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picardonhealth · 6 years ago

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Rural medicine: How a gamble to bring in doctors is paying off

Twelve years after the first class began at The Northern Ontario School of Medicine, many remote communities have ‘gone from crisis mode to planning mode’

André Picard, The Globe and Mail

Sunday, January 14, 2018

SUDBURY — When the Northern Ontario School of Medicine was created, it was based on a simple – but untested – premise: If you educate and train physicians in rural and remote northern communities, they will be more likely to practise there.

Twelve years later, the gamble is paying off better than anyone expected: 94 per cent of NOSM graduates who do a family medicine residency in the North stay there to practise, and 69 per cent of all graduates, specialists and GPs alike, have opted to work in remote and rural areas, particularly Northern Ontario.

"Has it worked?" Dr. Roger Strasser, the dean of NOSM asks. "Yes it has. Many northern communities have gone from crisis mode to planning mode thanks to our graduates. But we're still a long way from having the medical care we need in Northern Ontario." One of the success stories is Chapleau, located 850 kilometres north of Toronto. The blue-collar town went years without a physician before three NOSM graduates decided to set up shop for the 3,000 people in a catchment area that includes the township and the nearby reserves.

The trio established a family health team that operates a family medicine clinic, and they staff the ER in the small local hospital, oversee home care and long-term care, and run clinics in the two nearby First Nations communities, Brunswick House and Chapleau Cree First Nation.

"The area went seven years without a family doctor so there was no continuity of care and a lot of people's health was neglected. So, yes, they appreciate us," says Dr. Doris Mitchell, who graduated from NOSM in 2010.

A member of the Brunswick House First Nation, she worked as a nurse for 15 years before applying to medical school.

"I had aspirations to be a physician but I didn't want to leave the North, so NOSM was a perfect fit for me," she says.

Dr. Mitchell says that, after several years of practice, she really appreciates the school's hands-on approach to learning and its emphasis on rural medicine.

"They prepared us not only for the work environment, but for the emotional environment," she said.

Small-town medicine is rewarding because physicians dabble in a bit of everything, from minor surgery (sometimes even on patients' pets) through to trauma care and palliative care.

"The sense of community is wonderful but the reality is that working in your hometown can also be horrible," Dr. Mitchell says. There are unwanted pregnancies, suicides, heart attacks and deaths, and none of the patients are anonymous strangers; sometimes they are even family members and that can be awkward and ethically challenging.

The resources and technology can also be limited. Dr. Mitchell recounts the case of a car-crash victim with five fractures, as well as a perforated bowel and kidney, all of which had to be diagnosed without a CT scan or MRI, and whose care was complicated by the fact a snowstorm delayed the arrival of the air ambulance.

The right fit

The dream of a northern medical school dated back decades. When McMaster University was granted a medical school in 1972, there was hope that a school would also be established at Lakehead University in Thunder Bay. Instead, McMaster created a program to send its students to Northern Ontario for training and residency.

In 1999, the Ontario government established a commission to examine the province's physician supply and distribution problems. That report featured a single line saying the idea of a rural/northern medical school should be investigated.

An expert panel was appointed and they recommended against a school, saying they had reservations about the ability to attract qualified staff and quality training opportunities.

But access problems in the North were dire and the mayors of northern cities lobbied for a home-grown solution.

The Northern Ontario School of Medicine was approved in 2001, and the first class began in 2005, with two campuses, one at Laurentian University in Sudbury and the other at Lakehead University.

Today, NOSM has 64 places, split between the two cities. It gets more than 2,000 applicants annually. Tuition fees are $20,000 a year, middle-of-the-pack among Canada's 17 medical schools.

The selection process favours students from Northern Ontario, those from other parts of rural/remote Canada, francophones and Indigenous students, but there is no affirmative action program. "We consulted with the community and they don't want a quota because they feel it creates stigma," Dr. Strasser says.

NOSM does not use the Medical College Admission Test, because it has never been validated for francophone or Indigenous students. Instead, applicants undergo multiple mini-interviews, many of them involving community members such as patients, activists and First Nations elders.

Kimberley Edwards, a third-year medical student, says NOSM is the only medical school she applied to.

"Because of who I am, it felt like the right fit."

Ms. Edwards is Cree, but was brought up in Carleton Place, a small town outside Ottawa.

Like many NOSM students, she is older – she is 36 – and took a circuitous route to medicine.

After high school, she studied human kinetics at the University of Guelph. "But, to be honest, it didn't go so well. I was one of the only Indigenous students and I didn't feel like I fit in," Ms. Edwards says.

She left school and took a job in a sleep clinic, then went to Mohawk College to learn diagnostic heart sonography. That led to a job at the Ottawa Heart Institute, which sparked an interest in both medicine and the North. (Cardiac patients from Nunavut travel to Ottawa for care and the institute does regular clinics in Iqaluit, something Ms. Edwards loved.)

"Because my grades weren't great, I decided to return to school, and see if I could qualify for med school," she says of her decision to study in the physician assistant program at the University of Toronto. From there, she applied successfully to NOSM.

"I want to practise family medicine, to work with Indigenous people in the North, so the program has been great," Ms. Edwards says.

That decision on her future career was sealed when she spent a month in Moose Factory, not far (in northern terms) from Attawapiskat, where her father was raised.

George Payne, a first-year student, was brought up in Sault Ste. Marie but went south for school, at the University of Guelph, then Waterloo.

He was accepted to three medical schools, but chose NOSM because he wanted to be back in Northern Ontario. "I really missed the winters," he says.

Mr. Payne also loves the intimacy of NOSM. At the Thunder Bay campus, his class is only 28 students, and they mostly do problem-based learning in small groups and lots of field work.

"They really prepare you for the real world here," he says, excitedly recounting how he just returned from a placement with paramedics.

In first year, NOSM students must do a four-week placement in a remote Indigenous community. In second year, there are two two-week stints in rural areas, again often Indigenous communities. (There are more than 200 reserves in Ontario, most in the North.) In third year, there is an eight-month clerkship in one of 15 communities and, in the final year, students spend time in a tertiary hospital in places such as Sudbury or North Bay.

Almost two-thirds of NOSM graduates choose family medicine for their residency, double the national average; one-third chose general specialties and; only 5 per cent chose a subspecialty.

Andrew Ferrier is one who took the subspecialist route. He just began a five-year dermatology program at the University of Alberta in Edmonton.

He has studied both at Lake Forest College near Chicago (on a hockey scholarship) and University of Ottawa – where he earned a PhD in neuroscience – but, as a Métis from Cape Breton, he says rural life "has a big pull on my heart."

Dr. Ferrier had a placement in a dermatology clinic in second year and found his passion. He plans to return to Northern Ontario to practise. That's good news for patients – the wait list to see a dermatologist in Sudbury is more than 18 months. And patients in the North often have to travel to Toronto or Ottawa to see specialists.

Paul Heinrich, CEO of the North Bay Regional Health Centre, says NOSM has played an important role in attracting physicians to the region and retaining them. One in three new doctors at the hospital are NOSM grads.

But other measures have also helped.

A physician who chooses North Bay can qualify for a $25,000 relocation bonus from the regional health centre, and the city matches that amount; the provincial Northern Health Programs also provides an additional $80,000 over four years. In return, the doctor must commit to staying in the city for five years and taking on 1,200 patients.

"But the biggest draw isn't the money; it's the lifestyle," Mr. Heinrich says.

Dr. Renée Gauthier agrees.

She and three partners – all NOSM grads – opened the Northern Shores Medical Clinic after graduation.

"We all wanted to come back home because this is a nice place to live and raise a family," she says.

The clinic has room to take on a dozen physicians in total, and the need is there. North Bay, a city of 50,000, has an estimated 15,000 orphan patients.

François Doiron was a nurse with a family health team in Marathon, Ont., when he discovered his passion for rural medicine.

He applied and was accepted to three medical schools but chose NOSM. Dr. Doiron just graduated and is doing his family medicine residency with the Harbourview Family Health Team in Thunder Bay.

"I plan to practise in the North, so I wanted to be trained in this environment," he says.

While Dr. Doiron is almost two years away from completing his residency, he is already being wooed by several communities to set up a family medicine practice.

"The need is there, that's for sure," he says. "But I want to be careful not to be wooed by the money or the perks. I want to practise where I plan to spend my life."

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