Rapidly Expanding Medical Schools: The Student’s Perspective on Required
Competencies of Teaching Faculty
By T. Law
Faculty of Medicine, University of British Columbia
BACKGROUND: The Shortage Leading to Increasing Enrolment in Canadian Medical
Schools
The future status of Canada’s health care force has been highly scrutinized, given the
number of graduating medical students in comparison with the number of impending retirement of
many physicians and surgeons. Dating back to 1991, a report by health economists Barer and
Stoddart (Toward Integrated Medical Resource Policies for Canada)1 incorrectly projected a
surplus of physicians, which resulted in a significant decrease in the number of medical student
trainees. In 1999, Barer and Stoddart released another report2, and acknowledged that certain
recommendations were erroneously applied – leading to inappropriate decreases in first year
medical school enrolment which started in 1993 and resulted in reductions of approximately 10%
by 1997. Furthermore, in 1999, the CMA (Canadian Medical Association) and the ACMC
(Association of Canadian Medical Colleges) co-commissioned a report3 which, among other
things, discovered 1.83 physicians per thousand people in Canada. The OECD average
(Organization for Economic Co-operation and Development) was 2.6 physicians per thousand
people. Additionally, many other reports attest to the increasing numbers of people who do not
have family physicians – conservative estimates by Busing advocate for at least more 5000
physicians to fulfill this need4. Specifically, Busing states that although approximately 2500
medical student seats available per year across Canada, more than 3000 seats are needed. With
this in mind, 2628 and 2826 seats were made available in 2008 and 2011, respectively.
1
Among other strategies, the increasing enrolment was one method designed to
supplement our current physician workforce. In 2005, the Northern Ontario School of Medicine
(NOSM) became the newest Canadian medical school – the last one prior to that was established
over 30 years ago. Other medical schools responded by increasing enrolment within the existing
infrastructure. Due to physical capacity constraints, schools are opting to open satellite
campuses, accompanied by surrounding teaching hospitals, as seen with: University of Toronto
(Toronto, Mississauga), McMaster University (Hamilton, Kitchener, St. Catherines), Université de
Montreal (Montreal, Mauricle), University of Western Ontario (London, Windsor), Dalhousie
University (Halifax, Saint John), NOSM (Thunder Bay, Sudbury), and Université de Sherbrooke
(Chicoutimi, Moncton). Leading this revolution with the concept of remote sites is the University of
British Columbia (UBC). By doubling the class size, UBC has the largest Canadian graduating
class (currently 256 students) – with three functioning sites in Vancouver, Victoria, and Prince
George. In 2011, UBC surpassed this goal by welcoming a fourth site in Kelowna with an
additional 32 students, for a graduating class of 288 in 2015.
THE UNIVERSITY OF BRITISH COLUMBIA (UBC): A Case Example
As a UBC student, I have first hand experience with the trials and tribulations that follow
such an expansion. With satellite campuses, our lectures take place via real-time videoconferences to remote sites, including microphones that allow for cross-interaction. My
experience has included lectures with the lecturer in at the front of my lecture hall, as well as
lecturers with the lecturer at the other sites. Since faculty members prefer lecturing at the sites
closest to their established practice, the majority of lectures tend to occur within the Greater
Vancouver Area, and are video-conferenced to the other sites. However, as a part of their
commitment for cross-site equality, UBC is including locally-practicing lecturers at each satellite
site. On the whole, our teaching faculty is to be commended for their commitment to the
2
education of our future physicians – with clear, concerted efforts and patience with the distributed
sites. However, in keeping with our practice as a self-regulating profession, this paper aims to
employ critical thinking and self-reflection regarding the advent of satellite sites. This was
intended as constructive feedback and improvement that is applicable to both students and
faculty.
DISCUSSION: Teaching Faculty Competencies
1) TECHNOLOGICAL SKILLS
To begin, it is absolutely critical that the lecturer is technologically-enabled. Lectures are
no longer presented in large auditoriums with chalk boards. These days, the lecturer’s digital
notes are projected onto a screen, and the audible sounds are transmitted through a microphone
and speakers – not only for the benefit of the large group of students sitting in front of him/her, but
to enable the participation of students sitting in lecture theatres in other cities. The videoconferencing capability of a presentation is the framework that supports the medical school
expansion, and enables the feasibility of satellite sites. This includes the transmission of both
electronic and hand-written lecture notes. Hence, the lecturer has to be reasonably proficient in
using presentation programs such as Microsoft PowerPoint or the Dot-Matrix. Presentationenhancing skills include: the usage of video clips embedded in the presentation to illustrate
medical/surgical procedures, or the use of drawing tools available within the program. Using
these tools instead of a laser pointer allows concomitant visualization by remote sites. Further,
the faculty member should have reasonable internet skills, particularly through the school’s
educational web portal, and for email contact. Both options pose extremely effective means to
address the entire class, regardless of site, and are not restricted to lecture time. For instance,
notes posted online prior to the lecture provide the opportunity for students to maximize their
learning through pre-reading and by enabling them to be attentive to the lecture instead of
3
frantically scribbling notes. Other non-traditional uses of online technology is particularly
appealing for supplementary educational materials as well as to appeal to the more audio or
visually-inclined students. This includes links to online resources, videos, audio clips, which is
made available to students at all sites. Although tentatively explored by UBC, other Canadian
medical schools are consistent in making lecture podcasts available online to their students.
These podcasts are filmed video and audio versions of the actual lectures, and are excellent
resources for review. Extensive literature reports demonstrate the benefits of podcasts, which
includes spatial and temporal flexibility, and increased productivity5. Further, email
communication is appealing to both students and faculty, as it facilitates the contact of lecturers
located in other cities. With remote sites, it becomes unfeasible to make personal visits, and
avoids the temporal and economic logistics of trying to telephone a busy physician. It is
pleasantly noted that there does not appear to be a difference between the younger or older
generation of lecturers, as both appear to be suitably proficient with the necessary technology.
2) PRESENTATION STYLE
Secondly, with distributed programs, it becomes necessary to alter one’s presentation
style. Presenters often modify their presentation delivery and style by gauging students’ reception
throughout the talk. Traditionally, this feedback is based upon the students facing the lecturer –
however, with video-conferencing, the lecturer needs to remember to also be attentive to students
at the remote sites. Depending on the lecture theatre, the video screens of the satellite sites are
often displayed adjacent to the lecture visual, facing the students, but above the lecturer and
outside of his/her line of sight. In this situation, a student in a satellite site cannot easily capture
the lecturer’s attention by waving one’s arm vigorously. Thought-provoking questions have been
inadvertently dismissed when the lecturer failed to notice a student who indicated an intent to
contribute to the discussion, but is either unable to communicate through a disabled audio input,
or is reluctant to interrupt the lecturer’s speech. Although rare, less attentive lecturers have gone
4
through significant portions of the lecture before it becomes apparent that some students in a
remote site were unable to receive video or audio components of the video-conference.
3) PATIENCE & FLEXIBILITY
Thirdly, patience and flexibility are profound assets in faculty members, particularly during
technological failures. When malfunctions occur, unfortunately, students often become unruly with
side conversations, while the lecturer is faced with the responsibility of rapidly rectifying the
problem (with the aid of technological staff) – the allotted lecture time itself is scarce and usually
barely enough to cover all the material. Once, despite all attempts to ignore the incessant, loud,
static sounds that grew in intensity, it became too frustrating to continue, as it eventually
overlapped the lecturer’s speech. The technological staff took 20 minutes (of a 60 minute lecture)
to reset the system. In the interest of time and to maintain the class’ attention, it is to the lecturer’s
advantage if they use that time to answer questions or further elaborate on aforementioned
concepts. With technical delays, flexible lecturers are able to modify the presentation to omit
extraneous information to ensure coverage of the basic material. In addition, in order to include all
distributed sites, patience is required of lecturers with respect to repeating everything through the
microphone for the benefit of the other sites. This includes ill-transmitted speech through the
microphone, in addition to some indolent students who may opt to ask questions of the lecturer at
their site without using the microphone. The latter scenario is a source of exasperation for
students the remote sites, as the conversation becomes difficult to follow, as it becomes a onesided conversation. However the presenter often quickly addresses this issue by repeating the
question before answering. Conversely, student microphones are sometimes inadvertently left on;
leaving other sites privy to their conversations and faculty members scrambling to notify the sites
by other means (since this the activation of one microphone sometimes automatically disables
another). Further, during one fire alarm, lectures had to be rescheduled, which was a logistic
issue even with only one site involved. One can only imagine the increased difficulty when re5
booking lectures that would accommodate all three sites in the same timeframe, in addition to the
busy schedule of our faculty members. In other instances, with various logistical constraints,
lectures were simply cancelled and were not rescheduled.
4) CLERKSHIP EXPERIENCES
Fourthly, to accommodate the expansion, the new sites have some mandatory clerkship
rotations done at smaller, local community and previously non-teaching hospitals. In one
anecdotal instance, the hospital staff was unfamiliar with the procedures and a clinical clerk was
never paged for procedures during his first few weeks. Further, he felt that many of the teaching
faculty for remote sites were less familiar with the curriculum and the abilities associated with the
students from each level of training. After several rotations at other hospitals, he felt that he did
not have the full clerkship experience for that rotation. Although he acknowledged it was partly
due to a lack of initiative on his part, he felt still disadvantaged at the remote site, in comparison
to his colleagues at the primary sites (affiliated with long-standing teaching hospitals). This is a
large issue best addressed on its own6, and may or may not have further implications with
respect to residency spots.
CONCLUSION
Having mentioned all of these required competencies, it is important to note that it is
uncommon to witness the absence of these competencies in our teaching faculty. Technological
glitches occur fairly infrequently, and are often resolved very professionally, in a very timely
manner. Innovative solutions include angling the camera normally aimed at the faculty member to
the projected visual presentation at the local site (in the instance of malfunctioning presentation
slides but functioning video input for remote sites). There may be subtle differences between sites
during clerkship years, upon which I am unable to comment during my pre-clerkship years.
However, the situation may resolve as these remote sites mature and the teaching programs
6
develop further at each site. On the whole, it is generally felt by students that the education
received in one site is comparable to that received at another site.
Additional benefits of the distributed sites include: experience with the same videoconferencing technology used within the current health care infrastructure, and a diversity of
experiences and perspectives from teaching faculty who give insight into different medical
practices outside urban areas. Given that, medical schools and their teaching faculty are working
well to ensure the success of these expanded programs. With these increases in medical school
enrolment, the robustness of our future health care force is strengthened, which will ensure
greater health care accessibility for all Canadians.
7
References
1. Barer ML and Stoddart GL. Toward integrated medical resource policies for Canada: 9.
Postgraduate training and specialty certification. CMAJ. 1992 Oct; 147(7): 999-1005
2. Stoddart GL, Barer ML. Will increasing medical school enrolment solve Canada’s
physician supply problems? CMAJ. 1999 Oct; 161(8): 983-984
3. Tyrrell L, Dauphinee D. Task Force on Physician Supply in Canada. Canadian Medical
Forum Task Force. November 22, 1999.
4. Busing N. Managing physician shortages: We are not doing enough. CMAJ. 2007 April;
176(8):1057
5. Harris H, Park S. Educational usages of podcasting. British Journal of Educational
Technology. 2008 February; 39(3):548-551
6. McEachern W. Challenges and solutions to expanded satellite clerkship rotations. Can J.
Surg. 2008 October; 51(5):337-338
8