Within 15 s of beginning the first consultation of my general paediatric practice, I realized that there were some enormous gaps in my residency training.
I was sitting across from a 10-year-old girl and her foster mom. The referral request contained only the cryptic rhetorical statement, “Query difficulty at school”. It became immediately and abundantly clear, however, that difficulties at school were the least of this child’s problems. She had an explosive behavioural disorder; she was smearing feces all over the walls of her bedroom when angry; she was attacking her foster siblings with various and sundry utensils on a daily basis; and she would occasionally urinate into the air ducts of her foster home. She also had asthma.
I had just completed my training in a fully accredited and excellent residency program. I could intubate, insert femoral catheters and describe Ebstein’s anomaly, and I knew the underlying metabolic defect of metachromatic leukodystrophy. I even knew what a Mondini defect is. I had, however, absolutely no idea how to approach the problems that this child had presented me.
The main reason of course is that, with the exception of one month spent in a small, urban community, my entire residency was spent managing patients referred for services at a tertiary children’s hospital. The overwhelming majority of patients that I saw had been assessed by other paediatricians or emergency physicians. Rarely did I encounter a child who had not already been assessed by another paediatric practitioner. Furthermore, I had no opportunity to assess children with problems that did not require tertiary paediatric assessment and care. I learned how to do developmental assessments only in the context of a child development centre, where we saw one to two patients per day and where psychologists, social workers and audiologists were available on site, without delay. As such, I began practice with a very narrow view of paediatric service delivery, a view that was not the reality in most parts of the province.
Fortunately, while my training was ongoing, forces were beginning to stir both in the public and in the profession with respect to the training of physicians.
In the late 1980s, the Educating Future Physicians for Ontario (20) project consulted broadly with the public and profession, identifying eight important roles of a physician. The RCPSC adapted the results of this initiative into the CanMEDS framework (12), which forms the structural basis for specialty training in Canada. One of the important outcomes of this process was the determination that paediatric specialty training was over-focused in tertiary academic centres and failed to provide a complete and realistic view of paediatric medicine in Canada. It also pointed out that the nature of clinical encounters in such centres may not provide trainees with sufficient clinical problem-solving skills. Throughout the late 1990s, in response to these developments, extra funding was made available to postgraduate education programs to fund training opportunities outside of what was offered at traditional tertiary academic health science centres. In northern Ontario, these training opportunities were provided through the Northern Ontario Medical Program based in Thunder Bay and the Northeastern Ontario Medical Education Corporation, which had its administrative base in Sudbury. Paediatric residents spending elective months in the northern Ontario urban hubs consistently rated their experiences as highly educational, and wonderful opportunities to learn skills that were not easily gained in tertiary children’s hospitals. Having the opportunity to assess a complex disorder, see children with a variety of problems that do not typically require tertiary care services, as well as work in an environment with a 1:1 learner to preceptor ratio were found to be extremely valuable.
In response to these successes, the two northern educational corporations were given the opportunity to develop expanded training opportunities in conjunction with southern partners.
In July 2002, the first resident was admitted into the McMaster (Hamilton, Ontario)/Thunder Bay paediatric residency training stream. The first of its kind in Canada, this program included extensive rotations in northwestern Ontario. The learners spent up to one-third of their time working with general paediatricians in their consulting paediatric practices, providing care in the neonatal intensive care unit and wards of the Thunder Bay Hospital. Residents also spent two months in Sioux Lookout and had multiple learning opportunities in various clinical settings in Thunder Bay. The remainder of their training time was spent in Hamilton doing subspecialty rotations, ward rotations, and neonatal and paediatric intensive care training. The following year, the Northeastern Stream Paediatric Residency Program accepted its first residents in conjunction with the Children’s Hospital of Eastern Ontario in Ottawa (Ontario), with approximately one-third of their training occurring in Sault Sainte Marie, Sudbury and North Bay.
Both programs grew and thrived over the subsequent years. The number of applicants and residency spots increased each year. Residents consistently identified their northern rotations as extremely valuable and unique, learning opportunities that provided them with skills, knowledge and an awareness of the full scope of paediatric medicine, which were difficult for their colleagues in the ‘mainstream’ programs to develop. They have come to appreciate the value of longitudinal learning of each area of paediatrics. In addition to completing focused, one-month subspecialty rotations in tertiary centres at one point in their training, residents in these programs perform assessments in all of these areas as both junior and senior learners while on their northern rotations. The residents point out the enormous difference in working on the acute care services in the northern centres compared with the tertiary hospitals. When in the North, the residents are performing true consultations at the request of nonpaediatric providers. On the other hand, most encounters with new patients on the wards in the tertiary hospitals occur following assessment by another paediatric colleague and so they are doing admissions rather than consultations. Perhaps most beneficial of all is the preceptor model of training in the northern rotations. In this model, a resident and consultant work side-by-side, which is enormously valuable for both learner and teacher. The mentorship, teaching opportunities and supportive, collegial environment are difficult to replicate outside of this setting. The residents develop the skills critical to becoming effective, lifelong learners; identifying their own learning needs following clinical encounters; accessing appropriate resources; and subsequently, discussing them with their preceptors. While in the outpatient offices of the northern centres, the residents perform consultations and follow-ups with children experiencing a very wide variety of medical, developmental and behavioural challenges. They develop a practical approach to problems spanning all of the paediatric subspecialties. As one of our charter residents once said, “Everyday in clinic here is like a practice OSCE [objective structured clinical examination]”. The Northern Ontario School of Medicine (NOSM) opened in the summer of 2005, and with it came the need to develop postgraduate training programs. An opportunity therefore presented itself to bring the two northern stream paediatric programs together under the NOSM banner.
In anticipation of this development, a series of meetings and consultations with current and past residents, preceptors, NOSM administration and our southern tertiary partners led to the outline of a proposal that could be submitted to the RCPSC for consideration of new program status accreditation. This arduous process took several months in the winter of 2007/2008 and the submission was made in April 2008.
When developing the program outline, it was of utmost importance to strike the optimal balance between the many and varied learning opportunities in the northern centres, while ensuring that the residents would have sufficient access to all of the required subspecialty and acute care opportunities in the southern tertiary centre with which the program would be affiliated, the University of Ottawa, Ottawa. It was also believed that the program should have its own program of academic sessions, including an academic half-day. The best aspects of the northwestern and northeastern programs were blended so that a cohesive, pan-northern program could be created.
One of the main difficulties encountered while developing the NOSM paediatric residency program was in giving all of the accreditation stakeholders a clear understanding of what types of clinical encounters the residents would experience while in the north and why they were equivalent, if not superior, to the manner in which such patients would otherwise be encountered in the subspecialty clinic context. For example, anyone who has worked as a general paediatric consultant will know that children with developmental and mental health-related challenges are encountered every day. The prevailing bias that subspecialists are the best suited to teach residents their subspecialty resulted in a requirement to explain and re-explain to the accreditors the fact that not only are such patients managed frequently in northern practices, but that this occurs with a high degree of sophistication using evidence-based interventions. It was also pointed out that consultations occurred in a challenging ‘front-line’ setting where patients with undifferentiated symptoms and problems were being assessed by a specialist for the first time.
In September 2008, the program received accreditation with new program status, and we were free to enter its four residency positions into the Canadian Resident Matching Service for 2009.
We are fortunate that the two preceding northern training streams allowed us to work out most of the difficulties inherent in providing distributed education across such a vast geographic space. With this new program, we have strived to minimize resident travel requirements, taking full advantage of technological opportunities to bridge the physical distances. The northern preceptors have welcomed the challenge of incorporating both undergraduate learners and residents into their busy consulting practices, and we are all the richer for this.
Although there is currently no evidence to support the idea that the type of training offered in the NOSM’s program is superior to traditional training, feedback from residents in the northwest/McMaster and northeast/Ottawa programs and from subspecialist colleagues in our affiliated tertiary hospitals indicate that residents in these programs demonstrate notable strengths in problem solving, are more confident in novel circumstances, and particularly practical in clinical decision making. One of the northern residents once shared with me an anecdote wherein a neonatologist, after a busy weekend of working together, told the resident that she could tell that she was one of the northern trainees because of her calm, practical demeanour, which she had noted in other northern trainees. Other residents have told me that they have been given similar feedback. More than one northern resident has told me that the only weakness of the program is that you are required to leave the north so often to spend time in the tertiary children’s hospital.
Graduates of these two programs have gone on to multiple career paths. Several have gone into subspecialty fellowships and several are now established in practice in northern Ontario. Informal, post-training feedback from these clinicians have indicated that they felt very confident in the training that they received and that they felt significantly more prepared to enter practice than a large proportion of their colleagues in the ‘mainstream’ arm of their programs.
We are moving forward into a new era of paediatric residency training in northern Ontario, armed with the conviction that the program that we are offering will provide a more complete and well-rounded training experience than what has traditionally been offered. Graduates of our current northern stream programs and future graduates of our NOSM program will all know how to describe Ebstein’s anomaly, will know the genetic defect of metachromatic leukodystrophy, and will be able to intubate and insert femoral lines. They may even know what a Mondini defect is. They will, however, also have a practical approach to assessing and managing that 10-year-old foster child with behavioural and emotional disorders that befuddled me that day. They will have the ability to approach an undifferentiated collection of complaints and symptoms in any age of child. They will hopefully be on the road to becoming superb paediatricians.
