John C. Hogenbirk

Transforming health professional education through social accountability: Canada's Northern Ontario School of Medicine

Background: The Northern Ontario School of Medicine (NOSM) has a social accountability mandate to contribute to improving the health of the people and communities of Northern Ontario. NOSM recruits students from Northern Ontario or similar backgrounds and provides Distributed Community Engaged Learning in over 70 clinical and community settings located in the region, a vast underserved rural part of Canada. Methods: NOSM and the Centre for Rural and Northern Health Research (CRaNHR) used mixed methods studies to track NOSM medical learners and dietetic interns, and to assess the socioeconomic impact of NOSM. Results: Ninety-one percent of all MD students come from Northern Ontario with substantial inclusion of Aboriginal (7%) and Francophone (22%) students. Sixty-one percent of MD graduates have chosen family practice (predominantly rural) training. The socioeconomic impact of NOSM included new economic activity, more than double the Schools budget; enhanced retention and recruitment for the universities and hospital/health services; and a sense of empowerment among community participants attributable in large part to NOSM. Discussion: There are signs that NOSM is successful in graduating health professionals who have the skills and desire to practice in rural/remote communities and that NOSM is having a largely positive socioeconomic impact on Northern Ontario.

Using Fuel Characteristics to Estimate Plant Ignitability for Fire Hazard Reduction

There are areas in the boreal forest where the combination of highly flammable vegetation and frequent ignition events create a high fire hazard. The resultant fires cause considerable economic and social damage. During global change, fire frequency may increase in parts of the boreal forest. We are investigating the feasibility of using less-flammable vegetation to reduce the number of people-caused fires in herbaceous communities of northern Ontario. Herbaceous species abundant in these areas were ranked according to potential ignitability. Ignitability was estimated from chemical and physical fuel characteristics measured on live and dead tissue. Achillea millefolium, Aster macrophyllus and Anaphalis margaritacea had the lowest potential ignitability. Their rank was consistent for fuel characteristics measured on live and dead leaf tissue. Many of the commercially available forbs tested (e.g., Trifolium spp.) were of low to intermediate ignitability. Grass species such as Poa compressa and Agrostis scabra had the highest potential ignitability. Physical characteristics were not significantly correlated with chemical characteristics (p > 0.05, n = 20). There was a significant but trivial correlation between surface area to volume ratio and volume (r = −0.80, p ≤ 0.05, n = 20). There was a significant correlation between surface area to volume ratio and density (r = 0.54, p ≤ 0.05, n = 20). There was a significant correlation between total ash and silica-free ash content (r = 0.61, p ≤ 0.05, n = 47), between total ash and energy content (r = − 0.55, p ≤ 0.05, n = 47) and between silica free ash and energy content (r = −0.28, p ≤ 0.05, n = 47). Research is continuing to evaluate the feasibility of using less-flammable plants for fire hazard reduction. Planting less-flammable vegetation in fire prone areas, or around property and fire-sensitive natural areas, may help prevent ignition or slow fire spread. This technique could be a long term, cost effective and environmentally friendly method of fire prevention and control in selected areas of the boreal forest.

Temperature effects on seedling emergence from boreal wetland soils: implications for climate change

Abstract Temperature treatments simulated global warming effects on seedling emergence of wetland species from soil seed banks of the Peace-Athabasca Delta, Alberta, Canada. Introduced weedy species, such as Tanacetum vulgare L., had up to a 10-fold greater emergence at high temperature (30°C for 18 h with light, 15°C for 6 h in the dark) than at low temperature (20/10°C). Seedling emergence of native weedy species, such as Calamagrostis canadensis (Michx.) Beauv., was 1.5–3 times greater at low temperature. Other native weedy species, such as Rubus idaeus L., emerged only from samples at low temperature. Emergence of native non-weedy species was greatest at high temperature, even though mature plants of species such as Ranunculus hyperboreus Rottb. and Carex eburnea Boott are normally found in cool and moist habitats. Of those species expected to persist in warm and dry habitats, only introduced weedy species showed consistent and significantly greater seedling emergence at high temperature. It is hypothesized, therefore, that the abundance of introduced weedy species would increase in disturbed or sparsely vegetated zones around water bodies as these zones become dry and warm with climate change.

Starting rural, staying rural: how can we strengthen the pathway from rural upbringing to rural practice?

OBJECTIVE   To determine if selecting rural background students into the Monash Bachelor of Medicine and Bachelor of Surgery (MBBS) program affects vocational training location and intended practice location after training. DESIGN   Retrospective cohort mail survey. SETTING   Australia. PARTICIPANTS   Rural-background students at Monash 1992-1994 (n=24/40) and 1995-1999 (n=59/120) and urban background students (n=36/93 and 104/300, respectively). Overall study population: 62% female, average age of 28 years; 79% Australian-born; and 60% married/partnered. INTERVENTIONS   Rural or urban background, rural undergraduate exposure. MAIN OUTCOME MEASURES   Intent towards rural medical practice, vocational training location and subsequent practice location. RESULTS   There was a positive and significant (P ≤0.05) association between rural background and rural practice intent when respondents began (10-times higher than urban graduates) and completed (three times higher) their MBBS course. Rural practice intent increased fourfold in urban background graduates. There was a positive and significant association between rural background and preferred place of practice in 5-10 years in a Rural, Remote and Metropolitan Area (RRMA) 3-7 community (three times higher). There was a positive, but non-significant association between rural background and RRMA 3-7 community as their current location and first place of practice once vocationally qualified. CONCLUSIONS   Interest in rural practice is not fully reflected in location during or after vocational training. The beneficial effects of rural undergraduate exposure might be lost if internship and vocational training programs provide insufficient rural clinical experiences and curriculum content. Continuation of the rural pathway might be needed to maintain rural practice intent.

Clinical Telemedicine Utilization in Ontario over the Ontario Telemedicine Network.

Abstract Introduction: Northern Ontario is a region in Canada with approximately 775,000 people in communities scattered across 803,000 km2. The Ontario Telemedicine Network (OTN) facilitates access to medical care in areas that are often underserved. We assessed how OTN utilization differed throughout the province. Materials and Methods: We used OTN medical service utilization data collected through the Ontario Health Insurance Plan and provided by the Ministry of Health and Long Term Care. Using census subdivisions grouped by Northern and Southern Ontario as well as urban and rural areas, we calculated utilization rates per fiscal year and total from 2008/2009 to 2013/2014. We also used billing codes to calculate utilization by therapeutic area of care. Results: There were 652,337 OTN patient visits in Ontario from 2008/2009 to 2013/2014. Median annual utilization rates per 1,000 people were higher in northern areas (rural, 52.0; urban, 32.1) than in southern areas (rural, 6.1; urban, 3.1). The majority of usage in Ontario was in mental health and addictions (61.8%). Utilization in other areas of care such as surgery, oncology, and internal medicine was highest in the rural north, whereas primary care use was highest in the urban south. Conclusions: Utilization was higher and therapeutic areas of care were more diverse in rural Northern Ontario than in other parts of the province. Utilization was also higher in urban Northern Ontario than in Southern Ontario. This suggests that telemedicine is being used to improve access to medical care services, especially in sparsely populated regions of the province.

Framework for Canadian telehealth guidelines: summary of the environmental scan

A Canadian project (the National Initiative for Telehealth Guidelines) was established to develop telehealth guidelines that would be used by health professionals, by telehealth providers as benchmarks for standards of service and by accrediting agencies for accreditation criteria. An environmental scan was conducted, which focused on organizational, human resource, clinical and technological issues. A literature review, a stakeholder survey (245 mail-outs, 84 complete responses) and 48 key informant interviews were conducted. A framework of guidelines was developed and published as a preliminary step towards pan-Canadian policies. Interim recommendations were that organizations and jurisdictions might consider formal agreements to specify: (1) organizational interoperability; (2) technical interoperability; (3) personnel requirements; (4) quality and continuity-of-care responsibilities; (5) telehealth services; (6) remuneration; and (7) quality assurance processes. An additional recommendation was that flexible mechanisms were needed to ensure that accreditation criteria will be realistic and achievable in the context of rapid changes in technology, service integration and delivery, as well as in the context of operating telehealth services in remote or underserved areas.

Biotic versus abiotic control of plant density: studies of Medicago lupulina L. on a topographic gradient

Topographic variation in plant density has been attributed to changing abiotic conditions by some researchers and to changing biotic conditions by others. To help resolve this controversy, seedling emergence and plant survival were monitored for a short-lived herb (Medicago lupulina L.: Leguminosae) with other plants present or absent along topographic gradients on north and south slopes. Topographic variation in the number of seedlings emerging with vegetation present was inversely related to the amount of ground cover present. When vegetation and litter were removed about equal numbers of seedlings emerged at all topographic positions indicating that inter- ference from ground cover (i.e. a biotic factor) had more effect on seedling density than did abiotic conditions. In

Outcomes of the Northern Ontario School of Medicine's distributed medical education programmes: protocol for a longitudinal comparative multicohort study

Introduction The Northern Ontario School of Medicine (NOSM) has a social accountability mandate to serve the healthcare needs of the people of Northern Ontario, Canada. A multiyear, multimethod tracking study of medical students and postgraduate residents is being conducted by the Centre for Rural and Northern Health Research (CRaNHR) in conjunction with NOSM starting in 2005 when NOSM first enrolled students. The objective is to understand how NOSMs selection criteria and medical education programmes set in rural and northern communities affect early career decision-making by physicians with respect to their choice of medical discipline, practice location, medical services and procedures, inclusion of medically underserved patient populations and practice structure. Methods and analysis This prospective comparative longitudinal study follows multiple cohorts from entry into medical education programmes at the undergraduate (UG) level (56–64 students per year at NOSM) or postgraduate (PG) level (40–60 residents per year at NOSM, including UGs from other medical schools and 30–40 NOSM UGs who go to other schools for their residency training) and continues at least 5 years into independent practice. The study compares learners who experience NOSM UG and NOSM PG education with those who experience NOSM UG education alone or NOSM PG education alone. Within these groups, the study also compares learners in family medicine with those in other specialties. Data will be analysed using descriptive statistics, χ2 tests, logistic regression, and hierarchical log-linear models. Ethics and dissemination Ethical approval was granted by the Research Ethics Boards of Laurentian University (REB #2010-08-03 and #2012-01-09) and Lakehead University (REB #031 11-12 Romeo File #1462056). Results will be published in peer-reviewed scientific journals, presented at one or more scientific conferences, and shared with policymakers and decision-makers and the public through 4-page research summaries and social media such as Twitter (@CRaNHR, @NOSM) or Facebook.

Impact of the rural pipeline in medical education: practice locations of recently graduated family physicians in Ontario

BackgroundThe “rural pipeline” suggests that students educated in rural, or other underserviced areas, are more likely to establish practices in such locations. It is upon this concept that the Northern Ontario School of Medicine (NOSM) was founded. Our analysis answers the following question: Are physicians who were educated at NOSM more likely to practice in rural and northern Ontario compared with physicians who were educated at other Canadian medical schools?MethodsWe used data from the College of Physicians and Surgeons of Ontario. We compared practice locations of certified Ontario family physicians who had graduated from NOSM vs. other Canadian medical schools in 2009 or later. We categorized the physicians according to where they completed their undergraduate (UG) and postgraduate (PG) training, either at NOSM or elsewhere. We used logistic regression models to determine if the location of UG and PG training was associated with rural or northern Ontario practice location.ResultsOf the 535 physicians examined, 67 had completed UG and/or PG medical education at NOSM. Over two thirds of physicians with any NOSM education were practicing in northern areas and 25.4% were practicing in rural areas of Ontario compared with those having no NOSM education, with 4.3 and 10.3% in northern and rural areas, respectively. Physicians who graduated from NOSM-UG were more likely to have practices located in rural Ontario (OR = 2.57; p = 0.014) whereas NOSM-PG physicians were more likely to have practices in northern Ontario (OR = 57.88; p < 0.001).ConclusionsNOSM education was associated with an increased likelihood of practicing in rural (NOSM-UG) and northern (NOSM-PG) Ontario.

Driving Distance to Telemedicine Units in Northern Ontario as a Measure of Potential Access to Healthcare

INTRODUCTION The Ontario Telemedicine Network (OTN) uses technology to help make medical services more accessible to people in medically underserved rural and remote parts of Ontario, Canada. We examined access to OTN-enabled health and medical services in Northern Ontario, which has 775,000 people in communities scattered across an area of 803,000 km(2). MATERIALS AND METHODS We used ArcGIS Network Analyst (Esri, Redlands, CA) to conduct a service area analysis with travel time as a measure of potential access to care. We used road distance and speed limits to estimate travel time between Northern Ontario communities and the nearest OTN unit. RESULTS In 2014 there were 2,331 OTN units, of which 552 (24%) were located in Northern Ontario. All seven communities in Northern Ontario with a population of 10,000 or greater had OTN units. Almost 97% of the 59 communities with 1,000-10,000 people were within 30 min of an OTN unit. The percentage of communities within 30 min steadily decreased with decreasing population size, to 58% for communities with fewer than 50 people. In total, 86% (690/802) of Northern Ontario communities were within an hours drive of an OTN unit. CONCLUSIONS This study showed that most Northern Ontario communities were within an hours drive of an OTN unit. The current distribution of OTN units has the potential to increase access to medical services and to reduce the need for medically related travel for residents of these communities.