Roger P. Strasser

The Northern Ontario School of Medicine (NOSM) opened in 2005 with a social accountability mandate to address a long history of physician shortages in northern Ontario. The objective of this qualitative study was to understand the school's effect on recruitment of family physicians into medically underserviced rural communities of northern Ontario. We conducted a multiple case study of 8 small rural communities in northern Ontario that were considered medically underserviced by the provincial ministry of health and had successfully recruited NOSM-trained physicians. We interviewed 10 people responsible for physician recruitment in these communities. Interview transcripts were analyzed by means of an inductive and iterative thematic method. All 8 communities were NOSM medical education sites with populations of 1600-16 000. Positive changes, linked to collaboration with NOSM, included achieving a full complement of physicians in 5 communities with previous chronic shortages of 30%-50% of the physician supply, substantial reduction in recruitment expenditures, decreased reliance on locums and a shift from crisis management to long-term planning in recruitment activities. The magnitude of positive changes varied across communities, with individual leadership and communities' active engagement being key factors in successful physician recruitment. Locating medical education sites in underserviced rural communities in northern Ontario and engaging these communities in training rural physicians showed great potential to improve the ability of small rural communities to recruit family physicians and alleviate physician shortages in the region.

The economic contribution of medical schools to major urban centres can be substantial, but there is little information on the contribution to the economy of participating communities made by schools that provide education and training away from major cities and academic health science centres. We sought to assess the economic contribution of the Northern Ontario School of Medicine (NOSM) to northern Ontario communities participating in NOSM's distributed medical education programs. We developed a local economic model and used actual expenditures from 2007/08 to assess the economic contribution of NOSM to communities in northern Ontario. We also estimated the economic contribution of medical students or residents participating in different programs in communities away from the university campuses. To explore broader economic effects, we conducted semistructured interviews with leaders in education, health care and politics in northern Ontario. The total economic contribution to northern Ontario was $67.1 million based on $36.3 million in spending by NOSM and $1.0 million spent by students. Economic contributions were greatest in the university campus cities of Thunder Bay ($26.7 million) and Sudbury ($30.4 million), and $0.8-$1.2 million accrued to the next 3 largest population centres. Communities might realize an economic contribution of $7300-$103 900 per pair of medical learners per placement. Several of the 59 interviewees remarked that the dollar amount could be small to moderate but had broader economic implications. Distributed medical education at the NOSM resulted in a substantial economic contribution to participating communities.

Objective:  To determine if selecting rural background students into the Monash Bachelor of Medicine and Bachelor of Surgery (MBBS) program affects vocational training location and intended practice location after training. Design:  Retrospective cohort mail survey. Setting:  Australia. Participants:  Rural‐background students at Monash 1992–1994 (n = 24/40) and 1995–1999 (n = 59/120) and urban background students (n = 36/93 and 104/300, respectively). Overall study population: 62% female, average age of 28 years; 79% Australian‐born; and 60% married/partnered.Interventions:  Rural or urban background, rural undergraduate exposure. Main outcome measures:  Intent towards rural medical practice, vocational training location and subsequent practice location. Results:  There was a positive and significant (P ≤ 0.05) association between rural background and rural practice intent when respondents began (10‐times higher than urban graduates) and completed (three times higher) their MBBS course. Rural practice intent increased fourfold in urban background graduates. There was a positive and significant association between rural background and preferred place of practice in 5–10 years in a Rural, Remote and Metropolitan Area (RRMA) 3–7 community (three times higher). There was a positive, but non‐significant association between rural background and RRMA 3–7 community as their current location and first place of practice once vocationally qualified.Conclusions:  Interest in rural practice is not fully reflected in location during or after vocational training. The beneficial effects of rural undergraduate exposure might be lost if internship and vocational training programs provide insufficient rural clinical experiences and curriculum content. Continuation of the rural pathway might be needed to maintain rural practice intent.

Evaluation of rural clinical attachments has demonstrated that the rural setting provides a high-quality clinical learning environment that is of potential value to all medical students. Specifically, rural clinical education provides more 'hands on' experience for students in which they are exposed to a wide range of common health problems and develop a high level of clinical competence. Northern Ontario in Canada is a large rural region that has a chronic shortage of healthcare providers. The Northern Ontario School of Medicine (NOSM) was established with a social accountability mandate to contribute to improving the health of the people and communities of Northern Ontario, and is a joint initiative of Laurentian University, Sudbury, and Lakehead University, Thunder Bay, which are over 1000 km apart. The NOSM has developed a distinctive model of medical education known as distributed community engaged learning (DCEL), which weaves together various recent trends in medical education including case-based learning, community-based medical education, electronic distance education and rural-based medical education (including the preceptor model). The NOSM curriculum is grounded in Northern Ontario and relies heavily on electronic communications to support DCEL. In the classroom and in clinical settings, students explore cases from the perspective of doctors in Northern Ontario. In addition, DCEL involves community engagement through which communities actively participate in hosting students and contribute to their learning.This paper explores the conceptual and practical issues of community engagement, with specific focus on successful rural clinical education. Community engagement takes the notion of 'community' in health sciences education beyond being simply community based in that the community actively contributes to hosting the students and enhancing their learning experiences. This is consistent with the focus on social accountability in medical education. Implementing community engagement is quite challenging; however; its potential benefits are substantial and include the improved recruitment and retention of healthcare providers who are responsive to cultural diversity and community needs and are collaborating members of the whole health team.

Access to well trained and motivated health workers is the major rural health issue. Without local access, it is unlikely that people in rural and remote communities will be able to achieve the Millennium Development Goals. Studies in many countries have shown that the three factors most strongly associated with entering rural practice are: (i) a rural background; (ii) positive clinical and educational experiences in rural settings as part of undergraduate medical education; and (iii) targeted training for rural practice at the postgraduate level. This paper presents evidence for policy initiatives involving the training of medical students from, in and for rural and remote areas. We give examples of medical schools in different regions of the world that are using an evidence-based and context-driven educational approach to producing skilled and motivated health workers. We demonstrate how context influences the design and implementation of different rural education programmes. Successful programmes have overcome major obstacles including negative assumptions and attitudes, and limitations of human, physical, educational and financial resources. Training rural health workers in the rural setting is likely to result in greatly improved recruitment and retention of skilled health-care providers in rural underserved areas with consequent improvement in access to health care for the local communities.

Like many rural regions around the world, Northern Ontario has a chronic shortage of doctors. Recognizing that medical graduates who have grown up in a rural area are more likely to practice in the rural setting, the Government of Ontario, Canada, decided in 2001 to establish a new medical school in the region with a social accountability mandate to contribute to improving the health of the people and communities of Northern Ontario. The Northern Ontario School of Medicine (NOSM) is a joint initiative of Laurentian University and Lakehead University, which are located 700 miles apart. This paper outlines the development and implementation of NOSM, Canada’s first new medical school in more than 30 years. NOSM is a rural distributed community-based medical school which actively seeks to recruit students into its MD program who come from Northern Ontario or from similar northern, rural, remote, Aboriginal, Francophone backgrounds. The holistic, cohesive curriculum for the MD program relies heavily on electronic communications to support distributed community engaged learning. In the classroom and in clinical settings, students explore cases from the perspective of physicians in Northern Ontario. Clinical education takes place in a wide range of community and health service settings, so that the students experience the diversity of communities and cultures in Northern Ontario. NOSM graduates will be skilled physicians ready and able to undertake postgraduate training anywhere, but with a special affinity for and comfort with pursuing postgraduate training and clinical practice in Northern Ontario.

Like many rural and remote regions around the world, Canada's Northern Ontario has a chronic shortage of doctors and other health care providers. Recognizing that doctors who have grown up in a rural area are more likely to practise in the rural setting, the Government of Ontario decided to establish a new medical school with a social accountability mandate to contribute to improving the health of the people and communities of Northern Ontario. The Northern Ontario School of Medicine (NOSM), a joint initiative of Laurentian University in Sudbury and Lakehead University in Thunder Bay, was established as a rural, community-based medical school. NOSM is a long-term sustainable 'strategy that is expected to lead not only to more skilled doctors and enhanced health care with improved health outcomes, but also to broader academic developments for the universities and substantial economic developments for Northern Ontario communities.

Northern Ontario, like many rural and remote regions around the world, has a chronic shortage of health professionals. Recognizing that medical graduates who have grown up in rural areas are more likely to practice in rural settings, the Government of Ontario, Canada established a new medical school with a social accountability mandate to contribute to improving the health of the peoples and communities of Northern Ontario. The Northern Ontario School of Medicine (NOSM) is a joint initiative of Laurentian University in Sudbury and Lakehead University in Thunder Bay, cities one thousand kilometers apart. The NOSM model of medical education is built on several recent educational developments including rural-based medical education, social accountability of medical education and electronic distance education. This paper describes these developments as background to presenting the Northern Ontario School of Medicine as a socially accountable, geographically distributed rural-based medical school. NOSM MD PROGRAM: The school actively seeks to recruit students for the MD program from Northern Ontario or similar northern, rural, remote, Aboriginal, and Francophone backgrounds. The holistic, cohesive curriculum is grounded in Northern Ontario and relies heavily on broadband electronic communications to support distributed, community engaged learning. Students, both in classroom and clinical settings, explore cases as if they were physicians in Northern Ontario communities. Clinical education takes place in a wide range of community and health service settings so that students can experience the diversity of communities and cultures in Northern Ontario. Although NOSM is still in the early stages of development, there are encouraging signs that the school's evidence-based model of medical education will be successful in developing a sustainable, community responsive health workforce for Northern Ontario.