The Northern Medical Program (NMP) A Regional Campus to

The Northern Medical Program (NMP): A Regional Campus to Train Physicians for Northern BC Joanna Bates Centre for Health Education Scholarship, UBC David Snadden Northern Medical Program, UNBC Medical education rounds November 21 2008 Admissions to Canadian Medical Schools (Data from AFMC) What we will present today… of the NMP with some early outcome data (DS)  Three qualitative studies on early impacts of the NMP on the Prince George community (JB), and on the physician community (DS)  Planned long-term research program (JB)  Overview Background of NMP June 2000: 7,000 Northern BC residents & physicians protest physician shortage  6 months later: Agreement for distributed medical educ. between UBC/UNBC “Train physicians from the north, in the north, for the north”  2004: 24 students admitted  2007: 32 students admitted  2008: First cohort graduated  Overview of the NMP Distributed campus of UBC    Admits 32 students per year Admissions decisions weighted differently Majority of education takes place in Prince George and northern BC Community support high   Links to partner sites by Audio Visual technology for educational delivery Early Academic Outcomes  Positive accreditation decisions of educational outcomes  Comparability  Increased selection of primary care, generalist specialties, and rural postgraduate training by first cohort of graduating students reports of broad community  Pervasive impacts Next Steps: Long Term Outcomes   Outcomes from more than one cohort Exam performance on national licensing exams Choice of family practice or generalist specialties Choice of location of practice   Study 1 Impact of the NMP on the Prince George community: Exploratory study 2004 Chris Lovato, Joanna Bates, UBC Dave Snadden, Neil Hanlon, UNBC Funded by the Vancouver Foundation Research Question How does the introduction of a new undergraduate medical education program impact a small medically underserved community? Approach Literature review  Institutional documents  Interviews with 9 key stakeholders in 5 sectors (e.g., Mayor, Health Authority)  Primary analysis guided by hypothesized framework to identify sector-specific impacts perceived as already happening or hoped for the future  Secondary analysis explored underlying themes that crossed sectors  Five Spheres of Community Impact      Health Local politics Education Economy/Business Media Findings: Primary Analysis    Overall impact perceived as extremely positive – new educational opportunities – improvements in physician recruitment, health care services/facilities – enhancement of business opportunities Anticipated impact – increased research in northern health issues – improved economy – health care access and quality Negative impact – shift in priorities with need to support medical education – students in other disciplines feel “slighted” – possible strain on system as students move into clinical training Education “ The kids in the high schools who are beginning to come into my office to ask me how do they get in and I think this never happened before when the closest medical school was in Edmonton or Vancouver but it’s happening now…” (Secondary School Principal) Business/Economy “If an industry wants to start up a branch or plan a facility in a community, they have to first attract workers and secondly they have to take care of those workers. Workers aren’t going to come with their families unless they know they are going to get medical assistance.” (Business Person) Medical Workforce “ It (the NMP) is already acting as a magnet for medical staff…people are coming here now because they want to be here…… they want to be here simply because of the medical school.” (Health system manager) “You were beginning to see that they were recruiting, they were having people approach them and they hadn’t had that for some time.” (Physician) Results: Sector-specific Impacts  Perception sector  Impacts primarily positive  Anticipated future impacts in all sectors of current impacts in each But…….we were surprised by unclassified impacts that crossed all sectors, so we reanalyzed data. Findings: Secondary Analysis and status  Partnership Development  Community self-efficacy  Community development  Pride Partnerships “This whole cooperative thing, you can’t undervalue that. The physicians and the administration get along today because (of) the medical program.” (Health System Manager) Community Self-efficacy “It has given a tremendous psychological lift in the sense that it gives people the belief that things are possible. That rather than looking to a future which is only hoping to cobble things together so that something can be provided to people, it creates, whether it is real or not, a belief that really wonderful things can be done.” (Elected Official) Community Development “Technical people for the forest sector, the oil and gas sector, the financial sector: they’re more willing to come to Prince George if they know they’re going to get first class medical services….. In fact, having a healthy healthcare system is an economic development tool. Absolutely.” (Business Leader) Four emergent themes are related to social capital and social cohesion: Social capital refers to forms of social participation (i.e. the networks, norms, and trust) that facilitate cooperation between individuals and groups to achieve common objectives. Conclusions 5 spheres of influence in hypothesized framework useful to examine community impact  Reports of impact on human capital after one-year (not yet quantifiable)  Underlying theme related to social capital (pride/status, partnerships, community self-efficacy, community development) important area for further study  Study 2 Community Impact 2007 Follow-up Trish Toomey, Chris Lovato, Joanna Bates, Gary Poole, UBC Neil Hanlon, UNBC Funded by a grant from CIHR Research Questions 1. What are perceived current and anticipated future impacts of the NMP in Prince George in terms of economy, health, education, politics, and media? 2. Has social capital in Prince George been affected by the creation and implementation of the NMP? If yes, how? Methods methodology  Semi-structured interviews, 23 community leaders (saturation)  Snowball sampling  Questions related to current and anticipated impacts on economy, health, education, politics, media  Coded using framework, as well as open coding  Qualitative Findings Areas of Perception of Impact Capital  Health Services  Human Capital  Economy/Business  Physical Capital  Politics  Media  Education  Social Example of Findings Education Local (non-NMP) Students: “…what is very much lacking in this country is First Nations individuals in the health sciences…because of (the NMP) there’s groups of them that are looking into the medical profession…..” Increased interest in medicine  Increased opportunity to pursue medicine  Changes to medical education  Example of Findings Health Services: medical workforce Increased Recruitment:  Physicians  Professionals in other sectors  Faculty  Students and residents “Northern Health is starting to have greater success recruiting. I believe part of that is being able to say that we have a medical teaching program. People are aware of it. It puts you on the map...” Example of Findings Health services: access to care Increased access to care:  Increased access to specialists  Increased access to GP’s  Students and residents increased capacity “We now have 6 orthopedic specialists in Prince George who are flat out working around the clock. At one point in time we had one… (the NMP) changed the amount of people that had to travel out of the community...” Example of Findings Health Services System/ Resources Strain: Slows down clinical work  Diagnostic tests  Impact on physician workload  “I believe there's a potential negative in terms of slowing down clinical work. So as a physician with a student…I have to explain and the student often will take a look at the same thing I've taken a look at.” Example Social Capital Social Support “I think physicians derive significant professional strength by having other individuals to share their practice, to help deal with the pressures of being on call, and to maintain the professional stimulation, in terms of bringing back or being exposed to new ideas in the field.” Conclusions confirmed and extended our preliminary findings of perception of impact on education, politics, media, health services and economy  Confirmed and extended our initial impressions of perception of impact on social capital, leading to development of theory  Identified multiple quantifiable indicators of impact that can be tracked in longitudinal studies  We Study 3 Early Impacts of the NMP on Physicians in Prince George 2007 UNBC: Laura Ryser Greg Halseth Neil Hanlon Dave Snadden UBC: Joanna Bates Chris Lovato Funded by the Vancouver Foundation Research Question What are the impacts of the NMP on the physician community of Prince George? Methodology  Semi-structured interviews with 25 physicians involved with the NMP, and 5 physicians not involved  Purposeful sampling: (Age, gender, length of time in community; IMG/CMG; GP/specialist)  Data collection in 2007, after implementation of clinical teaching year  Framework analysis Interview framework the NMP influence physicians’ decision to practice in Prince George  Does the NMP influence physicians’ plans to leave Prince George?  How does the NMP impact the physicians’ work?  How does the NMP affect physician networks and cohesion?  Does Recruitment Almost all of the physicians who have practiced in Prince George for less than five years identified the NMP, the presence of support networks, and job satisfaction / flexibility as reasons for coming. Retention Physicians who have been practicing for longer than 5 years in the community identified that being involved with the NMP is an important reason why they have stayed in Prince George. NMP Impact on Physicians’ Work New roles, new staff  Less flexibility around holidays / time off  Difficulty finding substitutes to take time off  Commitments to teaching schedule  Expanding workloads  Teaching duties  Finding volunteer patients  More liaison with university staff  Affects patient waitlists, lack of office space, Lack of O.R. time  “Five years ago, I had 2 days of surgery a week and one family practice resident to teach. Now, I have 5 trainees (both undergrad medical students and residents) working with surgeons and I get only a half a day a week in the O.R.” NMP Interview 2007 Building Social Networks became focal point for cooperation  NMP broadened networks  Cooperation improved levels of trust “It’s popular to be part of the NMP. Nondoctors ask whether you’re involved. I think the community wants it to succeed, and they’re interested in people’s roles”. NMP Interview 2007  NMP Building Social Cohesion opportunities for interaction Faculty development information sessions Teaching rounds Sponsored lectures Surgery club  Enhances participation in existing events Northern Doctor’s Day Jasper retreat Bob Ewert dinner  More Building Social Cohesion participation increased sense of ownership over NMP  Physician morale improved  Physician “Everybody feels good that we’re not only a first class hospital, but also teaching the next generation of physicians”. NMP Interview 2007 Building Social Cohesion  NMP is fostering interaction amongst GPs, students, different departments, and academics “With students around, you tend to interact with many disciplines, so the students act as a second-hand bridge between the disciplines that might not be there”. NMP Interview 2007 But…. Some concerns were expressed about the potential undermining of the ‘small town’ environment that had been instrumental in attracting and retaining physicians in Prince George  Most of the problems expressed about professional networks came from participants who were recruited internationally  Impact on Physicians Practices  The NMP creates a learning environment  Creates an openness of new ideas / ways of doing things  Problem-based learning groups  Encourages doctors to be up-to-date “It’s important for the medical community to be involved in teaching because it keeps them up-to-date. When you’re teaching you can’t get sloppy. That’s the biggest benefit of the NMP”. NMP Interview 2007 Conclusions  Physicians have identified impacts of the NMP on recruitment, retention, workload, and their professional networks. This study has formed a foundation for development of survey instruments and quantifiable indicators to measure impacts on physicians in Prince George over time.  So What? Regional distributed medical education program can be successfully implemented with positive academic outcomes.  Reasonable to expect that a distributed medical education program will have a positive effect on  – recruitment and retention of physicians – community sectors  Further research needed to expand beyond one site, quantify, assess longterm outcomes, link with community and policy-makers. Collaborative on Research on Regional Medical Education (CRRME) UBC and UdeS; CAPER; CaRMS; individual researchers (NOSM, UdeM; Memorial)   Do graduates of northern regional campuses select different postgraduate training and why? Where do graduates of northern regional campuses locate their practices and why? Funded by Frontline Health CRRME: Work to Date study (completed)  Feasibility study (completed)  Prospective study (currently implemented)  Retrospective Medical Education and Northern Communities Research Alliance (MENCRA) UBC, UNBC, UdeS, UQAC; community agencies in Prince George and Saguenay; government policy-makers Funded by SSHRC Features of this Program of Research and Evaluation Based on community-university partnerships  Participatory action research approach  Collaborative nationally: UdeS; UQAC; UNBC; UBC; NOSM; UdeM.  Prince George and Sagueney- 2 case studies  Interdisciplinary: medical education, economics, medical workforce, social sciences  Multi-method approach: qualitative; quantitative; geomatic analysis; case study  Formally linked with policy-makers  MENCRA Research Questions: Phase 1 Which indicators of the impact of the regional campus and community development are meaningful to the community and feasible to track through secondary databases at the municipal, provincial, and national level?  How do the opportunities to participate in university-based teaching programs affect the recruitment and retention of physicians and other health care workers to an underserved area?  How and why does the implementation of a regional campus MDUP change the physician and health care culture in the north?  Conclusions education outcomes research is changing!  Interest across Canada from policy makers, northern communities, social scientists and others  Anecdotal impressions can give rise to questions that are worth exploring  An exploratory study can lead over time to a program of research  Medical Thank you ! Exs. of Quantifiable Outcomes from Interviews: Health Human Capital        Number of physicians (family practice and specialists) recruited to PG (and reasons why) Number of community members without family physician Wait-times to access specialist care in Prince George Range of specialist services offered in Prince George New services offered by physicians Number of community members who have to travel to access specialist services Length of time from ad to physician in place       Total number and proportion of CMG/IMG responses to recruitment ads Number and proportion of IMG’s practising in PG; IMG’s on temporary license Number of physicians per year leaving Prince George Number of professionals in other sectors recruited to Prince George (and reasons why) Average age/length of service of physicians in Prince George Number of physicians remaining in Prince George over the long-term (already licensed, NMPtrained, other rural trained, other?)