Hamil­ton’s New Heart, or how McMaster Med Cured the God Com­plex

Policy - - In This Issue - Yaroslav Baran

For half a cen­tury, Hamil­ton, Ont. was known as Toronto’s steel-town step­sis­ter; great for foot­ball fans, not much else to write home about. But as home­town boy Yaroslav Baran writes, the city has be­come a health sci­ences hub, largely thanks to McMaster Univer­sity’s dis­rup­tively in­no­va­tive teach­ing phi­los­o­phy and the world­wide ac­claim it has drawn.

Nes­tled be­tween the Ni­a­gara Es­carp­ment and the western end of Lake On­tario, Hamil­ton has tra­di­tion­ally been known for its steel in­dus­try. The “Steel City” brand was forged in the 1950s and 60s, a time when the city was boom­ing and its in­dus­trial North End housed half of Canada’s steel mills. It was a city, in the post-war era, to which im­mi­grants—in­clud­ing all four of my grand­par­ents— could come and build a new life for them­selves through well-pay­ing blue-col­lar jobs that did not nec­es­sar­ily re­quire a com­mand of ei­ther of Canada’s of­fi­cial lan­guages.

Stag­na­tion hit fol­low­ing global shocks to the steel in­dus­try in the 1970s and 80s, and Hamil­ton went into an eco­nomic slump. The old bustling boule­vards be­came boarded-up waste­lands, look­ing more like sets for a Hol­ly­wood mob film than like ar­ter­ies of thriv­ing com­mer­cial ac­tiv­ity.

That gritty and in­dus­trial per­cep­tion of Hamil­ton con­tin­ues to this day, though largely based on out­dated stereo­types. Mo­torists cross­ing the Sky­way Bridge will still see the old in­dus­trial build­ings abut­ting Hamil­ton Har­bour—a lin­ger­ing tes­ta­ment to a by­gone era. Yet, amid an eco­nomic re­vival, a new sec­tor has emerged as a dom­i­nant eco­nomic force in the re­gion.

At the very end of Hamil­ton Har­bour lies an idyl­lic la­goon named Cootes Par­adise. This lush, green sanc­tu­ary rep­re­sents an en­tirely dif­fer­ent pic­ture of the city: water­fowl, ca­noes and wa­terlilies are the dom­i­nant vis­ual mark­ers; the smoke stacks of the in­dus­trial—now gen­tri­fy­ing, gritty-cool—North End are nowhere to be seen. And perched above this dra­mat­i­cally green la­goon is McMaster Univer­sity—the en­gine be­hind a re­vived Hamil­ton.

Through a stealth tran­si­tion span­ning sev­eral decades, health sci­ences has emerged as the driv­ing sec­tor in Hamil­ton, and has al­ready dwarfed the steel busi­ness six-fold in em­ploy­ment. The sec­tor is bold, it is in­no­va­tive, and it is now a rec­og­nized in­ter­na­tional brand for the city.

McMaster Univer­sity’s med­i­cal school has just been named by The Times Higher Ed­u­ca­tion World Univer­sity Rank­ings as #23 in the world among med­i­cal schools.

Not sur­pris­ingly, the top three med school ranks are held by Cambridge, Oxford and Har­vard. The only Cana­dian school edg­ing out “Mac” in this year’s global rank­ing for med­i­cal schools is the Univer­sity of Toronto, which sits at 19. As a much larger univer­sity, how­ever, it can un­der­stand­ably con­trib­ute quan­ti­ta­tively more in terms of the eval­u­a­tion met­rics which fac­tor into the rank­ings. For its size, McMaster is punch­ing far, far above its weight. In fact, in 2012, McMaster’s med­i­cal school was ranked num­ber 1 in Canada, and 14th glob­ally. Glob­ally.

How did this hap­pen? How did a medium-sized univer­sity in a medium-sized postin­dus­trial city be­come a model in­sti­tu­tion for med­i­cal in­struc­tion, rec­og­nized the world over? It started a revo­lu­tion—a revo­lu­tion since em­u­lated by the most prom­i­nent med­i­cal uni­ver­si­ties on the planet.

Though founded in 1887, McMaster had no med­i­cal fac­ulty un­til the 1960s. Then, a pi­o­neer­ing med­i­cal aca­demic, a Toron­to­nian named Dr. John Evans who was 35 years old at the time, had a vi­sion. And in synch with the zeit­geist of his age, he took a bold risk.

Evans be­came the found­ing dean of McMaster’s new med­i­cal fac­ulty. He and his fel­low founders took a keen ex­per­i­men­tal in­ter­est not only in teach­ing medicine, but in how it is taught. With an icon­o­clasm typ­i­cal of the tur­bu­lent ‘60s, they chal­lenged the tra­di­tional “sage on a stage” model, con­vinced there was a bet­ter way to teach, and to pro­duce bet­ter physi­cians.

They ques­tioned the supremacy of a no­tion that medicine con­sists of a body of knowl­edge, to be passed on from mas­ter to pupil in a top-down for­mat, with the re­sult that stu­dents will absorb this knowl­edge and even­tu­ally grad­u­ate as the fu­ture masters who can, in turn, pass it further. What if, they won­dered, med­i­cal sci­ence is an ever­green col­lab­o­ra­tive en­deav­our of dis­cov­ery? What if stu­dents are ca­pa­ble of learn­ing them­selves—bet­ter—out­side a lec­ture hall?

In an af­front to cen­turies of tra­di­tion, they up­ended the model char­ac­ter­ized by two years of lec­ture, fol­lowed by sev­eral years of clin­i­cal en­gage­ment in teach­ing hos­pi­tals. Rather than teach­ing the stu­dents medicine, they de­cided to teach them how to learn medicine.

They gauged that al­most all their new med­i­cal school en­trants al­ready had un­der­grad­u­ate de­grees—so they knew how to think crit­i­cally. They har­nessed this crit­i­cal-think­ing abil­ity to spawn a new phi­los­o­phy of self-di­rected learn­ing.

The new sys­tem would be based on Small-Group Prob­lem-Based Learn­ing. There would be no for­mal ex­am­i­na­tions through­out the pro­gram. In­stead, they in­tro­duced sys­tems for on­go­ing as­sess­ment. The aca­demic pe­riod was also short­ened to just un­der three years, from the stan­dard four or some­times five in most med­i­cal schools.

In an­other move highly un­usual for med­i­cal schools of the time, stu­dents started to in­ter­act with pa­tients within the first six weeks of their aca­demic pro­gram—not af­ter two years. The in­ter­face was built in from the out­set as a foun­da­tion of the new ap­proach to health care as­sess­ment.

Stu­dents would en­gage with each other, and work col­lab­o­ra­tively, to learn meth­ods for col­lect­ing in­for­ma­tion, gath­er­ing data, and as­sess­ing new cir­cum­stances. Evans rec­og­nized that in most cases, physi­cians in the real world are fal­li­ble prac­ti­tion­ers who con­front sit­u­a­tions in which they have in­com­plete knowl­edge. So rather than per­pet­u­at­ing the myth of the all-know­ing doc­tor, Prob­lemBased Learn­ing (PBL) is built on the recog­ni­tion that what you don’t know is just as im­por­tant a part of be­ing a physi­cian as what you do know. And doc­tors need to train them­selves to nav­i­gate that un­cer­tainty.

McMaster built a new cul­ture that em­braced real-life cir­cum­stances. It was de­signed to make doc­tors bet­ter at as­sess­ing pa­tient con­di­tions col­lab­o­ra­tively, bet­ter at ask­ing ques­tions and bet­ter at com­mu­ni­cat­ing. They would ap­proach their craft through the lens of con­stant prob­lem-solv­ing. They would work with pa­tients— not at pa­tients. Through PBL, stu­dents would study an is­sue, go away, share the prob­lem, share their views, come back and con­tin­u­ally re­assess. It shifted the fo­cus from in­fal­li­bil­ity to col­lab­o­ra­tion—both lat­er­ally with other physi­cians, and with pa­tients.

The ex­per­i­ment paid off. Once fully op­er­a­tional­ized, as­sess­ment af­ter as­sess­ment found McMaster’s med­i­cal grad­u­ates su­pe­rior at learn­ing, com­mu­ni­cat­ing, and col­lab­o­rat­ing. When faced with fi­nal ex­am­i­na­tions at the end of their train­ing, they clearly av­er­aged bet­ter re­sults com­pared with other schools. McMaster med­i­cal grad­u­ates also have a greater sta­tis­ti­cal prob­a­bil­ity of go­ing on to teach, do re­search, and work in med­i­cal schools. They are widely con­sid­ered to be more well-rounded, and tend to be rec­og­nized for a more holis­tic ap­proach to health. They are also more lat­eral thinkers in in­ves­ti­gat­ing di­ag­no­sis.

If im­i­ta­tion is the sin­cer­est form of flat­tery, there has been no short­age of recog­ni­tion. A num­ber of schools have adopted the McMaster sys­tem out­right, start­ing with the Univer­sity of Maas­tricht in the Nether­lands, which over­hauled its model af­ter Mac’s in 1973. The Univer­sity of Cal­gary fol­lowed suit in the mid-1970s, as did other schools such as the Univer­sity of Lan­caster and the Univer­sity of New­cas­tle in the United King­dom. Far more schools have adapted the PBL ap­proach and emerged with hy­brid mod­els.

In fact, in a quirk of his­tory, Dr. Evans’ in­spi­ra­tion had orig­i­nally come from Har­vard, where a form of Prob­lem-Based Learn­ing was be­ing used in its law school. He and his new fac­ulty at McMaster were global pioneers in trans­pos­ing this ped­a­gog­i­cal phi­los­o­phy to a med­i­cal school. In the end, fol­low­ing decades of ac­co­lades for the re­sults it pro­duced, Har­vard re-adapted it from McMaster and partly redesigned its own med­i­cal school along McMaster’s model.

The ap­proach has since been ex­panded to the nurs­ing pro­gram and across Health Sci­ences – not just at Mac, but in many other schools in­spired by it.

What does this mean for health care writ large? Among the most se­ri­ous chal­lenges fac­ing today’s health pol­i­cy­mak­ers are the in­creas­ing costs of per­son­al­ized medicine (in­clud­ing ex­tremely ex­pen­sive bi­o­log­ics for rare dis­eases), and the cost and so­cial chal­lenges of pro­vid­ing med­i­cal ser­vices to re­mote com­mu­ni­ties with lit­tle or no reg­u­lar ac­cess to health care prac­ti­tion­ers.

McMaster’s model builds ideal prac­ti­tion­ers—both physi­cians and nurses—for the lat­ter chal­lenge. Health care prac­ti­tion­ers specif­i­cally trained for prob­lem solv­ing with many un­knowns are pre­cisely the kind to dis­patch for cir­cuit solo health care work in small re­mote com­mu­ni­ties.

On the for­mer prob­lem—deal­ing with the chal­lenges of re­sourc­ing— McMaster has of­fered the world an en­tirely sep­a­rate set of in­no­va­tions: it pi­o­neered Ev­i­dence-Based Medicine with a set of new method­olog­i­cal struc­tures for care­ful eval­u­a­tion of de­ci­sion-mak­ing. McMaster is the home of the so-called “GRADE” (Grad­ing of Rec­om­men­da­tions As­sess­ment, De­vel­op­ment and Eval­u­a­tion) Sys­tem, also known as “Ev­i­dence to De­ci­sion” or “EtD”.

In lay terms, it is a sys­tems-based model for gath­er­ing bet­ter data, and op­ti­mally eval­u­at­ing that data through stan­dard and sys­tem­atized pro­cesses, iso­lat­ing best avail­able ev­i­dence to in­form judge­ments about each in­di­vid­ual cri­te­rion un­der con­sid­er­a­tion, and ul­ti­mately in­form de­ci­sion-mak­ing. In a world where health sys­tems’ re­sources are fi­nite and de­ci­sions have to be made on which ther­a­pies and pro­ce­dures to cover, this has be­come the in­ter­na­tional gold stan­dard for data eval­u­a­tion against pro­jected out­comes.

McMaster’s GRADE toolkit is now used by the World Health Or­ga­ni­za­tion, the EU and over 100 health so­ci­eties around the world. Most guide­lines used to eval­u­ate treat­ment for chronic and acute ill­ness are now based on this sys­tem.

This is the new Hamil­ton. McMaster is now rec­og­nized as the most re­search­in­ten­sive re­search univer­sity in Canada, as a func­tion of peer-re­viewed and non-peer re­viewed fund­ing that comes into the univer­sity, mea­sured against size. On this mea­sure, McMaster stands at over twice the me­dian level of Cana­dian uni­ver­si­ties. It also boasts three No­bel Prize lau­re­ates as part of its legacy. The lit­tle city, ever in Toronto’s shadow, is all grown up. And its school is a ver­i­ta­ble pow­er­house.

McMaster Univer­sity has rev­o­lu­tion­ized physi­cian train­ing, pi­o­neered the global best-prac­tice in health sci­ence ped­a­gogy, and is the pro­pri­etary founder of “the” process for trans­lat­ing clin­i­cal re­search data into health care pol­icy—world­wide. For a steel town school, that’s not a bad legacy.

McMaster Univer­sity photo

The McMaster Univer­sity Med­i­cal Cen­tre, ranked the 23rd top med­i­cal school in the world.

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