Building Better Health Sciences Education

Jane Philpott
Faculty of Health Sciences
Queen’s University

Introduction

Universities and colleges have a social purpose beyond education, research, and knowledge mobilization. The discoveries we make and share through post-secondary institutions should be put into practice—to make the world healthier, safer, and more just. Sadly, that doesn’t always happen. Moving from knowledge to action is easier said than done. This chapter provides one exemplar from Queen’s Health Sciences about how we’re trying to break the impasse. Our intentions are to act on what we know. The motivation to do better is palpable. Work in health sciences education is in big demand. Canada is facing a health human resources crisis the likes of which we’ve rarely known in this country. To cite one snapshot, a report from Ontario’s Financial Accountability Office, regarding additions and departures in the workforce, makes a prediction that by 2027, Ontario will be short 33,000 nurses and personal support workers (Financial Accountability Office of Ontario, 2023). Educating the health workforce of the future is core business for faculty at Queen’s and elsewhere. We want to innovate our practices, to do things differently and better, based on what society needs now.

We’re purposefully re-inventing the future of post-secondary education to become a force that responds to social need and adapts our methodologies in a practice of continuous quality improvement. We haven’t fundamentally changed the model of medical education since the Flexner Report was published in 1910. And nursing school still resembles the model established by Florence Nightingale 160 years ago. Health care has changed a lot during that time. More care happens in communities (not just hospitals) and we’re gradually moving away from hierarchies to team-based care. The approach to education ought to reflect those differences.

Our creative work is also driven by the state of health care after enduring a pandemic that broke open all the longstanding cracks in our delicate and imperfect health systems. What Canadians have learned—although we should have understood it all along—is that our health systems are only as strong as the people who make them work.

Universities and colleges have a mammoth task ahead as we help rebuild the health workforce. While we could fill these pages with statistics about the number of doctors, nurses, and other health workers who have left their jobs and need to be replaced, it is the personal stories that are the most heart wrenching. On the one hand, I hear from health professionals themselves. For example, there are family doctors who want to retire, but they are worried about leaving their patients behind. I receive messages like this:

I have been in practice since 1983; six of the eight who are currently practicing in our group will be retiring at the same time at the end of May. It will orphan another 7000 or more patients in our area because, like most other family practices who have been recruiting to replace retiring physicians, we have had no luck (confidential personal communication, n.d.).

On the other hand, I hear even more from individual people telling me they have nowhere to go for primary care, wondering if I know someone who will take care of them. These health workforce shortages are at the root of ever-growing backlogs for surgical procedures; the new phenomenon of emergency room closures across the country; rising costs to health systems; and of course, a huge human toll among those who don’t have timely access to care. The post-secondary sector can’t continue with business-as-usual.

It was Winston Churchill who said you must never let a good crisis go to waste. He said that during the darkest days of World War II when he and others could have succumbed to despair, but instead they chose to forge new relationships and create better structures for the future. These are dark days for health care in Canada—and around the world. We must use this crisis for good. And where better to start that work than at the very places that create human resources for health? Across the country, the places where nurses, public health scientists, community health workers, and others are educated and trained, are places where many solutions can be found.

Although it is a mammoth task, universities and colleges have a critical role to help rebuild the workforce.  I’m convinced the post-secondary sector has not only an opportunity, but a responsibility, to drive innovation in response to this social need. We are the institutions who can do the analysis to determine what the health workforce of the future should look like. We can adapt, make curricular changes, and engage communities to build a better workforce and thereby more effective health systems. The incentives for us to offer solutions have never been greater. With about half of most provincial budgets spent on health, we should be allies with policy makers who need us to create some of the solutions that will make health systems sustainable and provide a high-quality stream of workers for the future.

What will it take to achieve change? And what should that change look like?

I offer here an overview of four initiatives we’re undertaking at Queen’s University to modify our educational programs in response to social needs: one program is for training family doctors; one for training Indigenous youth in the health professions; one for improving access to primary care; and one initiative to improve how we train students to work in interdisciplinary teams. I hope these initiatives will spark engagement and ideas in contexts beyond Queen’s, allowing for wide-spread efforts to connect health sciences education with societal needs.

Major modification in medical school

The first innovation is about access to family doctors or primary care. Permit me to set the stage for why this matters and show that it’s not just my bias because I am a family doctor.

There is a large international body of scientific evidence—going back decades—demonstrating that countries with strong systems of primary care have the best health outcomes, the most affordable costs, and they offer care in a way that is both equitable and accessible (Starfield et al., 2005). I’m disappointed to say that Canada is not one of those countries. We do not have strong, coordinated, universal systems of primary care. Some provinces do better than others, but none have fully figured it out. For example, look no further than the current crisis in access to family doctors or primary care teams. A recent national survey, called OurCare (n.d.), estimates about 22 per cent of Canadian adults do not have access to a family doctor,   and/or a primary care nurse practitioner. That’s close to seven million people who can’t access the front door to the health system.

Sadly, it’s getting worse. Across the country only 30% of medical students select family medicine as their first choice for specialty training (Canadian Resident Matching Service, 2023). And of those who finish their residency in family medicine in Ontario, as few as 15% are choosing to set up or join a community practice (HealthForceOntario, 2021). Of course, reasons for this shortage are multifactorial, but some of it is on us. It is essential that we evaluate the way we train, our processes for recruitment and selection, and the hidden curricula that persist in our medical training programs.

Universities are in the prime position to modify its programs in response to societal need. In this case, Queen’s University developed a plan to focus a portion of our medical school directly on the meeting the challenge of growing the family doctor workforce. We are a partner of Lakeridge Health, a hospital system in Durham region (east of Toronto). We have assigned 20 medical school seats to a new approach to medical education—intentionally selecting and training students for a career in comprehensive family medicine. It is heavily community-based and, most importantly, it is a seamless program of six years combining both medical school and direct access to family medicine residency, bypassing the traditional resident matching system. We specifically selected students with a demonstrable commitment to generalism, and it will be on us to make sure they have comprehensive competencies and confidence when they are finished—not to mention that they graduate with enthusiasm about being family doctors. We met an ambitious timeline and the launched the program at Lakeridge Health in September 2023.

Take the university to the community

A second innovation is our expanding partnership with the Weeneebayko Area Health Authority. This work is inspired by more than simply the clinical and social needs of the community. It is a response to the Calls to Action of the Truth and Reconciliation Commission. Call to Action 23 is an appeal to increase the number of Indigenous professionals working in the health care field and to retain those Indigenous health professionals in their communities (Truth and Reconciliation Commission of Canada, 2015).

Queen’s University has a six-decades-long relationship with the general hospital in Moose Factory as well as all the First Nations communities along the western side of James Bay such as Attawapiskat, Kashechewan, and Fort Albany. Since 1965, we’ve been sending doctors to work in that hospital, and they’ve been referring patients to Kingston for tertiary care.

Building on that long-standing clinical relationship, we are expanding it to add an educational partnership. We co-developed a plan to deliver university health professions education in Moosonee for youth living in those communities. We secured a large gift from the Mastercard Foundation to support this partnership, and we hope that both the federal and provincial governments will be key partners as well.

We are already working with local schools, school boards and high school students in the region to make sure students have the necessary prerequisites to enter a university health sciences program. It is our goal that, beginning in 2025, we will be delivering an Indigenous-informed curriculum for nursing, health sciences, and eventually medical school, physiotherapy, occupational therapy and more. We’re already seeing how Indigenous ways of knowing and doing will lead to dramatic changes in the way we teach and learn—including advice to amend our academic calendar to fit into the four-season patterns of how Indigenous students learn on the land.

The university as the convenor of partnerships

The third project is an example of how the university can be part of the solution on access to health care—and help meet our own program expansion needs along the way. I’ve already referred to the significant shortage of family doctors. This has an impact on the health sector, but also has an impact on the entire economy of our communities and country. Canada needs to develop better models so that everyone has access to a primary care home.

Some would say it’s not really the university’s problem to ensure access to health care. They might say we should let health system partners figure things out while academic institutions stand back and focus on either research, or on the education of students.

But universities are innovators. That includes being innovators in health systems. We can also be great convenors. That is the power we employed for this third project, in which we brought together nine local partners who have an interest or role in health care delivery—three local hospitals, the city, the public health unit, physician groups and all the schools in our faculty (nursing, medicine, and rehabilitation)—to design a modified model of primary care delivery.

Our model is an adaptation on the concept of the patient-centric medical home that has been promoted in the United States for decades. Access to primary care should be like access to public schools. It should be universally available and offered in every geographic region.

We cannot imagine a society that would find it acceptable for more than 20 per cent of children not to have access to a public school. So, why is it acceptable that millions of people don’t have a primary care home? We believe everyone who lives in Canada should have access to a team of health care providers, including family doctors, that becomes your first point of contact for continuous, comprehensive, coordinated, person-centric care.

Members of our faculty have helped develop a model for geographically-determined access to team-based care. The first phase will be a primary care home for 10,000 people in our region who don’t currently have access to care. We’re calling it the Periwinkle Model. The name Periwinkle was inspired by the beautiful five-petaled flower. The five petals are intended to represent the Quintuple Aim for Health Care Improvement—a healthy population, better care, happy providers, good value for money, and fairness or equity (Nundy et al., 2022).

One of the unique features of our model of primary care delivery is that, like everyone else on the team, family doctors will be on a salary, pro-rated according to the number of shifts per week and weeks per year that they want to work. This allows them to have holidays, which many family doctors currently don’t have because they’re tied to a roster of patients and can’t find temporary locum coverage. It allows new graduates and more experienced doctors to have much more control of their work/life balance. In fact, we’re seeing recently retired doctors offering to come back into the system if they have the ability to commit to only working a couple of shifts per week.

Most appealing for clinicians (and patients) in this model of primary care is that they can work with a team. Patients are seen by the most appropriate care provider—whether that is a family doctor, nurse practitioner, registered nurse, physician assistant, physiotherapist, occupational therapist, dietician, social worker, or another professional. Clinicians can outsource some of their administrative burden to team members who are best skilled to complete forms, make phone calls, and navigate the system on behalf of patients.

Radical collaboration in education

This brings me to the fourth initiative we’re working on—perhaps the hardest one, and the one that is still in development. But we’re trying to figure it out.

This is an initiative in keeping with the motto that emerged out of our faculty’s strategic plan developed a couple of years ago: “Radical Collaboration”. This initiative is to ensure 20 per cent of all our educational programs are delivered in an interdisciplinary setting. We don’t mean simply an interprofessional education lecture or module. We mean taking entire courses with students from another discipline. It would mean, for example, physical therapy students and medical doctor students taking their entire anatomy course together—or nurse practitioners and occupational therapists taking their entire communication skills course together, or shared courses in professionalism, in ethics… you name it.

The part of this interdisciplinary initiative that we are most excited about is the idea of team-based placements. We’ve experimented with this, it works, and the students not only benefitted tremendously, but they also loved it. For example, in the early stages of the pandemic, soon after vaccines were approved for use in Canada, Queen’s University was invited to participate in Operation Remote Immunity. The purpose of this project was to deliver and administer vaccines to remote communities in northern Ontario. Nursing students, medical students, residents, and faculty members from three universities were asked to help. We selected teams of learners: some from nursing, medicine, and family medicine residents. The teams went on two-week trips, staying at bases in northern Ontario and each day, flying into isolated communities. Together, they administered vaccines to residents living there.

When Operation Remote Immunity concluded, we brought the teams together to debrief. We wanted to find out what the students had learned and how it would impact them in the future. I expected these students to tell us they had learned so much about cultural safety and traditional Indigenous knowledge—which they did. But what was more striking to them was the chance to work on interprofessional teams. A medical student told us she hadn’t had such a positive experience of working on an interdisciplinary team like this before. She beamed when she talked about how working alongside paramedics, nurses, residents, and faculty members meant sharing stories, learning about each other’s roles, and understanding how they could best support each other. Her biggest takeaway was the new understanding and appreciation she had for her future colleagues. Our takeaway was that we must create opportunities like this on a regular basis.

Some of you who are not in health sciences faculties will assume we do interprofessional training already, but we do very little. The health professional programs currently run on very separate tracks, rarely meeting in an intentional way. And yet, we hope our students will graduate and know how to work in teams, and that they will understand each other’s roles and respect each other’s contributions.

If students don’t learn about related professionals, and how to work effectively and positively with them during school, it can be hard to learn later. For example, it can be hard to ask questions when it seems like the answer should be known. I remember a final-year medical student nervously asking me: What is an occupational therapist anyway? It should be our goal that no one graduates without a good understanding and respect for other members of the health care team—for the sake of better patient care.

This is the dream we’ve been working on, alongside communities who want to help. We want to build placements in interdisciplinary cohorts—perhaps they could even share accommodations in a housing unit provided by the community. They would do their orientation together, share cases together, debrief together about what they are learning. They can be specifically trained around task shifting. They might ask themselves: Is there anything I’m doing in my workday that could be done by someone else in the health team? Am I working to the full scope of my training?

Innovating to create high quality interprofessional training opportunities is far more complicated than it should be, and gets into issues like scheduling, timetabling, accreditation standards, union rules, and so much more. Even harder than those operational challenges are the culture changes required. It’s surprising to see how reluctant overburdened health workers can be to give up some of their work to another member of the team. But the days of turf-battles should be behind us. There’s more than enough work to go around, and we need to work together to get it done.

The key to the future sustainability of health care is all about teams. We can’t fix all the issues facing healthcare on our own, but universities and colleges can make significant changes through better training for future health care team members.

It’s a fascinating time to be in the business of preparing the health scientists and health professionals of the future and finding ways to do our work faster, smarter, better. It’s been a long time since there was significant innovation in the basic ways that we train doctors, nurses, and others. As a result, government leaders and policy makers may underestimate our ability to be nimble and creative. We shouldn’t wait to be asked. Many educational scholars have evidence and ideas about how to build a better health professional. We should go ahead and show how it’s done. The country and our local communities are counting on us.

As academics, we are limited in the levers we can access if we want to see changes in public policy and practices. But we are not impotent. The post-secondary sector must step up and offer hope to the public that things will get better. The good news is that we are in the business of producing the resource that health systems need the most. We are in the people business—the business of developing human resources for health. If we learned anything about health care through the pandemic, we learned that our hospitals and health systems are nothing without the people behind them.

Academics are also in position to assess for efficacy and adapt accordingly. Not only can we make informed decisions about innovations to training, but we can assess whether they are working as intended and plot a course for next steps. This puts us in a position for rapid, evidence-informed program development.

We can innovate how to train health workers so that they are fit for purpose and fit for serving in the areas of greatest need. We can take our educational programs to the communities that need them the most and have the least access. We can partner with other community agencies to demonstrate new models of care delivery and place our students in those demonstration sites to expand the workforce and given them exceptional placement experiences. We can assess for efficacy and rapidly identify new opportunities. And we can train our students to be the best possible teammates, ready to share the tasks with others and work to the maximum scope of their competencies.

As we do this work, and show how creative and agile we are, the post-secondary sector will increasingly be seen not simply as the places where the health workforce is trained, but also the places to provide the best solutions for society’s most pressing health challenges.

References

Canadian Resident Matching Service. (2023). R-1 Match Reports, Table 11: First choice discipline of CMG applicants. https://www.carms.ca/wp-content/uploads/2023/09/2023_r1_tbl11e.pdf

Financial Accountability Office of Ontario. (2023, March 8). Ontario health sector: Spending plan review. https://www.fao-on.org/en/Blog/Publications/health-2023

HealthForceOntario. (2021, August). Ontario Health—Health Force Survey Results. Ontario Health.

Nundy, S., Cooper, L. A., & Mate, K. S. (2022). The quintuple aim for health care improvement: A new imperative to advance health equity. The Journal of the American Medical Association, 327(6), 521–522. https://doi.org/10.1001/jama.2021.25181

OurCare. (n.d.). OurCare data explorer. https://data.ourcare.ca/all-questions

Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. The Milbank Quarterly, 83(3), 457–502. https://doi.org/10.1111/j.1468-0009.2005.00409.x

Truth and Reconciliation Commission of Canada. (2015). Honouring the truth, reconciling for the future: Summary of the final report of the Truth and Reconciliation Commission of Canada. Government of Canada. https://publications.gc.ca/collections/collection_2015/trc/IR4-7-2015-eng.pdf

About the author

name: Jane Philpott

Jane Philpott is dean of health sciences at Queen’s University. She is a family doctor and a former federal minister of health. She has recently published Health for All: A doctor’s prescription for a healthier Canada