Northern Ontario School of Medicine.

Abstract

Medical Education Program Highlights The Northern Ontario School of Medicine (NOSM) was established in 2005 as Canada’s newest medical school.1 It is a not-for-profit corporation that acts as the Faculty of Medicine of 2 universities, Lakehead University and Laurentian University.1 The school was founded with a requirement to be socially accountable: that its activities should lead to an improvement in both the health and health care of those living in the region it serves. Northern Ontarians experience generally poorer health than those living elsewhere in the province, due to the interplay of many factors including those related to geography and ethnicity.2 The region covers approximately 800,000 square kilometers, most of which is sparsely populated. Indeed, although some residents live in smaller cities of approximately 70,000–110,000 residents, many live in smaller urban, or in rural and often remote, communities. Many of the region’s communities have experienced difficulties recruiting and retaining physicians and other health care professionals, thereby limiting access to health care services. The region is also home to Indigenous and Francophone persons who experience higher levels of health inequity, including higher rates of morbidity and mortality.3 Socially accountable medical education at NOSM has therefore focused on the areas of greatest need, these being Indigenous health, Francophone health, and rural health. The curriculum includes a unique collection of educational experiences that aim to equip students with the necessary knowledge, skills, and attitudes to meet the needs of those underserved populations. These include: During the first 2 years (preclerkship) of study, NOSM students take part in three 4-week placements situated in rural communities across the region. In the first year, students study the historical, social, cultural, and geographic factors that determine the health of Indigenous peoples in Northern Ontario and take part in activities that prepare the student to deliver culturally safe care to their Indigenous patients. This begins with classroom-based sessions, some of which are taught by Indigenous persons including Elders. The year ends with a mandatory 4-week cultural immersion experience during which students live and learn in an Indigenous community, following a curriculum designed by the community itself. In year 2, students spend time in a rural and/or remote community during 2-month-long community placements to learn about and develop an appreciation for rural practice. During these 4-week blocks, students are taught by one or more of NOSM’s rural community-based faculty members. They also attend social and cultural events that aim to develop an understanding of what it is like to live in a small community as a physician. Once per week students take part in Community Learning Sessions (CLS) situated in a community setting related to health care. These could be the office of a physiotherapist or other health care professional as part of the school’s interprofessionalism curriculum, or in a health or social services agency such as addiction services or children’s mental health. CLS allows students to learn firsthand about the wider health care system. Clinical reasoning and decision-making, including the ability to generate differential diagnoses are key skills for medical students. A recent curricular innovation, Medicine in Practice (MIP), has first- and second-year NOSM students learn these skills directly from clinical faculty through a series of worked example cases. MIP also covers the realities of physician work, including ethical dilemmas, when and when not to order tests, and the influence of commercial interests on health care. Along with facilitated problem-based learning sessions, these innovative classroom activities assist students to gain confidence and ability in clinical work before entering their clerkship. In the program’s third year, students complete a mandatory 8-month comprehensive community clerkship (CCC) (also known as a longitudinal integrated clerkship). This occurs outside of the 2 largest population centers in mainly primary care settings. The clerkship functions both as an introduction to small-community practice and as a means for students to become aware of available career opportunities. Curriculum Curriculum description The MD is a 4-year distributed medical education program that supports each student to achieve the program outcomes (described below), which are aligned with the CanMEDS4 competency framework. The program is split into 3 phases. Phase 1 encompasses years 1 and 2 and is a mainly classroom-based preclerkship that takes place at one of the school’s 2 main campuses in Thunder Bay or Sudbury. This phase includes a cultural immersion, placements in remote and/or rural communities, and weekly community-based learning experiences as described above. Phase 1 consists of a 4-week introductory module followed by 10 modules (5 in each year) organized around the body systems: Module 101: Introduction to medical studies Module 102: Gastrointestinal system Module 103: Cardiopulmonary system Module 104: Neuroscience 1 with a focus on neurology Module 105: Musculoskeletal system Module 106: Endocrine system Module 107: Reproductive system and genetics Module 108: Renal system Module 109: Hematology and Immunology Module 110: Neuroscience 2 with a focus on mental health Module 111: Integumentary system and integrative physiology Phases 2 and 3 can be thought of as the equivalent to the traditional clerkship, providing clinical training supervised by a physician preceptor. Phase 2, the CCC, takes place during year 3 in a mainly primary care setting at 1 of 15 sites ranging from small rural to small urban. During Phase 2, students learn the core clinical disciplines, not as distinct rotations, but longitudinally throughout the year. Phase 3 in year 4 occurs in a tertiary care hospital, in Sudbury or Thunder Bay. It includes the traditional rotations of children’s health, women’s health, surgery, internal medicine, psychiatry, and emergency medicine, along with at least 14 weeks of electives. The program uses an integrated teaching model containing 5 concurrent curricular elements, termed “themes.” Each Theme Committee then designs and governs 4 year-long courses, 1 for each year of the program, making a total of 20 courses that all students must pass to obtain their degree. The 5 themes5 are: Theme 1: Northern and rural health Theme 2: Professional and personal aspects of health care Theme 3: Social and population health Theme 4: Foundations of medicine (the “sciences”) Theme 5: Introduction to clinical medicine in Phase 1, clinical medicine and therapeutics in Phases 2 and 3 Curriculum changes since 2010 The curricular blueprint has not been fundamentally altered since 2010 although updates and enhancements have been implemented for quality improvement purposes, including curricula related to pharmacology and therapeutics, clinical reasoning, the assessment and teaching of professionalism, culinary medicine, advocacy, and research. The program has begun planning curriculum renewal, a process that will begin in earnest in the 2020–2021 academic year. The class size was increased from 56 to 64 students beginning in the 2010–2011 academic year. To accommodate this change, additional community sites were added to the Phase 2 (year 3) clerkship, and two more 4-student streams to the Phase 3 (year 4) rotations. Assessment The medical education program objectives are organized by the program’s 5 themes (described above), and were written to align with the CanMEDS framework. See Supplemental Digital Appendix 1—Medical Education Program Outcomes—at https://links.lww.com/ACADMED/A871. The program’s assessment structure requires that students obtain a passing grade in each of the 5 courses that constitute each year of study. Some new assessment exercises have been added including student reflective exercises about time spent in the weekly CLS, and in the rural and remote community placements in year 2. The program has also limited the term “remediation” to major course fails that require either the repeat of a course or rotation, or the addition of nonroutine educational activities to the student’s program. Repeating a failed assessment is viewed as minor, is termed “reassessment,” and is not recorded on the student’s permanent record. Curricular Governance The academic governance of the program is unusual due to NOSM being the Faculty of Medicine of 2 universities (Lakehead and Laurentian Universities) and hence academic authority rests with 2 senates. Within the school curriculum, governance is situated in the Undergraduate Medical Education Committee and its Curriculum Committee Subcommittee, with the governance of each phase, theme, and courses, as well as different activities, being delegated to a series of subcommittees. There is a single curriculum governance structure that applies to all the teaching sites that make up the program. The faculty, staff, and students participating in governance are drawn from across teaching, sites which helps ensure consistency and feasibility of the program’s curriculum between locations. Participants attend meetings either in-person or by video- or teleconferencing. See Supplemental Digital Appendix 2—Curriculum Governance Structure—at https://links.lww.com/ACADMED/A871. Education Staff The Office of Undergraduate Medical Education (UME) is led by the associate dean for UME, who is the head academic and administrative officer for the program. A number of academic staff report to the associate dean including the phase leads (the assistant dean for Phase 1, and the clerkship directors for phase 2 or 3), the chairs for themes 1 through 5, the assistant dean for clinical education, the assistant dean for admissions, and the director of program evaluation and assessment. The senior director of UME administration reports to the associate dean for UME. The director is the most senior administrative position in UME and oversees the work of approximately 40 staff and managers. NOSM is headed by the dean of medicine, who is also the president and CEO of the corporation to whom the vice dean academic and several associate deans report (a number of associate and assistant deans report to the vice dean academic who oversees education including UME, postgraduate education, learner affairs, and continuing education and professional development). See Figure 1—Decanal organizational chart.Figure 1: Decanal organizational chart.The Office of UME has responsibility for the 4-year MD program, and also for the admissions unit, which recruits and selects students for entry into UME. Although NOSM does not have a Department of Medical Education, the Office of UME serves an equivalent function, appointing and supervising the faculty who serve in leadership positions within the program. NOSM also conducts medical education scholarship within the Medical Education Research Laboratory in the North, with which UME closely collaborates. See Supplemental Digital Appendix 3—Academic and Corporate Governance Structure—at https://links.lww.com/ACADMED/A871. Faculty Development and Support in Education Faculty professional development at NOSM is led by the Office of Continuing Education and Professional Development (CEPD). CEPD delivers a program of development opportunities in person, by videoconference, and by means of prepared online learning modules or sessions. The CEPD unit also runs Northern Constellations, an annual faculty development conference open to all faculty, and has hosted Northern Lights, a leadership development event for physician faculty. The school’s annual Northern Health Research Conference also provides faculty with the opportunity to develop their research and scholarship skills. The policies governing appointment and promotion of all NOSM faculty foster teaching excellence as a key component of career progression. Faculty develop a teaching portfolio that contains their teaching evaluations (by peers and students), and this, along with recommendations from peers and those in leadership positions, is used in the promotions process. Regional Medical Campuses The Phase 2 CCC takes place at 15 regional sites. See Table 1—Regional Medical Campuses.Table 1: Regional Medical Campuses