Med school tackles rural doctor shortage with crash course in community culture

Canada is often lauded for its universal health care system, but universal doesn't mean equal access. The reality is that seven million Canadians, particularly those in smaller communities, are without a family doctor — in Ontario alone the number is two million. 

The Northern Ontario School of Medicine University (NOSM) is working to change that with a curriculum that challenges how doctors get trained. The goal of the non-profit university is to teach them medicine, along with a few things that could influence where they choose to practice.

"We are actually addressing these problems through incredible education and training with a focus on family medicine and Indigenous health," said Dr. Sarina Verma, the school's dean.

"We think it's the template for success for all of Canada."

"The chronic doctor shortage in northern Ontario needs urgent attention," said Emily English, of the Ontario Medical Association. "The Northern Ontario School of Medicine is doing incredible work training future physicians and retaining their graduates to build practices in northern Ontario."

Originally a part of Laurentian and Lakehead Universities, NOSM became an independent entity in 2022 with campuses in Thunder Bay and Sudbury. It has a social accountability mandate to improve the health of people in the communities of northern Ontario. 

The program is expanding quickly, with the announcement in March that Ontario will open an additional 30 funded spots at NOSM for medical students and 41 extra spots for postgraduate students over the next five years.

"This expansion will increase access to family and specialty physicians and other health care professionals in every corner of the province to ensure that Ontarians can access the health care they need, when they need it, wherever they may live," Minister of Colleges and Universities Jill Dunlop said in a statement at the time.

NOSM actively recruits students from rural communities and 90 per cent of its student body comes from northern Ontario. The idea is that if students are already comfortable living in smaller centres, they're more likely to stay and practice there once they graduate.

So far, the theory has proven true. Each year NOSM enrolls around 80 students from more than 200 applicants, and 99 per cent of those admitted complete the program. Of the 902 doctors who have graduated since the school was founded, NOSM says about half have stayed in northern Ontario and the other half are scattered throughout smaller communities across Canada. 

"The distributed model like ours gets the learners, first of all, into an emergent program, which is four weeks in an Indigenous community," Verma said. "You live and work and breathe and understand what the context is, and then your training happens in communities. 

"We have learners who show up and within the first week they're actually assisting and delivering babies, actually doing surgeries as the first assist, they're on call in the emergency department," Verma added. "That's very different than having 14 other learners around you in a big hospital — you actually get to do a lot more, see a lot more, and be incredibly confident as a physician."

And 46 per cent of the graduates go into family medicine, which the school says is no accident.

Dr. Brenna Duffy is a graduate of NOSM who now works in one of the small communities Verma is talking about, at the Meno Ya Win Health Centre in Sioux Lookout, Ont., about 350 kilometres northwest of Thunder Bay. She agrees that the kind of medicine she practices here is unique.

"I had no interest in family medicine," Dr. Duffy said. "And then as a medical student, I came here and I followed family doctors to the floor and the emergency room, I followed them into the OR, we delivered babies, and I was like, 'What? This is family medicine?' And my heart and mind changed that year, and I decided to pursue rural family medicine."

Now she's a family doctor who also works shifts in the ER, a typical role for some doctors in small communities. The hospital Duffy works at is the only one for hours in any direction, so it services some 32 communities in a region the size of Germany.

Since most patients who come here fly in from surrounding communities and often stay for the duration of their treatment, the hospital built a hostel on site where patients stay. Duffy says it often means her cases are complicated.

"The general population doesn't really think about having to leave your family to come to the emergency room," Duffy said. "By the time people get here, often they're quite unwell, and so you have a high acuity in terms of what patients actually show up in our emerg."

Some people stay in the hospital's hostel for weeks or months if they're being treated for a chronic condition, like receiving dialysis. The hospital also has an obstetrics program where women from rural areas can come and stay at the hostel for two weeks before they are due to give birth to ensure a safe delivery.

And since the majority of patients coming to the hospital are from Indigenous communities, caring for them in a way that respects their culture is a core priority. 

The hospital prepares traditional foods for its Indigenous patients and provides on-site translation services for anyone who doesn't speak English. The idea is to remove barriers to health care however they arise, so that people don't hesitate to come to the hospital when they do need care.

Indigenous learning

NOSM's program is fully accredited, running the same length as any other medical school, but it also has Indigenous learning embedded within the curriculum.

Kathy Loon is the traditional programs manager at the health centre in Sioux Lookout.  On any given day she leads classes for NOSM students on rotation here that are part of the university's curriculum, but have very little to do with what you'd get through a typical medical school.

She is in charge of making sure students understand the culture of the population they are serving. She teaches them about the hospital's onsite healing room, for example, complete with traditional drums and clothing for ceremonies, and herbs used as medicines. Loon says these lessons are as important to the students' education as medical rounds.

"For Indigenous patients, it means that their culture is respected — 90 per cent of our patients that come here are Anishinabe and we believe it's very important that they are represented."

Loon adds that the approach helps with healing, too. 

"To get better you need to be emotionally happy as well, because you don't heal when you're not happy. In fact, you get sicker."

Students based in communities

The NOSM program goes even further to make sure students understand local communities and culture. All first-year medical students participate in a one month immersion program in an Indigenous community to learn how its people live and gain their trust.

Verma says the intention is to help heal old wounds.

"We live and breathe truth and reconciliation," she said. 

"Any student who goes through our program will know the history, they will understand the context, but more importantly they will have respect for the diversity of Canada. And you know what? That is what makes our entire system so unique, because we address the inequity we can't solve."

Patients CBC News spoke to didn't want to disclose their identities, but shared that having doctors trained with an appreciation for their cultural customs made them more comfortable seeking medical care.

Tafheem-Un Nisa, a NOSM student who recently completed her immersion program, was matched with the Lac Seul Indigenous community located 40 kilometres northwest of Sioux Lookout.

Nisa was raised in Pakistan and says the health inequities her family experienced there were part of the reason they moved to Canada. But after settling in Timmins, Ont., they soon realized that northern Ontario has similar issues with access to doctors.

"As I got older, I wanted to see a dermatologist and it was a three-year wait list. We had one dermatologist who would fly in to Timmins from Toronto," Nisa said. 

"During those years we realized there's such a lack of health care due to the geographical limitations of northern Ontario. And it made me want to pursue it, given that I already had a background coming from a country where it was underdeveloped and then in this new country that we called home there were also a lot of inequities for minority populations."

In her month at Lac Seul, Nisa was trained in the community's health centre, and she also took part in traditional drum-making workshops and learned how to make bannock, a historic staple for many Indigenous communities. 

The idea is that the more students understand and appreciate the culture of those they serve, the more willing the community will be to embrace them as well. 

According to the community's chief, Clifford Bull, the strategy is working.

"Well, you know, I really enjoy the students when they come, we try to make them feel at home. And the need is there, for sure, in terms of having more doctors in our communities," Bull said. 

"When they come back, they'll know that there are values that have to be respected. Protocols, traditions I guess, cultural language. All these things are what make us who we are as First Nations."

And the NOSM students do come back. It already graduates more Indigenous doctors than any other university in Canada, 78 since its inception and eight just this year. It also has a high retention rate, with 55 per cent of its graduates staying to practice in rural and Indigenous communities.

This has put the school at the forefront of addressing the doctor shortage in rural and remote areas of Canada, and its dean says other schools call her for advice on how to replicate the system. 

"Often I'm on the speed dial of these places," Verma said. "I've offered them help and advice — the model is often seen as being one of the gold standard models."

In fact, three new medical schools are opening in Canada in the next year — one in British Columbia, one in Toronto and one in Prince Edward Island — all with the goal of helping to tackle the doctor shortage, specifically in family medicine. The dean of the new Simon Fraser University Medical School in B.C., Dr. Roger Strasser, was a founding dean at NOSM and said he is shaping the new school around things learned at his previous post.

"That's what I call a cradle to grave approach," Strasser said. "Seeing them from starting in their own community, to serving their own community, to retiring in their own community."

The chair of the University of Toronto's Department of Family and Community Medicine, Danielle Martin, agrees NOSM is moving the needle on solving the doctor shortage crisis. 

"One of the best ways to recruit doctors and other health professionals to any community is to train people who come from that community, in that community. NOSM is helping to advance access to doctors in the North using that strategy," Martin said.

The fact that the school has had such an impact in Northern Ontario is also a draw for students who chose the program with the specific goal of giving back to the communities they call home.

"Growing up in a small community outside Sault Ste. Marie, I knew first-hand what not having a consistent doctor was like," said Rosemary Rankin, a first year NOSM student recently immersed at Lac Seul. 

"It inspired me to want to be that doctor for others living in a small and rural community."

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