This summer I have had the chance to tour this beautiful province and to date I have been to 6 of the health regions. I have met committed physicians, hard working hospital and community leaders and enthusiastic learners. I have also learned of the challenges with the longstanding shortage of doctors in Saskatchewan. It has reinforced to me why we must get distributed medical education right for the people of Saskatchewan. I will start with 3 anecdotes that align with the 3 principal reasons for distributed medical education that are evidence-based.
The Dean and I at Dalhousie visited the Integrated Clinical Clerkship site in Mirimachi, NB about 10 months into the 12-month program. There we met three keen and happy clinical clerks (JURSIs) and an engaged and enthusiastic faculty. They were chuckling at an incident that morning in the ER when during resuscitation efforts, the attending said to the medical student “you better let the RT do the blood gases – he is getting out of practice!” The reason the medical student was doing the blood gases was that he already had many intubations – well beyond the norm for a medical student.
The second is an old favorite of mine. At the Moncton Hospital (a 350 bed regional hospital) there was a regular PGY1 surgical resident. The local doc would take bets on how long it would take the incoming resident to say: “I can’t believe what you guys do here!” (And occasionally – “we are not even doing that yet in Halifax!”) It was usually within the first two days, and always by the end of the first week. It was often the residents’ first experience of a real healthcare system outside the tertiary centre, and for many, a sudden realization a career there may be very attractive.
The last story is the reason I pursued a career of leadership in medical education. About three or four years after we started a Family Medicine residency site in Moncton, the Chief of Staff, a superb internist and rheumatologist, came to me as I was the site director. The Chief told me he and his colleagues could see an improvement in the quality of care by family doctors in our town since the time when our program had started. What was most inspiring, was that this was across the entire community – not simply the dozen or so FD’s who were doing the bulk of the teaching. With acknowledgment to my Maritime roots – a rising tide raises all boats.
So, the first reason is clinical teaching capacity. For many reasons there is simply not enough room in our tertiary centres for all our learners. This phenomena has been demonstrated all around the world. For example: 4000 learners rotate through Halifax hospitals every year. Technology, drives for efficiency, and sub-specialization of tertiary hospitals are all contributing factors. . Many of us who trained over 20 years ago had our early clinical experience on patients (post-op cholecystectomies, croup, admitted for test, etc.) that are no longer in the hospital. Even more concerning from a pedagogic perspective, is most of the patients in our tertiary centres have complex, multi-system disease and often already have definitive diagnoses. However our junior learners must learn to reason clinically from first principles and develop a competent approach to the undifferentiated clinical presentation. Distributing medical education to many communities affords our learners a plethora of these learning opportunities.
In Canada we have nearly doubled our medical school capacity in 12 years. We have gone from 16 medical schools on 16 campuses (all of UGME as well as PGME training at that site) to 17 medical schools on 28 campuses. If we extended first year to Regina, that would be 29 campuses. In the early 90’s there were 25-30 FM residency sites in Canada, and today there are over 120 and an increasing number of RCPSC programs are based in regional centres. A very rough guess would be about50 – 60 towns and small cities (such as Prince Albert) across Canada now host students doing all of their third year as Integrated Clinical Clerkships (including the entire class at Northern Ontario School of Medicine). Not only do we need distributed medical education but it has become the norm.
The second anecdote also illustrates the issue of clinical teaching capacity, but more importantly, highlights the usual reason for DME – social accountability. Despite the increased number of trainees and now over-supply in some specialties, there is a huge problem across Canada with mal-distribution of physicians across geography and across specialties. The three main factors in geographic choice of practice are: where you are from, where you train and the wishes/career of your life partner. As a medical school, we can impact the first two! There is clear evidence our trainees exposed to community and rural settings are more likely to choose primary career and generalist specialties and locate in rural and community settings. We must do distributed medical education because our role as a medical school is to train doctors for all of the people of Saskatchewan. This also means we must do the specialty and sub-specialty training and the curricular innovation, educational support and intensive basic science and clinical research that can only be done in our major cities. There is room for all of us as we make our College of Medicine a truly provincial institution.
As I said, my favorite reason for DME is quality of care. All of my career I have heard it argued – the presence of learners and the enquiring mind approach to practice – lead to better clinical care. If we truly believe academic medicine helps our patients, then we should do everything in our power to see those advantages extended to as many people in Saskatchewan as possible. Again there is evidence to back up these ideas. Surveys of medical students and residents indicate at least 75% want to have education and/or research as part of their careers. Surely this is a sign we are succeeding in our pedagogic goals. Furthermore, there is good evidence that physicians who teach report greater career satisfaction and higher retention rates. So surely happier physicians and better clinical career are good for all of our communities.
Quality of education is always a stated concern, but here again, the evidence supports distributed medical education. Outcomes in the various models of distributed medical education consistently demonstrate equivalent or better outcomes. The literature around integrated clinical clerkships is now well developed and demonstrates equivalent scores on formal examinations, equivalent or better clinical skills, and higher scores on patient-centeredness/empathy. Finally, students do vote with their feet, and DME options are well subscribed at medical schools throughout the world.
The CoM has already come a long way in implementing DME. However, my travels to date reveal considerable confusion on the details of our long-term plan for DME. The strategic planning that led to The Way Forward emphasized the need for a clear governance structure for DME, but failed to come to a consensus. There is clearly a problem with the operational aspects of DME and the resources available in some locations to support DME.
For these reasons, I would like to launch a Task Group at the College of Medicine to articulate both a strategic plan and a business plan for DME here in Saskatchewan.
My goal is to see this work completed by the end of 2014. The Task Group will be inclusive of all key stakeholders including faculty members from our diverse communities, students, health regions and government.
Please feel free to provide me with your feedback at firstname.lastname@example.org I am keen to hear from you and my door is always open. Together, we are going to build our CoM into one of the leading medical schools in the country in our service to the people of Saskatchewan.