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The evidence is striking: Quebec is short of doctors. For the past few years, the faculties of medicine at the universities of Montreal, Laval, McGill and Sherbrooke have been admitting more students in response to the wishes of the Quebec government. But the faculties are in dire straits: they say they do not have the capacity to absorb all these increases year after year. And there is every reason to believe that they are right.

The challenge facing medical schools is multifaceted: adapting curricula, recruiting new teaching physicians and finding new sites for internship.

But the traditional academic institutions at the heart of training future physicians are already overwhelmed. And for good reason, because these institutions exist first and foremost to care for patients. They include university health centres (UHCs), institutes, integrated health and social services centres (CIUSSS) and family medicine groups (FMGs). The dilemma is that where there is a need to treat, there is also a need to teach. In many facilities, we don’t know where to put the patients. In those same institutions, we don’t know where to put the students.

Can we train more physicians in this context? In order to do so, one thing is clear. We can no longer proceed as before. Three new avenues are possible: review the length of studies; incorporate the teaching mission into the care mission of all health institutions; and train students directly in their region.

Shorten the length of medical school

In Quebec, a student generally completes initial training leading to the doctorate in medicine after four years if he or she has been admitted after university training in health. If the student has been in college studies, the doctorate in medicine takes five years. (The Université de Sherbrooke offers a four-year program regardless of the student’s profile at the time of admission. The question is, why is it the only one to do so?) To obtain a license to practice medicine, the doctorate must be complemented by specialized studies that last from two to seven years.

The length of medical education varies from country to country, both for initial and specialty training. However, there is no evidence to support a shorter or longer program. There are programs in Canada and the United States where initial training is only three years. But not in Quebec. The difference is that in these short programs, the student’s prior learning is taken into account and the vacation period is reduced. Why this is not done in Quebec remains a mystery.

The length of specialty training also varies by country and by specialty. Family medicine specialization lasts two years in Canada, but three in the United States and in most countries. A pediatrician or general internist is trained in three years in the United States, but in four in Quebec. Other specialties, such as psychiatry and obstetrics and gynecology, require five years of study here, but four in the United States. How can these differences be explained other than by tradition or opinion?

The health care system as a vast teaching environment

Learning to care requires seeing patients and working with practitioners. All students need to do institutional placements, and the challenge is to find new ones. To do this, practitioners from these new settings must be trained, recognized and compensated for their teaching role. In this sense, it is clear that separating an institution’s mission of care from that of teaching those who will become tomorrow’s caregivers is an aberration. Quebec Health Minister Christian Dubé’s recent health-care reform bill is silent on this point, since only the university hospital centres (CHUs) and the institutes have an explicitly recognized university mission. From this point of view, Bill 15 is a missed opportunity.

If we had a network of health-care institutions whose care mission also included training, universities would have a much larger pool of internship sites than currently exists. Each region of Quebec would have a recognized network of acute and long-term care hospital centres, CLSCs, FMGs and – why not? – private clinics, accessible to students. And this expanded network would open the door to the following solution: train medical students directly in their region.

Train the student in his or her region, using technology

Why can’t a student study medicine anywhere in Quebec? The universities of Montreal and Sherbrooke have been training students at campuses in the Mauricie and Saguenay regions for almost 20 years. More recently, Laval and McGill universities have also opened campuses, in Lévis and Rimouski for one, and Gatineau for the other.

There is also evidence that these regionally trained students do as well on the national certification exam as any other Canadian student. Moreover, they are more likely to opt for regional practice upon completion of their studies, a fact that should not be overlooked.

But let’s go further. The pandemic has opened our eyes to new ways of working, teaching and learning. For the theoretical portion of the medical program, distance learning is available. Self-learning modules already exist for students, some of which are designed by medical schools. Access to lectures and supervision of a small group of students at a distance by a professor has become a reality, not a utopia.

If the grouping of students in a specific location is necessary for a particular learning experience, agreements can be made with health-care institutions and those of the Université du Québec network that are well-established in the regions. Moreover, the latest medical technologies – to which a student must be exposed during training – are no longer the prerogative of the large centres and are increasingly available in the regions and even in the office or at the patient’s home.

The miniaturization of equipment and the development of digital technology are at the heart of these developments. Who would have thought 30 years ago that an ultrasound could be performed in the office? That a CT scan or a magnetic resonance imaging could be performed in a neighbourhood clinic? That complex surgeries could be performed outside the hospital? That a patient suffering from a cardiac pathology could himself document the evolution of his treatment and remain in constant contact with his doctor? That patients would become true partners in the training of future physicians, regardless of where they live?

These examples are the basis for what could be a real revolution in medical training. It could be more delocalized, more individualized, with more practitioners and even patients as instructors.

Reducing the length of training, recognizing the complementary mission of care and teaching for all institutions in the network, and learning medicine directly in the regions are three of the key elements that will enable us to meet the challenge of the physician shortage. Will we have the audacity to move forward?

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Raymond Lalande
Raymond Lalande is professor emeritus at the faculty of medicine of the Université de Montréal. He was vice-rector, academic, from 2010 to 2017 and vice-dean, undergraduate medical education, from 2000 to 2007. He was the designer of the UdeM’s delocalized medical training project in the Mauricie region. Twitter @lalanderudem

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