Report of the Brandon Medical Education Study
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Report of the Brandon Medical Education Study Submitted to the Steering Committee By the Co-Lead Consultants John Horne, PhD Daniel Klass, MD, FRCP Assisted by Amy L. Wyntjes, BA, MPA Research Associate July 3, 2012 TABLE OF CONTENTS __________________________________________ Acknowledgements ...................................................................... 4 Executive Summary and General Observations ....................... 6 Section I: Project Mandate and Terms of Reference……10 Section II: Activity Summary……………………..………….13 Section III: Community Consultations………………………24 Section IV: Overview of DME Programs...……………….....30 Section V: Literature Review and Commentary………….42 Section VI: Manitoba Context……………….…..……………75 Section VII: Recommended Options……………………..…109 Page 2 APPENDICES __________________________________________ APPENDIX 1 Reference List………………………………………..………………136 APPENDIX 2 List of Interviewees……………………………………...………….142 APPENDIX 3 Composition of Steering Committee…………………..………..149 APPENDIX 4 Feasibility Study Proposal………………………………………….150 APPENDIX 5 Proposed Parameters……………………..………………………..177 APPENDIX 6 Workshop Agenda………………………………………..…………181 APPENDIX 7 Workshop Participants List…………………………………....….184 APPENDIX 8 Manitoba RHA Data………………………………………………...186 APPENDIX 9 Workshop Suggested Questions……………….……….………..188 APPENDIX 10 Workshop Review…………………………………………………..190 APPENDIX 11 Table 6d.i……………………………………………………………..195 APPENDIX 12 Table 6d.ii……………………………………………………….……197 APPENDIX 13 Table 6d.iii……………………………………………………………199 APPENDIX 14 Public Consultation Information Document…………….……..203 APPENDIX 15 DME Program Scan…….………………………………………..…205 APPENDIX 16 Workshop Presentations…………………………………………..210 Page 3 ACKNOWLEDGEMENTS __________________________________________ We wish to thank all those who assisted us by agreeing to be interviewed and sharing their expertise, experience and perspectives on “distributed medical education”. Their willingness to do so amid busy schedules was impressive and much appreciated. Many of those same individuals deserve additional thanks for their participation in the Workshop hosted by Brandon University in January 2012. Their collegiality and genuine interest in the “options for distributed medical education in Manitoba” not only made the event a great success, but also helped “warm the room” during what were some of the coldest days of the 2012 Manitoba winter. We also wish to thank all those who attended the meetings we held in various communities. Their perspectives on the medical education options and the issues of recruiting and retaining physicians in their towns and villages gave us important understandings of the “rural realities” that are not well captured in either the popular press or scientific literature. We also wish to acknowledge a number of organizations and individuals whose contributions to this project deserve special mention. Senior staff at Manitoba Health and COPSE provided both valuable advice and data that were crucial to our elaboration of the Manitoba “context”, especially our analyses of physician human resources and the development of our “needs- based” projection model. At the University of Manitoba, Maureen Newman, Executive Assistant to the Dean of Medicine worked magic in arranging interviews and meetings, and Karen Howell, Project Manager, Office of the Dean, expertly guided us through the massive accreditation files. Keith McConnell, Director of Operations, Faculty of Medicine, deserves high praise for his instruction of a “student driver” in the use of the “road-tested” accounting vehicles we used to cost our recommended options; his patience in answering questions—many of which were naïve—and his prompt responses to multiple data requests were truly appreciated. We also wish to thank Rebecca Klass for ably assisting in our review and distillation of the burgeoning literature on DME, and for numerous other favours. Finally, it was our great good fortune to work with Amy Wyntjes. Amy relocated to Manitoba from New Brunswick in mid-2011 and joined the Office of the President at Brandon University as a Research Associate assigned to this project. Amy assumed responsibility for organizing the community consultations and the Brandon Workshop, and also took the lead in our environmental scan of DME programs at Canadian and foreign medical schools. As if all this were not enough, she cheerfully worked long hours to consolidate and edit both the draft and final reports to ensure we delivered “on schedule”. We are thankful as well to the members of the Steering Committee who agreed to extend that schedule by one month. From the outset we were concerned that we would be hard-pressed to complete our agreed “deliverables” by the original deadline of March 31, 2012. In the event, Page 4 the extra month was not only welcome but essential to our completing a report that we hope serves the purposes of the Steering Committee. We would be remiss (and also very foolish) not to acknowledge our spouses, Georgia Klass and Fran Horne, who showed great patience and tolerance in accepting the “opportunity costs” we imposed on them due to our project priorities, especially so during the last three months. To them we offer our sincere thanks and a promise to “dial-back” our professional commitments and spend more time with our families. We hope the Steering Committee understands when we say a project of this scale and scope represents a “minefield” of potential errors of both the omitted and committed variety. While we can reassure the Committee that we have worked diligently to avoid all such errors, it is inevitable that some will have escaped our scrutiny. For such departures from “best practice” research and consulting, we alone assume responsibility. Page 5 EXECUTIVE SUMMARY AND GENERAL OBSERVATIONS Here we provide explanatory commentary on important analyses, summary assessments and various recommendations reported in the following study. We deem it important to concentrate this end-point discussion on matters that will help the Steering Committee in its deliberations on what should and should not be included in any solution to the medical training needs of the province. First, our key recommendation that the solution not involve the establishment of a new and independent medical school at Brandon University is based on our ‘all things considered’ assessment of that option in the context of Manitoba’s needs. That assessment was informed by both ‘lessons learned’ in other jurisdictions and by our ‘closer to home’ appraisals of the province-wide need for more physicians, especially family physicians in ‘full-service’ primary care practices. First, in terms of addressing this need for primary care physicians with a rural inclination and capability, we conclude that current programs, planned and in place, in the UMFOM are not just present, but exemplary. Second, we took particular note of the precedent set by the Northern Ontario School of Medicine as a pioneering venture mandated to specifically train physicians for these types of practices in rural and northern Ontario. We concluded that the NOSM model uniquely fit a ‘niche’ in its own environment, including a catchment population of nearly one million northern Ontarians and a pre-existing foundation of postgraduate medical education that had been painstakingly constructed and maintained in northwestern and northeastern Ontario by the Faculties of Medicine at McMaster University (NOMP) and the University of Ottawa (NOMEC). For principally those reasons, we have appraised the NOSM model to be a poor fit for Brandon, judged not only by the much smaller regional ‘catchment’ population, but even by that population when doubled to include all Manitobans who currently reside outside Winnipeg’s ‘perimeter highway’. These two elements combined with our conclusion from the analysis of the physician resource status of the province that the present current input of new MDs was in a reasonable range, provides the underlying logic for our judgment that creation of a free-standing medical school in Brandon would be ill-advised. We do so fully understanding this will be disappointing to many advocates, as well as to those among the attendees at our community consultations who asserted that anything short of a free-standing school would be ‘no solution’ to the problems they have long experienced in their towns and villages (see Section 3 for pertinent summaries). However, it is our judgment that fully implementing the Rural Track Options as we describe, and building toward the Satellite Option (Option 2) will meet the physician resource needs of Manitoba’s rural and northern communities in a more cost-effective and timely fashion. We then gave more in-depth consideration to the other two options specified in our ‘project parameters’: a satellite program expansion of the University of Manitoba in partnership with Brandon University; and the continuation/expansion of existing models of rotational and education experiences at the University of Manitoba (respectively positioned, but not so- named, as options ‘2’ and ‘3’ in the parameters document). Following our comprehensive review of relevant precedents in Canada and abroad (see Sections 4 & 5), along with a careful elaboration of the Manitoba ‘context’ (see Section 6), we again came to an ‘all things Page 6 considered’ rationale for incorporating these two options into a progressive model featuring a defined temporal sequence beginning with the Rural Track (option 3) and evolving, when conditions