In a few months, Joseph Boyle will finish his studies at the Northern Ontario School of Medicine (NOSM) on his way to becoming the first doctor in his immediate family. “I don’t think I’d be in med school if it weren’t for NOSM,” Mr. Boyle says.
For him, being able to live at home with his parents while studying at the campus in Thunder Bay was part of the appeal. NOSM is Canada’s newest medical school, and is focusing its efforts on social accountability, advocating for health-policy change and serving communities in need, like northern Ontario. Since its inception in 2005, NOSM has arguably become the only medical school in the country to follow through on this kind of progressive, values-driven mandate. Mr. Boyle says those ideals also drew him to the program and have become “even more important” as his education has progressed. By embedding social accountability into students’ training, the hope is that physicians will be better prepared to improve health inequities. Similar ideas were endorsed in a document called the Global Consensus for Social Accountability of Medical Schools, which was written in 2010 by a group of international experts and, more recently, included in the strategic direction issued earlier this year by the Association of Faculties of Medicine of Canada (AFMC).
NOSM’s progressive view on medical education has caught the eye of Ryerson University, York University and Simon Fraser University. They’re emulating its approach as they aim to launch medical schools of their own. As well, NOSM has inspired long-established medical schools to embed similar ideals into their curriculum. “NOSM is one of the flagships in Canada,” says Shirley Schipper, vice-dean of education in the faculty of medicine and dentistry at the University of Alberta. “We can all look towards NOSM and all they’ve done around things like community-based training and trying to meet community needs.”
One key reason that the country’s medical schools must change is that they contribute to a basic inequity in the system: they don’t produce enough general practitioners. About five million Canadians currently lack a family doctor. To fix that, 50 per cent of all doctors need to work in family medicine. But just over 31 per cent of medical students make it their first choice for residency. And in 2021, 89 family medicine residency positions in Canada went unfilled. This issue is exacerbated in rural and remote communities. “Even within family medicine, the choice is often to practice in a more urban setting,” says Ann Collins, past president of the Canadian Medical Association (CMA) and a former general practitioner.
NOSM is trying to address the problem by attracting local students, in the hopes that they will practice in underserved regions. For example, about 100 more family doctors and 100 more specialists are currently needed in rural hospitals in northern Ontario. To make matters worse, about 50 per cent of physicians in the region are set to retire in the next five years.
However, the school is seeing encouraging numbers among its student population: 84 per cent of the entering class of 2021 is from northern Ontario. Twelve of the 64 students self-identify as Indigenous. Just shy of 50 per cent of graduates chose family medicine as their first choice in 2021, the highest proportion of any school in the country. Of the 196 graduates who have completed both their degree and residency at NOSM, 176 have remained in the region to work.
The school also favours a distributed-learning model in which students are embedded in communities (many of them remote and rural) 40 per cent of the time, while most other medical schools offer more classroom time and hands-on learning in hospitals. “Developing the best health professional workforce is less about the university setting and more based in clinical practice,” says Sarita Verma, dean, president and CEO of NOSM, adding that the goal is to “seriously engage” with the people that students are being trained to serve.
Canada’s newest medical school at a crossroads
In April 2021, the Ontario government announced that the Northern Ontario School of Medicine (NOSM) would cease to operate via a partnership between Lakehead University and Laurentian University. This was one of the outcomes of Laurentian declaring itself financially insolvent earlier in the year. NOSM became an independent medical school.
“There are many freestanding universities in the world,” says Sarita Verma, dean, president and CEO of NOSM. She admits to logistical challenges ahead, including seeing if NOSM can extract roughly $14 million in tuition, research and endowment money trapped in the Laurentian bankruptcy process. NOSM will have to set up its own administrative functions. While that comes with a price tag, being affiliated with two separate universities meant NOSM often saw double costs. Dr. Verma thinks going it alone will be cheaper.
However, not everyone welcomes this change. “We do have some concerns about the impacts on research, innovation and on the accreditation of the degrees themselves,” says Lakehead president and vice chancellor Moira McPherson. “The aspirations some at NOSM have expressed about growing and expanding services throughout the North were all possible under the current partnership model. There may be some challenges for a standalone institution to achieve these same goals.”
Ryerson, York and SFU are clearly drawing inspiration from NOSM as they plan to launch their own medical schools. Each one has developed a values-first agenda that promises to prioritize social justice, treat underserved communities, decolonize medicine, upend racism and other forms of prejudice, and push on with a new approach to teaching medicine that could, in turn, influence health care delivery from coast to coast.
York has been planning to open its medical school for over a decade. In 2010, it shelved a proposal when the provincial government said it wasn’t ready to fund it. Then in May, York relaunched its proposal, with a mandate to train family doctors and focus on the region’s many underserved communities. “York’s med school would be grounded in our overall approach to health, which is keeping people healthier for longer, at home in their communities,” says Rhonda Lenton, the university’s president and vice-chancellor. “The training would be very interprofessional, working with other health-care providers and focusing on the social determinants of health.”
York’s renewed efforts coincide with a similar plan from Ryerson. Fresh off launching its law school last fall, Ryerson landed a planning grant from the Ontario government in March for a school focused on community-centric primary care, addressing social determinants of health, senior care and implementing new technologies.
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“We believe we can offer a new approach to medical education in Ontario,” says Ryerson president and vice-chancellor Mohamed Lachemi. “Our commitment to community diversity and inclusion and innovation will, I think, be strong ideas to build our school upon.” Ryerson hopes to locate its school in Brampton, Ont., and build the curriculum around gaps in care in that racialized, underserved city. The school will be “not just about doctors,” Dr. Lachemi says, noting that Ryerson already teaches nursing, midwifery and occupational health and safety. “We want to have better communication, better collaboration and better outcomes.”
It’s not clear if the provincial government will approve two similar medical schools in the same area, but Dr. Lenton is optimistic. “My view is there’s room for more in the GTA [Greater Toronto Area], even three schools,” she says, adding that Boston, which is four times smaller than Toronto, has three such institutions. Dr. Lenton also says York would consider working with the others. “I think that universities need to do more around collaboration and less around competition.”
Meanwhile, the provincial government in British Columbia announced its support for establishing a medical school at SFU in October 2020. That would make the medical school the second in the province after the University of British Columbia’s (which operates four campuses and accepts 288 students a year). “This is something that SFU has been thinking about and working towards and hoping for more than a decade,” says Catherine Dauvergne, vice-president, academic, and provost. SFU aims to sign an agreement with the Fraser Health authority and the First Nations Health Authority, which spans the province. “Our plan is to create a three-way partnership from the beginning, to prioritize values and vision for the school,” says Dr. Dauvergne. “We haven’t mapped out what our curriculum will look like, but we’re thinking students will work more in communities and clinics and spend much less time in hospitals.”
Making textbooks more inclusive
When Iku Nwosu was in her third year of medical school at Queen’s University, she noticed that her instructors only showed images of white people when explaining that illnesses can manifest themselves on the skin. “To be unable to identify skin conditions on people that are not white, it was very disturbing to me,” Ms. Nwosu says.
“That’s what happens when you have medical school curriculum developed without Black people or people of colour at the table.”
She and a group of volunteers took it upon themselves to review all the learning materials being used in medical school courses. They discovered that 90 per cent of images were of white skin. Ms. Nwosu and her team then created packages for their professors with suggested updates. Their project gained media attention, and many Queen’s professors vowed to update their teaching materials.
Ms. Nwosu, who is now in her final year and also serves as chair of the Black Medical Students Association of Canada, says she has seen a change in responses to such concerns since the murder of George Floyd in the U.S. “I did this work before it was cool to be into EDI,” she says.
“Before, it was never taken seriously or it was sent to committees or we had to prove why others should care about this.”
Focus on underserved regions
Already-established medical schools are also modifying their approach to recruitment, placements and curriculum to train more doctors who are eager to work in regions our health-care system has long ignored. The AFMC’s new strategic plan, which emphasizes “social accountability for the health of all Canadians” as a core part of its vision, will likely intensify these changes.
Hands-on training in underserved areas is pivotal to the social accountability approach to medical education. “When you’re exposed to different people and cultures and ideas, it can open your horizons, and you become more accepting and more open to different ways of doing things,” says Geneviève Moineau, president and CEO of the AFMC.
One study conducted by Julie Massé, a graduate student in community health at the Université Laval, found that doctors working in a Montreal perinatal clinic for marginalized women and their families looked at the profession very differently after the experience. “They wanted to do more than observe social inequities in the health-care system and actually do something about them. They wanted to be advocates for new ways of doing things,” says Ms. Massé. “It helped them define their ideal frontline scenario, the ideal environment in which they want to practise medicine.”
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Some schools have set up facilities far from their main campus so that rural students can do their didactic learning closer to home. Dalhousie University operates five different sites in New Brunswick, allowing 30 students to complete their studies without leaving their home province. UBC runs similar programs in various parts of B.C. “These programs make a difference,” says Dr. Collins, the CMA’s past president. In the case of Dalhousie’s New Brunswick program, 63 per cent of graduates were practising in the province as of 2020.
While more schools are offering rural and remote placements, they’re still not plentiful. Setting up community placements takes years of legwork. “It’s a more expensive way to do things, to be honest,” says Nancy Fowler, executive director of academic family medicine with the College of Family Physicians of Canada. These kinds of placements are crucial, she says, but “there’s much more development. You have to work with the local community.” They take more administrative support to keep running, too.
Meanwhile, no amount of community training can change the hard work of running a general practitioner’s office. “Students need to have a really clear sightline to a good career in family medicine,” says Dr. Fowler. “Right now, what students probably experience is seeing a lot of burnt out family doctors.” The move in some regions to establish multidisciplinary care teams is helping, but it’s still a tough career path, she says.
Doctors at the outset of their careers who want to do things differently can also run into roadblocks. In Ms. Massé’s study, she found that doctors inspired by their experience in the Montreal clinic often wanted to make changes at subsequent jobs to benefit patient care, but they found it difficult. “There are a number of organizational barriers, and often young doctors in these environments don’t feel their organization supports them as actors of change,” Ms. Massé says. “Rather, they are encouraged to fall in line and not ask too many questions.” Broader systemic barriers can also work against those pushing for change in the medical system, she says.
No amount of medical school reforms can change the fundamentals of what it means to be a doctor, and to be a doctor in Canada’s imperfect health-care system. But the model tested by NOSM, and now echoed in many existing and proposed programs, might help things improve for doctors and their patients. “We need to take better care of people,” says NOSM’s Dr. Verma. “Our system will be judged on how well we take care of the most vulnerable.”
I can attest that social accountability is one of the main draws for why I chose NOSM. The school really does do a good job of increasing the physician numbers in underserved areas and helps to improve the lives of many citizens in remote communities.
Doctors need to train at hospitals to see the sickest patients, experience the full spectrum of health, and in the process learn risk management, prioritization, what they can and can’t do. Hope the new medical schools figure out a good balance.
All medical programmes have to fulfil learning objectives that require students to have quite a lot of hospital experience. What has been lacking in many is the community medicine and social accountability aspects and the opportunities to get experience in underserved areas. These doctors from programmes like NOSM are and will be every bit as qualified as those schools that don’t have these experiences available and possibly will be better practitioners because they will better understand the realities of the needs of all the communities in Canada.