Roger Strasser | Creating Innovative Medical Schools around the World

Roger Strasser: I grew up in Melbourne and studied medicine at Monash University.  Even then I was interested in medical education and the academic side of things. The original GP training program for Australia, which was called the Family Medicine Program, started while I was a student and I connected with the leaders of that program. So, that interest in the academic side of things began early on in my medical professional journey.  I chose to be a rural GP and undertake rural GP training which I did in in Australia, on the program in the State of Victoria.

In those days it was pretty common for Australian junior doctors to go to the UK for further training to prepare, particularly, for rural practice. That is what I decided to do but I was persuaded, because of my involvement and interest in education, to delay going to the UK. I spent almost a year with the Family Medicine Program as co-state director while still really a trainee.  While I was there we hosted visitors from Canada, and specifically a guy called Michael Brennan.  I met Michael and got to know him, and learned about the Master’s program that they offered at what was then called the University of Western Ontario in London, Ontario.  At the end of the year I went to the UK and pursued further training in surgery and anaesthesia, which had been my plan. 

On my first day in the UK I met Sarah who subsequently became my wife and, in many ways, a co-conspirator in the story.  She started GP training in the UK which she completed when we went to Canada. I was really taken by what I had heard from Michael Brennan about the training available and thought that, while I wasn’t thinking of this kind of further training yet, since I’m away from Australia, why don’t I just apply and see if I can get in. 

So, after two years in the UK, I went to Canada and spent two years in London, Ontario.  The chair of the department was Ian McWhinney and he is one of the founding fathers of academic Family Medicine. He was originally from the UK. It was a very exciting Department to be part of, and Sarah completed her family medicine training with Ian McWhinney as one of her supervisors.We then returned together to Australia and my interest in academia had grown having undertaken the training.  Neil Carson connected fairly quickly and encouraged me to develop a master’s program for Monash called the Master of Family Medicine, drawing on my experience from Canada.  And so I worked in Neil’s department, together with Leon Piterman in particular, to develop this program.

Leon and I trained in distance education in order to turn the Master of Family Medicine into a distance education program and, more or less overnight, we went from struggling to attract half a dozen GP graduate students to the Department each week, to having over 100 students, about half of them in rural practice, spread around Australia and subsequently around the world.  This Monash Master of Family Medicine program really took off because it was by distance education and accessible to GPs.

There was another development at that time. It started off as the ‘Centre for Rural Health’ and subsequently became the Monash University School of Rural Health.  In 1992 I was appointed as the first Professor of Rural Health in Australia which was something that was pretty much unknown at that time in Australia, and probably anywhere in the world.

During this time there were developments, not only in Australia but also in Canada. There are lots of parallels and similarities, although major differences between Australia and Canada.  In Canada, they simply didn’t have enough doctors, even in the big cities, and even in Toronto, Ontario, they had a shortage of doctors. That led, in 1999, to the appointment of an academic rheumatologist called Rob McKendry as a ‘ fact-finder’ on behalf of the Ontario Government to look into these issues and make recommendations on the medical workforce for the Province. There was just one line in this full report that mentioned the idea of a northern rural medical school for the Province.

DMacA: Perhaps you explain the geography of Northern Ontario to those who are unfamiliar.

RS: Northern Ontario is north of the Great Lakes and south of Hudson Bay and James Bay, so almost into the Arctic region. The eastern border of Ontario is the Province of Quebec and the western border of Ontario is the Province of Manitoba and it takes about two days to drive from the East to the West or vice versa.  It is geographically vast. Thunder Bay has a population of about 120 000, Sudbury about 160 000 and they’re 1000 kilometres or 700 miles apart.  It’s never a straightforward drive because, of course, in winter there’s snow and ice and that affects travel on the roads. And, when it’s not winter, it’s construction season as they repair the roads that had been damaged by the winter weather.  It takes a minimum of 12 hours to drive between Thunder Bay and Sudbury. Northern Ontario is geographically vast and never had enough doctors or other health professionals providing health care.  Just to put that into perspective, it’s includes nine percent of the population and 90 percent of the geographic area of Ontario.

In 2001 the Ontario Government announced that, what later became the Northern Ontario School of Medicine (NOSM), was going ahead.  In 2002 I was recruited to be the founding dean of NOSM. By that stage Sarah and I had five children and Sarah and the five children relocated to Northern Ontario and we made our home in Sudbury. 

DMacA: Running a medical school in Northern Ontario was quite a challenge and clearly there was a need for doctors.  Where did your students come from and did they stay?

RS: Because people across Northern Ontario had advocated to have a Northern Ontario School of Medicine, there was a widespread excitement, anticipation, and desire for this medical school to happen, to be a success, and to deliver for the people in the communities of Northern Ontario.  It was fertile ground for developing NOSM, very much driven by social accountability.  The Government decided that NOSM would serve as the Faculty of Medicine of the universities in Thunder Bay and Sudbury.  In order that the Laurentian University in Sudbury and Lakehead University in Thunder Bay could have a single medical school for Northern Ontario, while serving the Faculty of Medicine for two universities, NOSM was created as a separate entity, a not-for-profit corporation, with the two universities as the members acting like shareholders. Written into the founding documents, was what we came to describe as a social accountability mandate- the commitment to improve the health of the people and communities of Northern Ontario. That drove everything we did, including the selection and admission process so that it reflected the population distribution of Northern Ontario.  It was generally successful and 92 percent of medical students at NOSM have grown up in Northern Ontario.  The other eight percent come from remote and rural parts of the rest of Canada and, within that group, 40 percent from rural and remote backgrounds.  Generally about 20 percent were francophone which is about right for the population.  In the first decade, it was seven percent Indigenous so we tweaked the selection process and brought that up to 12 percent, as it is now. We were basically looking for students who were likely to thrive in the Northern Ontario setting, and those who’ve grown up in Northern Ontario were much more likely to thrive and be responsive to the curriculum model we had developed. 

DMacA: I’ve read about your curriculum, and the students’ immersion with the Indigenous communities.  How did that work?

RS: The background is that we started the curriculum development for NOSM with a curriculum workshop in January 2003.  We invited everybody who had an interest to come to this workshop.  We thought that if we got 200 people we’d be pretty doing well but we had over 500 expressions of interest and, of the 300 who were present, there were about 50 Indigenous people. Most of the three-day workshop was in groups of 20.

Listening to what I was hearing from the Indigenous people, I realized that if we were to  really understand their needs, and deliver what Indigenous people were looking for from their medical school, we needed to have a separate workshop just for Indigenous people.  We did that a few months later in June 2003 in the Northwest, just near Kenora where we had three days in small circles and large circles and listened to the experience of Indigenous people as medical students and as doctors. At that first workshop gathering of Indigenous peoples we had over 100 Indigenous people from right across Northern Ontario.  It was called ‘Follow your Dreams’.

The recommendations from ‘Follow your Dreams’ included some key elements that helped shape the Indigenous dimensions of the school. The first of these was that all the students should have an early immersive cultural experience in Indigenous communities and that’s what happens with the NOSM curriculum.  As far as I know it’s still the only medical school in the world where all of the students have four weeks of living and learning in Indigenous communities.

I described the geography of Northern Ontario earlier and these communities include very remote communities that you can only access by airplane most of the time. In winter they cut ice roads to bring in heavy supplies and equipment but they’re very remote and the students, generally two students for each community, spend four weeks in the community. They’re there to learn about the history, the tradition, the social and the health issues of the community.

DMacA: Having set up this medical school with a really Innovative curriculum, I guess people ask how do you measure the success of the innovation.

RS: It was very important for us from the beginning, to study what we were doing.  We began tracking research from the beginning of NOSM – looking at the impact of NOSM on the communities of Northern Ontario, in terms of success or otherwise on recruitment and retention of doctors, and also looking at the economic impact.  Over time we’ve been able to study what happens to graduates in terms of their choice of specialty and location of practice.  So, in 2019, 10 years after the first graduation class of 2009, we found that 74% of the NOSM graduates were in Family Practice and another 14% in other general specialties such as general medicine general surgery, paediatrics, etc. In total, 91% were generalists and nine percent in sub-specialties like Dermatology, Radiation Oncology, Neurology. That nine percent are, of course, important to us because those sub-specialists are needed in Northern Ontario.  They had gone elsewhere for their postgraduate training but many of them had come back.  And we found that, of those who went into Family Practice and did both their undergraduate and their postgraduate training in Northern Ontario, 92 percent were practicing in Northern Ontario. 

We also did research looking at particular communities and found that those small communities that had embraced the NOSM model, and got involved with having students and residents in their community, turned around their medical workforce problems.  Before NOSM there were 30 full-time equivalent vacancies between these eight communities and, at the time of the later study, there was only one vacancy amongst those eight communities.

The students’ classroom learning is in small groups, what we call patient-centred case-based learning, and each case is a complex real-life scenario set in real communities in Northern Ontario.  Even in the classroom the students are learning in teams, and how to be team players, but also learning as if they’re going to be serving these communities in Northern Ontario – learning in context. 

They have four weeks in the Indigenous community in first year and, in second year, they go twice to small communities for four weeks of immersive community experience.  This is a clinical attachment to the health team in those communities, usually in populations of less than five thousand.  Then in the third year, which is the principal clinical year, the year where students make the transition from being classroom learners to clinicians, they leave Thunder Bay and Sudbury and go to one of 15 communities and they live in that community for the whole Academic Year which is eight months.  They are based in general practice and they see patients. So, you could say, the curriculum walks through the door; the first patient might be pregnant, that’s Obstetrics; the next patient might be a child, that’s Paediatrics; the next patient might have a surgical problem.  The learning objectives or learning outcomes set for that year in the six core clinical disciplines of medicine are just the same as in the other medical schools that do block rotations – clerkship blocks as they call them- but the learning environment is very different.  The students are learning their core clinical medicine from the community family practice perspective.  And what we’ve found by studying this is that it’s the intense interaction with patients that really motivates the students to study hard and do the best they can for their patients. I think that helps to explain the outcomes in terms of their career direction.

That’s the curriculum model. But, it costs more per student per year than the standard model and so it was important for us to show that it was a worthwhile investment on behalf of the Ontario Government.  We were able to show the economic impact of NOSM and, that for every one dollar taxpayer money spent, there was more than two dollars of new economic activity that wouldn’t have happened without the medical school.  And that economic benefit flows through to the small communities, not just the big centres like Thunder Bay and Sudbury, but to the small communities more or less proportional to the number of learners, medical students, and residents that they have.

DMacA: I’m incredibly impressed by your terrific pioneering achievements.  What are you going to do next?

RS: Sarah was very much on the same journey and got involved in the academic side of things as I did.  She was, you might say, ‘a partner in crime’, in establishing NOSM in the early years.  After about five years she was drawn back to Australia and she helped Flinders University establish the Northern Territory Medical Program in Darwin, in the far north of Australia, very much modelled on the NOSM experience.  While she was there and I was still in Northern Ontario, I would come over and talk about what the tropical North could learn from the frozen North.  Later, she was with the University of Queensland and helped start regional medical programs in the southern part of rural Queensland.  After NOSM, we decided we’d like to work together and live in the same place and that opportunity came up in New Zealand.  We spent a couple of years with the University of Waikato, where Sarah was the Dean of the School of Health, and we were advocating for a medical school. Unfortunately, the New Zealand Government wasn’t persuaded by this advocacy and our current new opportunity is here in Vancouver where Sarah and I are working together. I’m the interim Dean and she’s the interim Vice Dean helping the Simon Fraser University prepare to establish the Simon Fraser University Medical School.

DMacA: I can only say that the Simon Fraser University are incredibly lucky to have you.  It’s been fascinating talking to you.  Thank you very much for sharing your incredible career and may I wish you success in this new venture.