Medical Education

Medical Education

There are several phases to a contemporary Canadian medical education. The first part of the admissions process in most Canadian universities is passing the Medical College Admissions Test (MCAT) to assess problem-solving, critical-thinking and writing skills and comprehension of scientific concepts. The way the test is used in admission varies by the medical school. An undergraduate degree is necessary before admission to most Canadian medical schools, but some schools (such as the University of Saskatchewan) require only 2 years of baccalaureate education. Students then attend medical school where they are taught the basic knowledge, skills and attitudes of the physician. Upon completion of their medical study, students are awarded the degree of medical doctor (MD).

To be eligible for a licence to practise, all MDs must complete at least one year of internship during which time they work under supervision in a hospital or clinic, gaining practical experience and increasing responsibility for the care of patients. Many graduates choose to undertake a minimum 2-year training program leading to accreditation by the College of Family Physicians of Canada and become a family physician; others enter 4- or 5-year programs leading to certification in one of the 44 medical specialties recognized by the Royal College of Physicians and Surgeons of Canada and become a specialist. To become a subspecialist, such as in neurosurgery or adolescent medicine, an additional 2 years of training in the subspecialty is required.

The most recently developed phase is continuing professional development (CPD). This includes all programs of independent or supervised study through which practising physicians seek to keep abreast of the latest developments in medicine of concern to them and their patients. CPD is important for preventive medicine because it keeps physicians up-to-date on new treatments and disease management methods.

Undergraduate and postgraduate education is provided exclusively by Canada's 17 university medical faculties. Eight provinces have medical schools, and New Brunswick and Prince Edward Island help fund medical schools in neighbouring provinces. Continuing education is provided by the medical faculties, by various national, regional or local professional societies, by hospitals or pharmaceutical companies and by other agencies or groups.

History of Medical Education in Canada

The first program of medical education in Canada was created in 1824 at the Montreal Medical Institution, which 5 years later became the Faculty of Medicine at McGill University. By the turn of the century, schools had been established at McGill, the University of Toronto, Laval (which had schools both in Québec City and Montréal - the latter eventually becoming the Medical Faculty of Université de Montréal), Queen's University, Dalhousie University, the University of Western Ontario and the University of Manitoba. An 8th school at the University of Alberta in Edmonton was opened in 1913. By 1950 additional schools had been established at the University of Saskatchewan, the University of Ottawa and the University of British Columbia, and the Montréal branch of Laval had become an independent school.

Two events in the early 20th century profoundly affected the quality of medical education in Canada. The first was the publication in 1910 of Medical Education in the United States and Canada by the Carnegie Foundation for the Advancement of Teaching. Written by Abraham Flexner and based on his visits to the 155 schools of medicine then existing in the 2 countries, the publication proposed that acceptable schools of medicine must have high standards for the admission of students, must be part of and subject to the rigorous academic standards of a university, must base their educational programs on a scientific approach to medicine and must encourage the scholarly research of their faculties.

So profound was the impact of the Flexner Report that within 15 years of its release most of the schools identified as substandard (nearly half of the total) had closed their doors forever. Although no Canadian schools were closed, standards at the weakest were improved greatly.

The second important influence was the formation of the Medical Council of Canada in 1912. The council established a single standard examination for the graduates of all medical schools in Canada which was eventually accepted by all provincial medical licensing authorities as a criterion for awarding licences. As a result, the quality of medical education across the country became more standardized, and, just as important, medical graduates became free to move from one part of the country to another with the reasonable expectation that their credentials would be recognized and accepted.

The next major influence on medical education was the publication in 1964 of the report of the Royal Commission on Health Services. The commission, under its chairman Mr Justice Emmett Hall, was established to investigate the provision of health services. It concluded that the supply of physicians provided by the 12 medical schools was insufficient to meet the country's needs without continued reliance on high levels of immigration of physicians trained in other countries. This led to the almost immediate establishment of new schools at McMaster University, the University of Calgary and Memorial University and to the accelerated development of the school at the University of Sherbrooke.

The total enrolment of first-year medical students in Canada has fluctuated over the years. In the early 1980s the number peaked at just below 1900 students. Except for rebounds in 1988 to 1991 and in 1993, the number declined to approximately 1575 in 1997. Since then, enrolment has increased significantly to 2569 students in 2008.

Different Approaches to Medical Education

Prior to the Second World War, the curricula in Canadian medical faculties had generally evolved from that first established at McGill, which was in turn based on the Edinburgh model. Strong emphasis on bedside teaching was introduced at McGill by William OSLER in the 1880s. The curriculum consisted of 2 years of lectures and laboratory exercises in the basic sciences of (with greater or lesser emphasis) anatomy, physiology, biochemistry, bacteriology, pathology and pharmacology, followed by 2 years of clinical instruction in hospital wards. The Flexner tradition, with its emphasis on the theoretical basis of the fundamental medical sciences, shaped the basic sciences teaching. In contrast, clinical instruction emphasized the practical aspects of medical care and was based almost entirely on the exposure of students to hospital patients.

Scientific knowledge, much of which was quickly absorbed into medical practice, increased dramatically during and after the Second World War. Consequently the already crowded curriculum of medical students expanded as well. At about this time a new breed of clinical teachers appeared in the medical schools. Young men and women, attracted by the increasing support available for research and by the opportunities a research career could offer, were no longer satisfied with training only in the clinical disciplines but sought a broader and more profound theoretical grounding in one or more of the basic sciences. They became the forerunners of the new generation of clinical scientist-teachers who now strongly influence all medical faculties.

By the late 1950s and early 1960s Canadian medical faculties were staggering under the stresses of a rapidly expanding body of knowledge that could not be adequately conveyed in the curriculum then in use. Medical students became increasingly frustrated and vocal about the volume of information they had to learn, the relevance of which was not always apparent. In response, most schools started introducing students to patients in the first rather than the third year, in order to provide a framework of relevance for the basic sciences that still had to be taught. To accommodate the change, basic science laboratory exercises were either reduced in number or eliminated.

Many schools adopted integrated or "systems," curricula in which the basic and clinical features of such systems as the cardiovascular, musculoskeletal, respiratory or digestive were taught in integrated blocks. The students learned, in a co-ordinated sequence, the basic sciences of the particular system as they were learning its clinical features, diagnosis and management. It was expected that the systems approach would provide students with a conceptual framework on which they could base their diagnosis and treatment. In the new curricula, lecture and laboratory were no longer relied upon as the principal educational tools. Seminars and tutorials were emphasized. To cope with the growing body of knowledge that had to be absorbed, schools also encouraged students to assume more responsibility for their own education and to develop their problem-solving skills.

The most radical of the new curricula, and one that attracted worldwide attention, was the problem-based learning approach adopted at McMaster. In this curriculum, small groups of students, under the guidance of an instructor, worked together in collecting and integrating information, either from books and journals or from faculty consultants, to solve problems devised for them by the faculty. The program emphasized teamwork between students and faculty. The faculty made no pretense at providing students with an encyclopedic fund of medical knowledge but assumed that after the experience of a problem-based curriculum students would have developed the ability and self-reliance to deal with the clinical problems they might encounter in practice.

Critics of the program claim that the performance of its graduates has been consistently below the average for graduates of other Canadian schools and that failure rates have been higher. On the other hand, graduates of McMaster have been accepted into some of the most prestigious postgraduate training programs in North America and elsewhere, where they have received highly favourable ratings. The curricula at McMaster and Calgary are both concentrated into 3 undergraduate years, with only a month of vacation per year. The 5-year program at the University of Montréal is designed to provide students with greater opportunities to "ripen" into their roles as future physicians. The other medical schools have 4-year curricula, as have almost all others in North America.

Accreditation of Medical Schools

Since 1934 schools in Canada have been regularly accredited by the US body now called the Liaison Committee on Medical Education. With the advent of universal healthcare in Canada in 1970 the patterns of medical care and practice in the United States and Canada began to diverge, making it necessary for Canada to adopt a system of accreditation more appropriate to the country's needs. Accordingly, in 1979 the Committee on the Accreditation of Canadian Medical Schools was formed as an independent body to examine and attest to the quality of educational programs in Canadian medical schools. Schools in Canada are now jointly accredited by both bodies, with the assurance that Canadian schools meet Canadian standards.

Emerging Issues

The rapidity of technological change and scientific advancements of the late 20th and early 21st centuries require medical educators increasingly to adapt teaching methods to the evolving environment in which physicians practise. Advancing technologies related to organ TRANSPLANTATION, dialysis, GENETIC ENGINEERING and reproduction now make it possible for more and more people to survive to an advanced age in which health care costs are likely to be highest. Not only must students learn the new technologies, they are also required to understand the social and ethical implications of patient care. Students of the future will have to be prepared to advise other care givers and legislators on the economic and social costs of new technologies and on the integration of medical advances into Canada's unique health care system. As well, future medical students will increasingly require advanced computer knowledge as part of their education and as an adjunct to diagnosis, prognosis and patient care.

The worldwide epidemic of Acquired Immune Deficiency Syndrome (seeAIDS) increased the need to expand medical teaching in both EPIDEMIOLOGY and virology. Educators must exploit advances in both these fields, not only in relation to AIDS but in applications to other viral diseases such as INFLUENZA and the common cold, whose costs in human productivity are astronomical.

Preventive medicine is a major issue for the 21st century. It is based on the concept of avoiding illness by avoiding disease, such as by vaccination, and by avoiding flare-ups in chronic diseases such as asthma by reducing exposure to triggers such as allergens and second-hand smoke. Preventive medicine requires physicians to work with patients in order to reduce illness and maximize health. The increasingly high cost of health care and access issues such as a shortage of doctors make medical practice to help prevent illness especially relevant. Another aspect of preventive medicine is properly treating infectious diseases. The widespread development of ANTIBIOTIC-RESISTANT strains of bacteria leads to increased difficulty and expense in treatment. When medicine is prescribed and used properly, it helps to reduce the development of drug-resistant bacteria. Maintaining current medical education helps physicians to be aware of the active strains of bacteria and viruses and improves the effectiveness of treatment.

There are concerns about a shortage of physicians in Canada, both family practitioners and specialists. One reason for the shortage is the increase in Canada's population, especially in metropolitan centres such as Toronto, Vancouver and Calgary. The decrease in the number of students attending medical school during the 1990s lowered the overall number of doctors who graduated in Canada. In addition, some Canadian-trained physicians leave the country to work in the United States after medical school. In 2002 the Royal Commission on the Future of Health Care in Canada, also known as the Romanow Commission, investigated and made recommendations on key issues for the Canadian health care system. The commission's final report determined that, despite costing $100-plus billion a year, Canada's health care system lacked accountability guidelines. No government had done a good job of implementing such a series of principles. To improve the system's accountability to the public, the report called for accountability to be made the 6th principle of the Canada Health Act, joining universality, portability, accessibility, comprehensiveness and public administration.

While the medical needs of the future cannot be accurately predicted, we can be sure that all concerned with the health care system will need to be prepared to meet unexpected demands. Of particular concern in this regard will be the medical disorders that can result from lifestyle changes in human behaviour - such as substance abuse, obesity and type II diabetes. Fads and fashions in behaviour can develop rapidly and unpredictably and many of them can be expected to result in health problems that require prompt medical or political response.