Medical Education Strategies for Rural and Remote Communities
Two major factors affect the availability of high quality health care to rural and remote populations. First is the reluctance of health care professionals to locate in rural and remote regions. Second, the mix of generalists and specialists required for rural/remote areas is different from that characteristic of major cities which can function with a high degree of specialization. A general trend toward greater specialization means fewer generalists available for rural and remote practice.
Urban-based medical education is poor foundation for rural practice
Medical education takes place mostly in large urban centers where students are exposed to teaching hospitals with a high degree of specialization and high technology treatment options. The large range of cultural attractions in big cities also acts as a social magnet to young professionals. After immersion in such a rich cultural and technological environment, the prospect of medical practice in rural and remote areas is unappealing to many students. Also their clinical experience in an urban setting may not adequately prepare them for rural remote practice.
Generalist versus Specialist approaches
The Association of Faculties of Medicine of Canada, in two reports of the future of medical education in Canada, has highlighted the need to achieve the right balance between generalist and specialist approaches to health care (AFMC; AFMC 2012). The strong linkage of specialty medicine with the development of new scientific knowledge and technological innovation has lent it great prestige and made it harder to portray a generalist approach in an appealing light to students. This poses a special problem for rural and remote areas where specialists are less available and family physicians and other primary care providers must provide a wider range of services than their urban counterparts.
Designing medical education for rural/remote practice
There are a number of ways in which MD programs can make rural practice more appealing and do a better job of preparing their students for it. A program which declares its aim of focusing on rural remote practice will attract more applicants with a natural affinity for this work and admissions criteria can give priority to factors predicting high probability that graduates will adopt rural practice. Ensuring students are exposed to clinical practice in rural and remote settings for the major part of their program will more readily prepare them for practice in these settings. It has also been shown that students learn very effectively about the specialty disciplines when they encounter relevant cases in rural clinical settings rather than from specialists in teaching hospitals (Worley et al: 2004). Learning medicine in this way is much more likely to lead to a positive image of family practice in a rural environment.
While a number of rural streams have been created as satellite programs within the framework of existing MD programs, the Northern Ontario School of Medicine was designed as a new stand-alone school dedicated to meet the health care needs of northern, rural and remote populations. (Tesson et al. 2009)
NOSM’s MD program has a number of features which make it particularly effective in meeting its mandate of serving the rural and remote populations of Northern Ontario:
Applicants who meet the required grade average standard (3.0 on the 4.0 scale), are then evaluated on the degree of their experience and interest in northern and rural communities. The School’s goal is to seek a student body profile reflecting the demographics of Northern Ontario.
There are distributed learning sites across the whole of Northern Ontario with special focus on rural and remote sites (see map). Students work in small groups using a case-based learning model and are mentored by family physician preceptors.
As part of their third year Comprehensive Community Clerkship, students spend eight months in a host community in Northern Ontario. They study specialty disciplines, pursuing them as cases arise within their community practice. They meet the same standards as students in urban teaching hospitals, but their learning takes place within the context of rural community medicine.
Northern and Rural Health is one of five core themes woven through the 4 year MD program. It covers the teaching of cultural competency especially in relation to populations in Northern Ontario such as francophone and aboriginal peoples. All students spend four weeks in an aboriginal community in their first year and can opt for a francophone community for other placements.
NOSM has been in operation now for over seven years and has a high success rate in placing its graduates in northern, rural and remote settings and with more than half its students opting for family medicine as their specialty. Its students have also achieved excellent results in meeting national standards, showing that there is no reason why an MD program focusing on rural and remote communities should compromise on quality. On the contrary, rural and remote communities have proved to be rich learning environments for clinical practice.
|Author :||Geoffrey Tesson, Ph.D.
Centre for Rural and Northern Health Research
The Association of Faculties of Medicine of Canada. The Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education. Report.
The Association of Faculties of Medicine of Canada (2012). A Collective Vision for Postgraduate Medical Education in Canada. Report.
Tesson, G., Hudson, G., Strasser, R., and Hunt, D. (2009). The Making of the Northern Ontario School of Medicine: A Case Study in the History of Medical Education. Montreal: McGill-Queen’s University Press. Also in French: La création de l’École de médecine du Nord de l’Ontario : Une étude de cas dans l’histoire de la formation médicale. Montreal: McGill-Queen’s University Press.
Worley, P., Strasser, R. and Prideaux, D. (2004). Can Medical Students Learn Specialist Disciplines Based in Rural Practice: Lessons from Students’ Self reported Experience and Competence. Rural and Remote Health, 4 (4):338.