team," he explained.
"Then there's a real buzz and that actually helps to lift the spirits of the physicians and the health team members."
Strasser says Canadians expect high-quality health care close to home, so they should be excited about what the new medical education models represent.
"The graduates of these new medical schools will have the skills and the commitment to provide that kind of care — team-based community level care."
ABOUT THE AUTHOR
Karen Pauls covers Manitoba stories for CBC national news. She has worked across Canada, U.S. and Europe, and in CBC bureaus in Washington, London and Berlin. Some of her awards include the New York Festivals for coverage of the Greyhound bus beheading and a Quirks & Quarks question show, and from the Radio Television Digital News Association for stories about asylum seekers, the Michif language, the Humboldt Broncos bus tragedy, live elections and royal wedding shows. In 2007, Karen received the Canadian Association of Journalist’s Dateline Hong Kong Fellowship and did a radio documentary on the 10th anniversary of the deadly avian flu outbreak. Story tips at email@example.com.
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