I enjoyed the chance to speak in Canada to
rural docs and educators at the
Canadian FP meeting in Montreal. 15 of the 16 departments and programs were
represented. My thanks to Dale Dewar, Karl Stobbe, Peter, Pierre, Dan, Jim,
and others at the SRPC and the FP Association who took great care of me.
My talk was on the role of FP and restoration in communities, the nation,
and the world. You are all greatly needed and should be better appreciated!
My presentation in Montreal with links may be helpful to you in this area:
http://www.unmc.edu/Community/ruralmeded/restoration_with_links.htm
At this first meeting were significant players, the FP heads of the section
on teachers and one of those involved in accreditation of FP graduate
programs. This is a measure of the importance of rural health to FP and
vice versa, something we could recognize better in the US where we rarely
get a chance to work with accreditation folks. It looks like one of the
first tasks of this group will be working in this area.
Canadian medical educators, working out of the oldest city in this
continent (and throughout the province) have also been doing rural medical
education longer than anyone else on the continent. Great people, great
ideas, great needs.
Canada faces similar problems with the match, increasing duties, etc. They
have a worse problem with lack of respect, the local MD stories, and also
being a specialty of convenience for those who want to practice part time
or have a 1 year shorter route to do emergency room practice (2 yrs FP, 1
yr ER fellowship). This also makes it difficult to interpret surveys of
medical students, since they are a mixed bag of interest in FP.
The new northern medical school is being built with Roger Strausser there
from Australia to be Dean. They will begin assembling faculty and
curricula. They are working on admissions policies and plan to get the
right students admitted to be able to return to rural Ontario and Canada.
They will have to deal with the same LCME situation that took so much time
and effort and legal and legislative work at Florida State. God be with
them. Canada also does not have small rural colleges that can assist them
in this effort, as they have helped Rabinowitz in PA, and us in Nebraska,
and others. The college feeders of medical students in Canada are private,
urban, and centralized. The students from lower socioeconomic groups that
would have the right stuff have to work to support themselves in college
more and this makes it far more difficult for them to do well enough to get
into medical school. Indigenous peoples and those from other underserved
areas have a difficult time. I wish Canada had some rural schools in the
smaller towns that could feed medical schools the kids that preferred the
rural lifestyle, etc. This would be helpful to avoid the urban culture as
much and as long as possible.
The completely problem based curricula at one school might offer the
potential to do college and medical school and residency completely in
rural areas! This would be the ultimate recruitment and retention model.
Again I had a chance to reflect on how far we have gotten away from the
initial concepts of medical education reform and how far we have gotten
into rigidity and infrastructure. Somehow we have forgotten that Flexner
really wanted to be practical, utilitarian, patient-focused, and connect
preprofessional to medical school and medical school to residency training.
(Robert Ebert, former Harvard Dean, Flexner's Model and the Future of
Medical Eduation, Academic Medicine 67:11 Nov 1992) It was not Flexner's
fault that mainly urban colleges and high schools woke up to provide
academically prepared candidates for medical school, thus worsening the
maldistribution and distressing Flexner, Osler, and others, as well as all
of us. We have shown that we can indeed restore high school and small
college education with the leadership of medical education in Nebraska to
reach out preprofessional to small colleges and advisors.
The distancing that goes on in academics, the reduction in the value of the
hospital since patients are there so little now, and other factors have
changed and so must accreditation. Particularly difficult is the lack of
ability for students and residents to be able to make decisions. This is
something regularly noted by Canadian med students who come back from US
rotations. They hate being 5th in line. Their better liability situation
and their better continuity has not impacted training as much.
In this country, it is my view that the subtle changes year to year in loss
of medical mastery and confidence is particularly devastating to primary
care, family practice, and consideration of careers of service to the
underserved. It is clear that unless students master medicine in a
facilitated fashion, they will not move on to mastery of relationships with
patients and those impacting medicine from without (practice management,
insurance, communities, public health, government, etc.).
The big debates in Canada in the FP world are changing from a 2 to a 3 year
residency program. This would perhaps give up flexibility (since so many
interested in rural do 3 - 12 months extra prep) and perhaps some rural
numbers (we lost same going from 1 to 3 yrs) In exchange they are hoping
for more credibility with the powers that be, of course this, as we know,
is a long slow process that may not work well at all. I also pointed out
the Alaska model where FP grads in Alaska would exchange with faculty at
the residency program to allow better cooperation, better training, better
balance, better CME, etc. Two of the speakers cited the US as "actively
debating" an increase to 4 years. Something I rose in questions to point
out that this was not true. I did note that osteopaths in the US were
moving from 2 to 3 years for FP residency length. I guess I have managed to
make some enemies in two nations now at the dean and medical leader level.
FP in Canada is perched on the edge of some very big potential for positive
changes. Major government leaders at the national and provincial level have
stepped up verbal support and some major reports have come out. There is a
major movement for social accountability for medical schools also. They
have studies noting that FP docs there are more highly valued than any
other part of health care, including other providers, administrators,
government, and specialists.
An example of the flexibility in Canada is discussions with the accrediting
doc regarding continuity. He noted that the best evidence of continuity was
in questioning the residents in this area. When residents consistently
noted "ownership" of patients, continuity was evident. This was not as
important as half day backs in a so-called "continuity clinic" or times of
months where residents were away thus disturbing "continuity" as if our
hospital orientation and the dominance of specialty rotations did not
disturb continuity enough. (sorry for the emotion, this is a key area for
RME) Other rural faculty noted that his continuity was not always a
consistent view by accreditors, but nonetheless if was refreshing to hear
this view from an experience leader in FP accreditation in Canada whose
program has been doing FP and rural medical education longer than anyone
else in perhaps the world. The consensus of the group was that true
continuity was something that you began to realize after about 4 years of
practicing in the same location with the same patients.
The potential in Canada is tremendous to do a 3 year prep in med school
(some schools do have 3 yr programs) then an M-4 rural preceptorship like
Syracuse (modeled on MN RPAP) and then do a 2 year FP residency. This might
also be something that osteopathic schools in the US should consider. The
flexible and optional 3rd year extra training offers much potential.
Preceptor pay was also an issue and I pointed out that the loss of pay on
taxes ($300 or more of a $500 pay per week) and the quantification of pay
(risk of loss of preceptor through comparison of hours to teach vs pay)
might not work as well as other methods, particularly what folks like Joe
Hobbs are doing in Georgia where preceptors become faculty. Mutual benefit
and in kind contributions may outweigh any pay. We also talked about rural
networks of physicians that work together for education, grants,
recruitment, expense sharing, negotions, etc. We also discussed community
friendly rural med ed where resident and student rotations are designed to
contribute to community and doc instead of taking more than they give.
http://www.unmc.edu/Community/ruralmeded/community_friendly_aspects.htm
Rural Medical Education Group info and list serve is
http://www.unmc.edu/Community/ruralmeded/narme.htm
Canadian Rural Med ed list serve at
redlist@cfpc.ca or
topps@ucalgary.ca
Robert C. Bowman, M.D., Co-Chairman
Rural Medical Educators Group of the National Rural Health Association
UNMC Department of Family Medicine Director of Rural Health Education and
Research
983075 Nebraska Medical Center
Omaha, NE 68198-3075
(402) 559-8873 or fax at -8118
Email: rbowman@unmc.edu
http://www.ruralmedicaleducation.org or
http://www.unmc.edu/Community/ruralmeded/