By Professor Roger Strasser, Northern Ontario School of Medicine
Over the last decade, there has been a growing discourse on “generalism” in health care, medicine and medical education. This discourse has occurred in the context of greater sub-specialisation and recognition of the growing need for doctors and other health professionals with the skills and commitment to provide care where it is most needed, particularly in underserved remote, rural and Indigenous communities. The Future of Medical Education in Canada (FMEC) Visions for MD Education in 2010 and Postgraduate Education in 2012 both emphasize the importance of students and residents developing generalist knowledge and skills, and learning in relevant generalist clinical settings. The Royal College of Physicians and Surgeons of Canada defines generalism as “a philosophy of care that is distinguished by a commitment to the breadth of practice within each discipline and collaboration with the larger health care team in order to respond to patient and community needs”. This emphasis on responding to community needs is consistent with social accountability which, for medical schools, the World Health Organization (WHO) defines as “the obligation to direct their education, research, and service activities towards addressing the priority health concerns of the community, region and the nation that they have a mandate to serve”. In addition, the College of Family Physicians of Canada (CFPC) and the Society of Rural Physicians of Canada (SRPC) collaborative Task Force on Advancing Rural Family Medicine produced The Rural Roadmap for Action whose recommendations emphasised generalism in rural health care and medical education.
Located in a vast rural region of Canada, the Northern Ontario School of Medicine (NOSM) opened in 2005 as a stand-alone medical school with a social accountability mandate focused on improving the health of Northern Ontarians. NOSM recruits students from Northern Ontario or similar backgrounds, and provides Distributed Community Engaged Learning (DCEL) in over 90 clinical and community settings. NOSM was the first medical school in the world in which all students undertake a longitudinal integrated clerkship, the Comprehensive Community Clerkship (CCC). Based in family practice, the CCC is the third year of the four year graduate entry undergraduate program. Rather than a series of clerkship block rotations, students meet patients in family practice such that “the curriculum walks through the door”. In essence, NOSM students learn their core clinical medicine from the family practice and community perspective, while also gaining exposure to community based specialist care.
For NOSM, generalism is one of the key academic principles that guide the development, delivery and evaluation of its academic activities including student admission process, faculty appointment and development, curriculum, teaching methods, clinical training, and community placement. Generalism as it is used and represented in the NOSM curriculum, entails a broad scope of skills, attitudes and knowledge, regardless of whether or not the medical practice is primary, secondary or tertiary care. At NOSM there is an emphasis on: learning in context including community/clinical settings where NOSM graduates are expected to practice; longitudinal learning which supports continuity of relationships with patients and clinical teachers; interprofessional collaboration and integrated clinical learning; community engagement with authentic participation by community members; and support, recognition and reward of community clinicians as faculty members and as role models of a breadth of expertise, as well as mentors for the students.
Generalism at NOSM applies therefore to student learning in the curriculum, as well as the education sites and the clinical faculty members who serve as educators. In addition, generalism, while wholly applicable to all stages of medical education is applied also to all NOSM programs (health sciences, interprofessional and research).
After 12 years, there is evidence that NOSM is successful in producing generalist physicians who choose to practice in Northern Ontario or in similar northern, remote, rural community settings. Since the first graduation in 2009, 62% of NOSM MD graduates have chosen to train in family medicine (predominantly rural), 33% other general specialties (internal medicine, general surgery, pediatrics, etc) and the remaining 5% are pursuing careers in subspecialties like dermatology, ophthalmology and radiation oncology. NOSM offers residency programs in family medicine and eight other general specialties. Seventy percent of NOSM residency graduates are practising in Northern Ontario and 94% of NOSM MD graduates who undertook residency training in Northern Ontario are practising in Northern Ontario, including 33% in remote rural communities.
Several studies have explored aspects of students’ and graduates’ experiences of NOSM. NOSM students commented that the CCC: “creates “generalists” and encourages students to maintain a broad focus”. Beyond primary care, a rural medicine “true generalist” is viewed as a complete package, a doctor who provides care ranging from promoting prevention to performing specialist tasks. NOSM students and graduates consider generalist care as a comprehensive service with a strong focus on responding to the health needs of the community they serve, reflecting adherence to social accountability. In contemplating the practical, embedded CCC rural practice experience, another student referring to rural medicine commented that: “You don’t know it until you live it.”
The need for generalism in health care and education is most obvious in remote, rural and Indigenous populations and this has provided impetus for the three World Summits on Rural Generalist Medicine since 2013. The first World Summit in 2013 led to the Cairns Consensus Statement on Rural Generalist Medicine (RGM) and was followed in 2015 by the 2nd World Summit on RGM is Montreal. The 3rd RGM World Summit on 28 April 2017 in Cairns, Australia developed a worldwide RGM Action Plan that addresses four themes: Achieving recognition; Gathering and generating the evidence; Rural Generalist Medicine Toolkit; and Rural Generalist Engagement.
In my view, there is a strong case for all socially accountable education to have a substantial emphasis on generalism including: training in a variety of community and clinical settings; learning key competencies to meet community needs; and training where graduates are expected to practice. Generalism competencies include: comprehensiveness; adaptability; clinical courage; improvisation/resourcefulness; risk tolerance; endurance/resiliency; collaboration; lifelong learning; integrity; and humility.