Nurturing rural doctors

Cate Swannell
Med J Aust || doi: 10.5694/mja17.1906C1
Published online: 19 June 2017

Professor Roger Strasser is an Australian rural health educator and academic, running one of the most successful training programs in the world, the Northern Ontario School of Medicine in Canada

PROFESSOR Roger Strasser knows a thing or two about rural medicine. When he hasn’t been providing health care to rural communities, he has been teaching medical students about it, and when he hasn’t been doing that he has been designing, implementing and running rural medical schools.

His list of achievements and awards is long and glittering: Honorary Fellowship of the Royal College of General Practitioners in recognition of his world leadership in the field of rural health; the Louis Ariotti Award for excellence and innovation in rural and remote health in Australia; Fellow of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) in recognition of his outstanding service to WONCA and family medicine around the world; the inaugural Small, Rural and Northern Award of Excellence by the Ontario Hospital Association; and the Australian College of Rural and Remote Medicine Life Fellowship Award for outstanding and meritorious service to rural and remote medicine in Australia. In 2011, he was honoured with the Order of Australia (AM) for “service to medicine, through improving the health care of people living in rural and remote communities in developed and developing nations as an educator, researcher, and practitioner”.

It perhaps comes as a surprise, given his dedication to rural medicine and training rural clinicians, to find out that Professor Strasser was born and bred in urban Melbourne. Despite that, he knew early in his time as a medical student at Monash University that rural medicine was the direction he wanted to take.

“My mother had been a high school teacher in rural settings,” he tells the MJA. “I spent long summer holidays on farms of friends and that’s where my interest in rural communities started.”

Today he is the founding Dean of the Northern Ontario School of Medicine (NOSM) in Canada. He started NOSM from the ground up in September 2002 after running Monash University’s School of Rural Health.

But it was a circuitous route from Melbourne to Canada.

“As was not uncommon in those days, after graduating I headed off to the UK for a couple of years’ training — 6 months in surgery, 12 months in anaesthesia, another 6 months of GP locums.”

During a stint in Taunton in Somerset, Prof Strasser met Sarah Robinson, whom he would later marry. Professor Sarah Strasser is now the Head of the Rural Clinical School at the University of Queensland – a long-distance relationship with a difference.

“We’re used to it these days,” says Prof Strasser. “Skype is wonderful, and it’s not the first time Sarah’s returned to Australia to work since we moved to Canada.”

While training in England, he heard about a Masters of Clinical Science (Family Medicine) being offered at a university in western Ontario, and, on a whim, he applied and was accepted.

Then followed 2 years at Western University in London, Ontario.

“It was a very exciting time to be there,” says Professor Strasser. “Dr Ian McWhinney was the head of department at that time.” Dr McWhinney was the inaugural Professor of Family Medicine and the first to introduce family medicine as a distinct discipline within medicine. He championed the concept of patient centeredness and helped to create this as a major research theme. “He was leading the way.”

In 1985, the Strassers returned to Australia and filled two vacancies at the Moe Medical Centre in the Gippsland region of Victoria as general practitioners.

“We settled nicely into practicing in Moe. We were very much enjoying rural practice in Gippsland. At that time Moe had its own hospital.

“But what became very clear was that there just weren’t enough of us [practicing in rural settings], and we wondered what we could do to attract more graduates to train in the Gippsland region.”

In 1987, after much talking and negotiating, the Strassers helped set up the Gippsland Regional GP Training Program, but “it didn’t go very well”.

“We couldn’t attract enough graduates,” says Professor Strasser. “After doing a lot of research we worked out that we needed to start the process at the undergraduate level.”

By 1992, Monash University had set up its Centre for Rural Health, which later became the School of Rural Health. Roger Strasser was the head of the school until the call came from Canada.

“The government in Ontario had decided to establish the Northern Ontario Medical School and they offered me the chance to help build it from scratch,” he says.

“It wasn’t easy. There were a lot of challenges and difficulties. The local doctors all had their own idea of what a medical school should look like, particularly the specialists.”

Northern Ontario covers 800 000 km2 and has less than 800 000 inhabitants.

“Its economy is that classic boom and bust economy — mining, forestry, tourism. And they never had enough doctors.”

Despite what the local doctors may have thought, there was impetus for the medical school.

“There was advocacy from within the community, there was a groundswell,” says Prof Strasser.

The NOSM is a joint venture between two universities — one at Thunder Bay, and one over 1000 km away in Sudbury.

“There were historical enmities,” says Prof Strasser. “Some people said it was ‘against the natural order’ and nobody expected that it would actually happen, so our biggest challenge was to develop some confidence within the community.”

The squabbling between northwest and northeast worked in the new school’s favour, he says. “It gave us the opportunity to design our own model in a Northern Ontario context, rather than trying to translate someone else’s model.”

Community engagement through curriculum workshops, including a separate Indigenous partnership gathering, dubbed the “Follow Your Dreams Workshop”, resulted in a model called “Distributed Community Engaged Learning”.

“Ninety sites, heavy reliance on e-communications, digital library resources, community engagement through partnerships,” Prof Strasser says.

The training program is heavy on community engagement and clinical experience.

In the first year, every student spends 4 weeks in an indigenous community. Second-year students spend two 4-week blocks in “integrated community experience” in smaller communities, attached to health teams engaged in clinical work. Third-years move to one of 15 communities for 8 months, based in general practice. Fourth-year students train in regional hospitals

“The curriculum walks through the door,” says Prof Strasser.

“All the elements are evidence-based, and centred on the three factors we know encourage graduates to practice in rural settings: a rural upbringing, positive rural clinical experiences as an undergraduate, and postgraduate training in a rural setting.”

Ninety-two per cent of NOSM students grew up in Northern Ontario; 62% of NOSM graduates choose to be rural GPs – double the national average; 33% pursue other generalist specialties like paediatrics; and 5% go on to subspecialise. Ninety-four percent of doctors who completed both undergraduate and postgraduate education with NOSM practice in Northern Ontario, 33% of them in small, remote communities.

Can a similar training model work in Australia?

Roger Strasser says a successful rural training program has two key elements that could work anywhere.

“Role models are important,” he says. “Medical students are ambitious high achievers. If their teachers are hospital subspecialists then it’s likely the students will want to be hospital subspecialists.

“In our program, up until the final year, the teachers are rural generalists.

“The second key element is intense interaction with patients. Students learn from the patients and it motivates them to study hard and do well.”

Prof Strasser will finish as Dean of NOSM in mid-2019, but he has no plans to retire.

“I was back in Australia recently for the rural health conference in Cairns and I reconnected with a former colleague from Gippsland who I hadn’t seen for 20 years. He had retired, and then completely unretired again. He told me retirement had nothing to recommend it.

“So, no, I have no plans to retire.”

  • Cate Swannell



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