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AAMC Reporter: November 2006Viewpoint:
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Canada has had to face a significant shortfall in its physician workforce size during the last decade. This was partly due to a 10 percent cutback in first-year enrollment in Canadian medical schools in the early 1990s. But there were at least two other contributing factors. One was a pre-existing maldistribution of the Canadian medical graduates in the workforce, favoring the larger urban centers at the expense of the smaller provinces with larger percentages of rural communities. International medical graduates typically filled those less-favored practice locations. Another explanation for the shortfall was the falling physician productivity.More recent graduates, on average, demonstrated lower practice productivity than their seniors, thereby redefining the meaning of full-time equivalent physician activity over time.
Since 1999, many of Canada's 16 existing medical schools, working with their local ministries of health, have returned to their pre-1990s physician production levels. In addition, Ontario, the province with the largest population, started a new medical school in the northern region. It took its first class in 2005.Yet given the other factors mentioned, many felt that Canada would still underproduce physicians compared with its maldistribution issues and falling productivity.
The response was not to open more medical schools. Developing new medical schools as independent academic health centers is expensive. In addition, the ability of the existing medical schools to expand their enrollment beyond the most recent bump-up to their pre-1990s levels was limited.
Another option was considered, which was supported by the deans and their faculties: create satellite learning centers with educational programs covering all core learning objectives of the undergraduate program but emphasizing local needs. This "distributive learning model" had been used in the past for post-graduate clinical education in Canada. Certainly, the Wyoming, Alaska, Montana, and Idaho (WWAMI) program spearheaded by the University of Washington School of Medicine has served as a model for the undergraduate extension of the distributive learning model in Canada.
As of August, 11 satellite campuses have been started or are in development. The first two campuses, both affiliated with the University of British Columbia, are now functioning in Victoria on Vancouver Island and in northern British Columbia at Prince George, with a third campus to be opened in 2009 in eastern British Columbia. A site opened in 2005 in the Mauracie region of Quebec between Montreal and Quebec City, and another began this fall in the northern Lac St. Jean region of Quebec. In New Brunswick, which has no medical schools, the University of Sherbrooke worked with a French campus to create a satellite site in Moncton opening this fall, and Dalhousie University will partner with an English campus to open a site in St. John in 2007. In 2007 and 2008, satellites will open in southern Ontario at Windsor, Kitchener, St. Catharines, and Missisauga.
The results of the 11 initiatives will be followed with great interest. The Canadian Post-graduate Educational Registry (CAPER) will be tracking physician output from the sites, as it does for existing programs. The issues that have attracted the most interest are those that one might expect: How will the graduates from these programs perform on their licensure and certification assessments? Will the push for more "e-educational" learning be effective—and serve as an alternate approach for adoption by the existing programs? And perhaps most important, where will these young physicians locate once they are trained? After all, an improved distribution of physicians, especially Canadian-trained physicians, is a major expectation of these initiatives. CAPER has put in place certain tools that will allow us to see exactly which communities benefit from these additional graduates.Many authorities feel, since Canada still has about four applicants for every first-year position in its medical schools, that the 250 new graduates expected each year from the satellite campuses will most likely be quite capable of meeting performance expectations. A key outcome will be whether the admission and retention processes at the new sites will be effective in identifying and retaining those applicants who would prefer to practice in the areas of need.
Canada has a long and successful history of using satellite or distributive learning sites for post-graduate clinical education. The challenge will be whether those same sites, with modest teaching backup, will be able to do as well with undergraduates, who require a great deal more attention at the basic clinical levels. The Liaison Committee on Medical Education and the Canadian equivalent, the Canadian Accreditation Committee on Medical Schools, have been monitoring these developments carefully with the sponsoring Canadian medical faculties. After all, it is those same faculties, with their educational and clinical partners in these communities, who are taking on the responsibility to make a significant improvement in both the total number and geographic location of new physicians in Canada over the next decade. American faculties in underserved areas will no doubt be watching this development with interest.
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