Pioneers in Canada / by Vic R. Neufeld

Pioneers in Canada Rather than acquiring information from lectures offering an arbitrary sequence of courses, medical students at McMaster University in Hamilton, Canada, acquire most of their knowledge and skills from the study of problems or cases I n the global "long march" to-ward Health for all, universities can be active partners by con- tributing their academic perspective and leadership. This idea was elab- orated in 1984 through the technical discussions on the role of universi- ties in the strategies for Health for all, at the time of the World Health Assembly . Some additional poten- tial contributions by universities were suggested during the 1986 technical discussions on "intersec- toral action for health." One Canadian university, McMaster University in Hamilton, Ontario, has long pioneered some new approaches to the education of health workers, to health research, and to partnership with community health services. In the mid-1960s there was a perceived need in Canada for more health profession- als, and in particular for more primary care physicians. As a re- sult , four new medical schools were established, bringing the total in Canada to 16, and the eventual an- nual output of medical graduates to about 1800. The Faculty of Health Sciences at McMaster University was one of these new institutions , and became the fifth medical school in the province of Ontario. The "founding fathers" of the Faculty made an early and critical decision to try something different from the usual. They analysed the past and present problems of medi- cal education, the current issues and trends in health and health care, and the special opportunities which presented themselves in the Hamilton community. They then formulated a "vision" of a health worker whose knowledge , skills and performance would be more 20 by Vie R. Neufeld attuned to the health needs of the community. They saw the need for more interdisciplinary and targeted research. And they saw special op- portunities for the university as an academic partner for collaboration with regional health service agen- cies and institutions. By the time the first class of medical students began studies in the M.D. (Doctor of Medicine) Programme in 1969, the basic elements of an innovative approach to health sciences edu- cation and research were in place. Good leadership consists of motivat- ing people to their highest levels by offering them opportunities, not obli- ga~ioos. That is how things happ~Q na ly, Life is an opportunity 0 !;llfgati,on. 0 ' , ... ! Among the various actiVIties of this new Faculty , five features stand out as departures from the norm in most other similar institutions. - Firstly, the university is situ- ated in a community of about 300,000 people. Hamilton is an in- dustrial city, with several large steel mills and its citizens represent a rich blend of cultures from coun- tries around the world. The city also is fortunate to have forward- looking leaders in its hospitals and health agencies. Through their efforts, a city-wide coordinating group called the Hamilton and Dis- trict Health Council had been formed, to promote communication among health institutions and with the provincial government, and to help in collaborative long-range planning of regional health ser- vices. The Faculty of Health Sci- ences became an academic partner in this Council, contributing its ex- pertise in health services research , training and health care evaluation. Rather than being situated in a " university hospital, " members of the Faculty are located in various health agencies and hospitals throughout the community, includ- ing academic primary care centres (family medicine units). This ap- proach to regional health planning has continued, with the university taking an active leadership and supportive role , consistent with its academic mission. - Secondly, the Faculty's inno- vative educational methods. When considering what competencies future health workers would re- quire, the first planners of the med- ical school curriculum made a care- ful analysis of their own experience as students and teachers. They all agreed that much of their previous experience was educationally obso- lete and not relevant to many of the health problems of the community. Several particular strategies were then introduced into the under- graduate medical programme including: Problem-based learning: Besides acknowledging that there would continue to be an ever-expanding volume of information in the health sciences this strategy recognised that human memory retained knowledge more effectively when learning occurred in the context of real-life experiences. Rather than acquiring information through lec- tures and laboratories offered by disciplines in an arbitrary sequence of courses , McMaster medical students acquire most of their W ORLD HEALTH, April 1988 knowledge and skills through the study of problems or cases. These include both individual patient and community problems. Self-directed learning: Within a few years of practice, most health professionals become rapidly and progressively out-of-date. In fact, there is convincing evidence that the quality of medical care declines in relation to the interval since graduation from medical school. By allowing McMaster medical stu- dents to learn in a largely indepen- dent mode, and by providing spe- cial training in learning skills and in the critical appraisal of scien- tific publications, they will have as medical graduates the skills and confidence needed to continually change their behaviour in profes- sional practice in the light of new knowledge and new practice opportunities. Small group learning: Besides spending considerable time in inde- pendent learning, McMaster medi- cal students work in small groups of five or six students, together with a faculty tutor. Here they analyse the problems (cases) they are given, practice applying the knowledge they have acquired in solving or understanding the problem, and assess each other's contributions to this learning task. This forum of learning is active and participatory , and helps the students to acquire not only the needed knowledge but also the teamwork skills they will require in their future work. - Thirdly , an interdisciplinary research programme. The Faculty decided early on to concentrate its research efforts in a few major areas , with teams of scientists from different departments. The success of this strategy can be measured by substantial advances in knowledge in such areas as thrombo-embol- ism, host resistance, and education- al research . A committee for Scien- tific Development provides a wide range of logistic support for all researchers , and determines policy guidelines on behalf of the Faculty. - Fourthly, an alternative ap- proach to public health. In many universities, the "profile" of public health rates very low in the opinion of students and of many faculty members. Nevertheless, it was felt by the founders that a "population perspective" was essential, and had to be made attractive to the major W ORLD HEALTH, April 1988 Old-style lecture-rooms like this are no longer seen as the best means of acquir- ing information. McMaster medical stu- dents acquire most of their knowledge and skills through the study of problems or cases. Photo W HO/E. Rice clinical groups. So a group of applied health research methodo- logists was assembled, including clinical epidemiologists , health economists , biostatisticians and behavioural scientists. These col- leagues collaborate with clinicians in a wide range of research and educational activities . - Finally, multi-professional col- laboration. Within a few years of its inception, the Faculty of Medicine was joined by a previously existing School of Nursing to become a Fac- ulty of Health Sciences. This has facilitated an inter-professional approach to educational planning, and to health research. The Facul- ty's activity will shortly include programmes in occupational health and physiotherapy. Working to- gether in a single Faculty makes it possible to address issues of com- mon concern to several health professions. No institution can rest on its past achievements without becoming complacent and obsolete. The lead- ership of the Faculty has realised this and has encouraged new ven- tures and fresh ideas. Here are some examples : - The Faculty has entered into a contractual partnership with the city's Department of Health to form a " Teaching Health Unit," to strengthen community-based research and education. - Each year a cohort of young fac- ulty members are enrolled in an educational leadership develop- ment programme, consisting of selective courses, preceptorships and projects. - A major government grant has been awarded to set up an Educa- tional Centre on Aging and Health as a province-wide resource to en- hance the care of Ontario's elderly citizens through the improved edu- cation of health professionals. - The faculty is strengthening its capacity in the field of international health to ensure that its education and research programmes will have a global perspective. Many lessons could be drawn from this twenty-year experience of one institution, but just two will be stated here. Firstly, the preparation of ,faculty colleagues for new skills and perspectives in education and research requires sustained and sensitive effort. And, secondly, it is critically important to have an "outward view." • 21