An election-year pledge to redress the shortage of physicians in British Columbia's rural and northern communities triggered a groundbreaking transformation in medical pedagogy in Canada's westernmost province.
The reconfiguration relies on distributed education to complete the delivery of the full medical school curriculum at two regional campuses, the University of Victoria on Vancouver Island and the University of Northern British Columbia (UNBC), a very remote 700 miles to the north; and the “mother ship,” the existing medical center at the University of British Columbia, just outside of Vancouver. The linchpin of the pioneering strategy is a robust IT network that broadcasts live, interactive classes among multiple university campuses and teaching hospitals at a total of 19 current sites (with more coming online in the coming year) throughout the vast province, which is larger than California, Oregon, and Washington put together.
The project mandate, to double medical student enrollment in the province by 2010, had support at the highest levels of the provincial government, a factor that undoubtedly contributed to achieving the goal three years ahead of schedule.
“We had the full backing of the BC provincial government,” says Joanna Bates, M.D., who as senior associate dean, education, faculty of medicine, University of British Columbia (UBC), led the initiative. (Bates now serves as director of UBC’s Centre for Health Education Scholarship.) “Our premier had full interest in this coming about in the specified time frame. That helped to quickly align all the bureaucratic functions that normally get in the way of something as big and visionary as this project. The universities also made a public promise to the government and to the premier that they would deliver the expanded and distributed program on time.”
Nevertheless, it took more than government support and the universities’ commitment, first, to translate the pledge into an action plan, and then to engage representatives from the three campuses and the province’s hospital network in a cooperative, cohesive collaboration.
“This kind of project could flounder without alignment with multiple sectors,” Bates continues. “As a leader, you have to find ways for everyone to benefit.”
In retrospect, Bates singles out five critical strategies responsible for the project’s success.
“They weren’t necessarily the strategies that we had going in, but when we looked back to see what we had done that was really key, this was our list: pedagogical approaches, multi-institution funding streams, organizational change strategies, collaborative models and tools, and technologies and systems.”
Broadening the Mission Brings Multi-Institution Funding
At the time the program was conceived, UBC had the only complete program for medical education in the province. The University of Victoria, on Vancouver Island, would normally expect to be next in line as a site for medical education, an assumption challenged by the political commitment to also serve the northern populations. However, building a new undergraduate medical program in the rugged northern environment would be extremely resource-intensive, taking away important funding from the other schools partnering in the project.
It was at this point that the internal project team recognized that the mission had both idealistic and practical dimensions, and the combination should be reflected in an expanded scope.
“Our mission was not just producing doctors,” explains Bates. “It included addressing the mal-distribution of physicians and the lack of healthcare in the north and providing an increased opportunity for young people, especially for rural northern people, through our expansion. We recognized medical education was an economic driver, and we wanted to place that economic driver in the northern economy.”
That led to the concept of an IT infrastructure and network to support electronic delivery of the program, essentially erasing geographic barriers throughout the province. The distance learning approach would also resolve the many complexities of housing a full program in the north—for example, challenges in recruiting faculty to a remote area and minimal access to the campus in severe weather.
Such extensive distributed education was truly a ground-breaking solution, Bates admits.
“We were the first campus in Canada, and one of the first two in the US to open a distributed site delivering all four years of medical school,” she remarks. “There are 35 regional medical campuses in the United States with some distance education, but not nearly to the extent we have.”
A heightened emphasis on the expanded mission allowed the pedagogical strategies to gain acceptance and fall in to place.
“We encouraged everyone to talk about the mission all the time, and it became one of the key enablers for our efforts to put programs both in the north and on the island,” Bates comments.
Consensus-building in the university communities also emphasized the physical rewards for participating campuses.
“By broadening the mission, we brought a lot of stakeholders to the table who could see the potential for addressing some of their concerns,” Bates continues. “You had to have a way for people to buy in, whether through idealism or some other impact.”
The expanded mission also opened additional funding streams, including federal economic development incentives. Realizing the benefits of the medical program and ancillary development, major industries in the north—forestry, paper, mining, for instance—stepped forth with donations.
“We were surprised at the uptake across sectors and the amount of broad support at all levels of community and government,” says Bates. “This was very important for our initiative.”
In addition to $15 million for video conferencing and IT infrastructure, approximately $35 million was made available for new construction across 27 hospitals with varying levels of physician education. The funding was allocated to projects ranging from libraries and seminar rooms to new research space and call rooms for medical students.
“The upgrades benefited everyone in the hospital. UNBC and the University of Victoria got the cachet of hosting medical programs, plus new faculty positions and new kinds of health research. Everyone wound up with something they cared about in the program. When you are asking people to put things on the table, you must make sure they get something they want,” she advises.
Organizational Change and Collaboration
The expanded mission united the institutions and opened up other funding sources. Organizational change strategies and collaboration models and tools were similarly inter-related, Bates observes.
“We used integrated planning whenever we could at all levels. All the planning committees operated across all three universities, often across the health authorities as well,” she says.
In the beginning, once the five associate deans were recruited, the planning group met for half a day with an outside facilitator who helped them to understand the different skill sets each brought to the project. Participants learned how to use their strengths to work as a team and move the project forward.
The structure of regular project meetings was revamped to accommodate the geographically dispersed members. Weekly video conferences were acceptable for “hot items,” but not for budgets and other difficult discussions, so once a month team members flew into UBC for full-day sessions.
“People got to know each other at the face-to-face meetings, and they used their developing personal relationships to solve problems that occurred,” Bates recalls. “This was a really important strategy.”
The university partners also had to change their management and decision-making structures, and finance officers had to comply with new parameters. The guiding principle was that no one organization would have complete power or control in any area. For example, because faculty would be teaching students from three campuses, the search and appointment process was restructured to include new forms of faculty appointments so that faculty at the distant sites also held UBC appointments. Program funding was delivered in trust so it could not be reallocated to a different purpose.
“These were really different processes for the universities, and for our dean as well,” Bates comments. “It was not streamlined; in fact, it was almost the opposite, and everyone had to adjust.”
Another impetus for smooth collaboration was “water-tight affiliation agreements” with both the universities and the hospitals in order to meet accreditation standards. Very early on the partner institutions understood the potential loss of funding for new faculty positions should they withdraw from the initiative. To resolve group stalemates Bates also crafted a formal process that brought in government representatives, a consequence designed to minimize disagreements and encourage rapid consensus-building.
“I was advised to have provisions in our affiliation agreements for times of conflict,” recalls Bates. “I tried to imagine what was the worst that could happen and how we could manage that. The process was incorporated into a legal document specifying how things would work when there was a disagreement, and everyone signed it.”
Long-accustomed to their live teaching methods, the faculty needed assistance with the transition on several fronts. To make the caliber of the video-conferenced pedagogy equivalent to the on-site experience, they needed training in the new technology and confidence that components like cameras would function as specified. They also had to acquire a level of comfort in the new classroom format, where they would be interacting with students in all three locations. (Students, who could also see and speak to each other, had to be comfortable with the configuration as well.)
Ultimately, the curriculum comprises a blend of distributed and face-to-face instruction, and the process of assigning faculty positions and hours was location-neutral.
“We couldn’t assume where the teaching would originate, so we did not factor video conferencing into the faculty location,” remarks Bates. “In the long term, we wanted all sites to be able to self-sustain. Students need face-to-face as well as video contact with faculty, but as long as it is working well for everyone, I’m not ideologically wedded to any single approach.”
Bates is quick to point out that professionals both inside and outside the provincial healthcare network provided invaluable guidance throughout the project. External expertise was especially critical when it came to the technology at the center of the comprehensive distributed scheme.
“In 2002 we didn’t see a stable IT infrastructure anywhere that could do what we needed,” she notes.
Vancouver-based AMBiT Consulting filled the technology void, equipping interactive lecture theaters, laboratories, and meeting rooms on each campus with the capability for sound and image transmission over a dedicated, high-speed network.
“Integrating this technology into the building is not as simple as going out and buying a television set. You have to pay close attention to things like acoustics, lighting, and camera angles, and consider how to provide power and network connectivity to the individual devices,” says Katya Wilson, a principal with AMBiT Consulting.
The visually oriented gross anatomy lab required special attention. Mounted on a joystick-controlled robotic arm to minimize vibration, a $30,000 high-definition camera provides the requisite image magnification and resolution. A second mini-camera mounted on a flexible stem allows the anatomist to focus on internal cavity details that can’t be captured by the ceiling-mounted camera.
Dan Zollmann, also a principal with AMBiT Consulting, advises that due to the rapid change in video-conferencing technology, there is no benefit to early procurement. Being an early adopter is undesirable from the standpoint of the user community as well. He recommends waiting as long as possible in the construction cycle to get the latest technology at the lowest price.
He is also a staunch advocate of maintaining strong ties and open lines of communication with faculty and all other program participants. Including the faculty in commissioning of the facilities is an important step towards success.
“You really want to bring in your staff and have them sign off on the facility. The level of buy-in you can get by showing it to them before the first day of classes is amazing,” he concludes.
By Nicole Zaro Stahl
This report is based on a presentation given by Bates, Wilson, and Zollmann at Tradeline’s 2008 Academic Medical and Health Science Centers conference.