NBB

By Dr. Preston Smith
For the Times & Transcript

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The recent and long awaited decision by the New Brunswick government to launch the Dalhousie Medical Education Program in New Brunswick (DMEP NB) with Moncton and southeast New Brunswick as a full partner is essential to the future supply of doctors for the province and part of a world-wide revolution in medical education.

This trend is seeing the establishment of part or all of medical education in communities all over the world that are far from the traditional "ivory tower." These changes are in response to the need to train more doctors; train the right doctors for our communities; enhance recruitment of doctors and finally take advantage of the economic development opportunities that go with medical schools.

Recently I represented Dalhousie Faculty of Medicine at the International Conference on Community Engaged Medical Education in various communities in Northern Ontario hosted by the Northern Ontario School of Medicine (Canada's seventeenth medical school and the first new one in 40 years) and Flinders University of Australia.

This was an incredibly inspiring week with some very dedicated and forward thinking medical educators. One hundred and twenty-five delegates from all five continents enthusiastically described programs like DMEP NB delivered in diverse communities ranging from medium sized cities to aboriginal communities of 500 people.

These are possible through the creative use of technologies from bush planes to modern educational approaches like video-conferencing, web-based curriculums, sophisticated software for anatomy teaching, e-libraries, etc. Speaker after speaker described how they used these tools to deliver "continuous care and education in the communities where people live."

MORE DOCTORS

There is a desperate shortage of doctors such that, for example, five million Canadians do not have a family doctor.

Since the late 1990s Canadian medical schools have expanded enrollment from 1,500 to 2,500 first year students today with some projections it may need to go as high as 4,000. When modern medical schools evolved early in the 1900s teaching hospitals in big cities were large and patients were in hospital for long periods. For example a gall bladder operation resulted in seven to 10 days in hospital, a heart attack was six weeks and patients were routinely admitted for tests.

Hospitals had many patients who learners could get to know while learning and assisting in their care. Today given technology, drugs and an ever-increasing pressure for efficiency, gall bladders are out-patient operations, heart attack admissions are six days and no one gets admitted for tests.

Formerly medical school was two to three years of classroom work focused on basic sciences and one to two years of "clinical" teaching in the hospital. Given the explosion of clinical knowledge over the last 40 years more and more of the teaching has become clinical and many schools including Dalhousie start this in first year, increasing the time needed for students to learn from real people.

Furthermore since the early 1900s we have seen more allied health professionals with broader roles and growing enrollments such as nurse practitioners, pharmacists, physiotherapists, etc. who all need clinical training in hospitals. Simply put there is no room for more learners in the traditional "teaching hospitals."

"Medical Education is going to the community because that is where the patients are" and Dalhousie needs Moncton if we are ever to train enough doctors.

THE RIGHT DOCTORS

All medical schools have a declared mission to train competent, compassionate, patient centered doctors with broad skills that are able to respond to the needs of the community they serve.

However the ultra-efficient hospitals described above (some teaching hospital CEOs proudly refer to their hi-tech acute care factories) are often only filled with Intensive Care Unit patients and people waiting for nursing homes! Many of these patients can really only be cared for by senior learners and the brief glimpses medical students do get don't allow really knowing the patient or developing any relationship. This is not conducive to learning the compassionate, patient centered approach.

If you have a heart attack in a big teaching hospital you may see three or four sub-specialists in cardiology. The sub-specialists are all there because of their research careers, but the hidden message to students is the only people that can provide good care are the super sub-specialists. This is resulting in a growing reluctance to choose the generalist specialties so desperately needed in our Maritimes communities.

By training doctors in the community they will see and choose career paths that are needed, and by being closer to the patient and the community they will learn the compassionate patient-centered skills we all want in our doctor.

RECRUITMENT

Research shows that the three main influences on where a doctor settles are where they are from, where their spouse is from and where they trained. However even some rural medical students are enticed to stay in the big city after eight to 10 years of city life with the attendant social activities, entertainment opportunities, etc. By training New Brunswick students in New Brunswick we will greatly enhance the possibility of recruiting them to our communities. Our experience at Dalhousie Family Medicine with our Family Medicine residency programs in Moncton, Fredericton, Saint John and Sydney bears this out.

ECONOMIC DEVELOPMENT

Good jobs, quality education for their children and accessible health care for their families help attract and retain people in our communities. Thus having sufficient health care professionals is essential to any community's prosperity.

With the current emphasis on training doctors to have an enquiring mind and a commitment to lifelong learning, the vast majority of graduates want a career in which they can incorporate teaching and research. Without DMEP NB in our community many graduates, even our children, will go elsewhere. With programs like DMEP NB developing all across this country they will have many choices.

Finally estimates are that the economic multiplier is at least four to one for every dollar invested in medical schools.

However if one could see the pride and enthusiasm with which local communities recently described their role in the Northern Ontario School of Medicine it is obvious there is much more to what NOSM calls "community engagement."

One example is the warm welcome and personally guided tour of the community by the mayor of Sault St. Marie and the wonderful dinner provided us by their Economic Development Commission.

I questioned their Economic Development Officer as to why they would do this for a bunch of medical educators from away and his response was insightful: "the integration of health, learning and economic development is absolutely essential to the well-being of our citizens and our community."

The enthusiasm in these communities is matched by those promoting a new approach to educating doctors. Not only are they enthused about the potential to train doctors for their own communities, they are also convinced they are going to do it better.

Although the first two "classroom" years of DMEP NB are based in Saint John, many of these students will live, learn and work in Moncton during their final two clinical years.

The Moncton Hospital has a proud history of training doctors which goes back to the 1950s and will surely continue to excel as a full partner of DMEP NB.

Preston Smith, MD, CCFP, FCFP, is Chair of the Implementation Committee of the Dalhousie Medical Education Program, NB, and Head of the Department of Family Medicine at Dalhousie University in Halifax, N.S.

Français: Preston Smith, président du Comité d'implantation du Programme de formation médicale de Dalhousie et responsable du Département de médicine familiale à l'Université de Dalhousie, à Halifax, a déclaré que le nouveau programme de formation médicale de Dalhousie offert au Nouveau-Brunswick est essentiel afin de combler la pénurie future de médecins pour la province et une partie de la révolution mondiale en éducation médicale