One of the primary mandates of a medical school is to prepare future physicians to meet the current and emerging health care needs and expectations of the population it serves. The importance of making medical education more responsive to public needs was recognized by the Educating Future Physicians for Ontario (EFPO) project,1 which established “the discovery of needs and expectations” (of the population) as one of its main objectives. This project identified, among others, two key roles that people of Ontario expect of today's physician: those of communicator and health advocate.2 In this light, it is generally accepted that the care rendered to minority population groups is greatly enhanced by incorporation of the linguistic and cultural aspects of these groups in the provision of medical services. Similarly, for the health care provider to be an effective health advocate for population groups, it is important that the specific contexts in which their members live be familiar to him or her.
As a minority group, the francophone population of Ontario has three specific needs and expectations: to receive health care in its mother tongue, to be treated by professionals who know the community well, and to have access to good medical services in ambulatory and rural settings. In order to be responsive to these societal needs and expectations in its undergraduate program, the Faculty of Medicine at the University of Ottawa has developed a French-language stream which, through the novel character of its educational activities, also serves to enrich the pre-existing English-language stream. This experience could inspire other medical schools that serve linguistic minority groups to initiate similar undertakings.
In this article we describe the context in which the project took place, the specific needs and expectations of the Franco-Ontarian population, the planning and implementation of a French-language stream that addresses the needs of that population, and the major outcomes of the innovation.
CONTEXT OF THE INNOVATION
The Francophone Population of Ontario
With a population of approximately 10.5 million people, Ontario is the most densely populated of the ten provinces of Canada. Numbered at 542,340, French-speaking Ontarians constitute the largest francophone population group of Canada outside the province of Quebec.3 However, at about 5% of the population of Ontario, Franco-Ontarians are definitely a minority group in the province, as is the case for francophones in all other provinces across Canada except Quebec. Within the province of Ontario, the francophone population is unevenly distributed. While the central and southern regions of the province are the most heavily populated, the communities where Franco-Ontarians are in the largest numbers are primarily in northeastern and eastern Ontario. These regions correspond, to a large extent, to rural and remote areas that are chronically underserved with respect to health care. Due to the shortage of physicians and other health care professionals in these regions, francophone patients seldom have access to physicians who are familiar with their language and culture.
The University of Ottawa
Situated in the capital of Canada, a country that has French and English as its two official languages, the University of Ottawa is a leading bilingual institution of higher learning in the country. In 1965, through the University of Ottawa Act, the institution received from the Government of Ontario the specific mandate “to further bilingualism and biculturalism and to preserve and develop French culture in Ontario.” Consequently, in the following three decades, the University of Ottawa developed a wide spectrum of programs in French and English in all of its Faculties in order to better serve the population of Ontario.
The Faculty of Medicine
The Faculty of Medicine at the University of Ottawa was established in 1945 as one of five medical schools in Ontario. In recent times, it enrolled 84 students per year until September 2000, when enrolment increased to 91 students. About a fourth of the class is made up of students who have French as their mother tongue. There are 480 full-time and about 865 voluntary part-time faculty members in total at the medical school. For both groups, the number of francophone faculty members is approximately one sixth the number of their anglophone counterparts. Thus, there is a significant discrepancy between the numbers of teachers who can teach in English only (anglophones, who are mostly unilingual) and those who can teach in either French or English (francophones, who are all bilingual). Bilingual teachers often have the dual responsibility to teach in both French and English, a situation that further taxes scanty resources.
In 1992, the Faculty of Medicine took advantage of a major curricular reform from a traditional to a problem-based learning (PBL) curriculum4 to begin to implement learning activities in French for its Franco-Ontarian students. From 1992 to 1996, French-language activities consisted in two weekly sessions totaling five hours of small-group learning for two PBL groups, each composed of seven students and a tutor. In 1995, following the evaluation of the pilot project by an external evaluator, the Faculty developed and adopted an action plan aiming to develop a French-language stream for the entire undergraduate curriculum. A systematic educational planning approach was adopted for this vast project, which is now in its last phase of development.
SOCIETAL NEEDS AND EXPECTATIONS OF A MINORITY GROUP
To Receive Health Care in One's Mother Tongue
The importance of language in the provision of health care cannot be overemphasized. It is through language that health care providers are able to obtain the necessary information to arrive at a diagnosis, to formulate a treatment plan, to counsel the patient, and to provide information regarding health promotion and disease prevention. Yet, communication through this medium is fraught with problems even when the physician and the patient speak the same language.5 When an already emotionally charged encounter such as a physician—patient interaction is compounded by a linguistic barrier, communication problems are accentuated, to the detriment of both parties and at great societal cost.
Thus, communication in the patient's language is an important and inexpensive diagnostic and therapeutic tool for the caregiver. The importance of this factor in the provision of health care is stressed in a recent report on French-language health services in Ontario, where it is stated that “communication being an essential factor in health care delivery, providing care to francophones in French will improve the health status of that community and at lesser social, psychological and financial costs.”6
To Have Physicians Who Know the Community
In order for the Ontario physician to be a health advocate for a population group, the professional must be thoroughly familiar with the characteristics of the population it is serving, its cultural traits, its health care needs, etc. Minority groups have a great need for physicians who are knowledgeable about their psychosocial circumstances, who can communicate effectively with them, and who are willing to intervene on their behalf. For Franco-Ontarians, community hospitals where services are provided in French by family physicians who know their community well are a most precious asset. The Montfort Hospital, which is located in the east end of Ottawa, is regarded as one of these facilities.
To Receive High-quality Medical Care in an Ambulatory Setting
The past 15 years have been marked by a gradual shift in medical care from the tertiary care hospital setting to the ambulatory care setting. This movement, which aims to make medical care more efficient and cost-effective, has led to the development of services that are closer to the health care consumer, such as community-based facilities and home care. While the availability of a wide spectrum of services in out-of-hospital settings is important for the population of Ontario as a whole, it is even more so for the Franco-Ontarian communities that are largely found in suburban, rural, and remote regions of the province.
PLANNING THE NEW PROGRAM
In order to move forward with the Faculty's action plan, entitled “Studying Medicine in French at the University of Ottawa,” the dean and the vice-dean of the Faculty recruited five faculty members to constitute a steering group and created the Office of Francophone Affairs (OFA). This steering group, headed by the vice-dean as director, was given the mandate to plan, develop, and implement the francophone program. Funding was obtained from the University of Ottawa to support the steering group and from the Ministry of Education and Training of Ontario to support the five-year action plan.
In the design of the new program, a systematic educational planning model was chosen. This model, adapted from the objectives-oriented approach proposed by Tyler,7 had been used extensively for the educational development of faculty members at the University of Montreal and at the University of Sherbrooke.8 The model has the learner as its center and focus; it also puts emphasis on the learning environment. As a first step, educational needs of students are defined, taking into account the competencies required for their future professional tasks. Educational objectives and methods to achieve the learning goals are defined next. The achievement of learning objectives is then determined through the assessment of learner competence. The educational program as a whole is also evaluated in order to improve its quality.
The creation of a more socially responsive medical curriculum was one of the main objectives of the new program. Making such a change requires planning and implementing activities that enhance the relevance of curricular content. In several medical schools across Canada and the United States, this has taken the form of increased ambulatory and community-based experiences for students.9,10 Medical schools also offer some learning opportunities in the rural setting to students, usually in the final year of their undergraduate programs.11,12 However, in most North American medical schools, core clerkship rotations remain concentrated in tertiary academic medical centers, where patients with rare diseases congregate.13 This practice does not foster clinical training that is truly relevant to the general professional education of the physician. In addition, it has been shown that students who do most of their training outside academic medical centers are more likely to practice in rural and underserved areas.14 Thus, social responsiveness requires that medical schools drastically increase the number of training opportunities in primary care settings and focus on learning activities that are relevant to the education of the future generalist physician.
Another challenge of the new program was to define the educational needs of students and plan appropriate learning activities. In addition to having to acquire the knowledge, skills, and attitudes of a good physician, students of the new program would have to develop competencies that would allow them to fulfill societal needs that are specific to the Franco-Ontarian population. The three societal needs mentioned earlier were focused upon in planning the program: (1) the need for effective communication with the francophone population during health care delivery, (2) the need for good knowledge of the community, and (3) the need for the provision of health care in an ambulatory care setting.
In order to fulfill educational needs of students relative to these societal needs, three learning activities were developed for francophone students. These constituted educational innovations at our school. The first innovation was the development of a communication skills laboratory, the second was early exposure to community patients for the physician skills development course, and the third was the implementation of clerkship rotations in a francophone community hospital that has a strong ambulatory care emphasis.
IMPLEMENTING THE PROGRAM
The first innovation of the French-language stream of the undergraduate medical program was a communication skills laboratory. It was developed in order to allow students to learn effective interviewing and physical examination skills in French in a nonthreatening setting. The laboratory was modeled after the one that was developed at Maastricht.15 It makes use of simulated patients who are trained to play specified roles and to give feedback to the student following the encounter. A clinician who has been trained to use observation and feedback techniques observes the encounter, asks the student to self-assess, and then gives feedback to the student. Facilities are in place for filming the session on a videocassette that the student can keep for review. This powerful learning activity is offered to francophone students throughout the first two years of the program.
A second innovation was developed in order to allow students to acquire clinical skills that would prepare them to give high-quality medical care in the ambulatory setting. To achieve this goal, it was felt important to expose them regularly to that environment. Opportunities for early and regular student exposure to francophone patients in an ambulatory practice setting were therefore developed as another innovation of the program. This learning activity consists in having francophone students spend a half day each week with a community preceptor in order to see patients in an ambulatory, primary care setting, starting within the first month following admission to medical school. In addition to allowing students to develop their interviewing and physical examination skills, this activity improves their understanding of psychosocial and cultural health and disease determinants in the francophone population.
The development of clerkship rotations in a francophone community hospital constitutes the third major innovation of the French-language stream of the undergraduate medical program. Through this important component of clinical training, program developers wanted to expose students to the type of medical practice that most closely resembles the future practice of the majority—that of a generalist physician. This experience outside tertiary care centers was felt to be more appropriate to fulfill the learning needs of students who are called upon to provide care to the francophone populations in remote regions and rural areas.
In addition, as part of the systematic educational planning approach, learning needs of francophone faculty were also given a high priority. In order to prepare them for their leadership role in designing and implementing the new program, members of the steering group received a master's level course in medical pedagogy.8 They also received specific training in order to be able to offer faculty development activities to future PBL tutors, preceptors, and instructors to enhance their skills in PBL sessions, clerkships, and communication skills laboratory sessions, respectively. In the course of five years, OFA members have organized and given more than 50 training workshops to francophone faculty in order to prepare them for their new teaching tasks within the program. Faculty development activities were particularly important in preparing community preceptors for their new role as clinical teachers and learning facilitators.
The systematic educational planning approach also led to the involvement of francophone medical students in developing the new program. Program developers felt that students' contributions in shaping curricular content were essential in order to make the program responsive to their learning needs. Several learning activities were designed by students working closely with OFA members, as part of summer projects. Students participated extensively in faculty development activities such as PBL tutor training and instructor training workshops and served as simulated candidates in training interviewers for the Faculty's admission committee. They contributed to the creation of several videos that were used for faculty development purposes. They played a key role in demonstrating a PBL session to the new class of students and new tutors of both streams during the orientation week each fall.
In addition to their ongoing participation in developing and improving the new program, francophone medical students also play a major role in the recruitment of young Franco-Ontarians to the program. The OFA organizes regular promotional tours in francophone high schools across the province where students act as the ambassadors of the program. It also organizes enrichment courses for francophone high school students, where medical students of the program are also the key players. These activities are highly successful with high school students, in large part because of the invaluable contribution of the medical students.
Impact of the French-language Stream on the English-language Stream
Throughout the planning and implementation phases of the program, great care was taken by the developers to maintain one curriculum for the two streams. Students in the French-language stream have to meet the same objectives as do students in the English-language stream, and are exposed to the same educational content and subjected to the same assessment measures. However, the means to achieve the educational objectives differ in the two streams, the francophone students studying medicine in French and having substantially more of their learning activities in the ambulatory and community settings than the anglophone students.
In 1992, the implementation of a PBL-based curriculum at the medical school had changed the educational philosophy from one that was teacher-centered to one that was student-centered. It is fair to say that the French-language stream has taken the student-centered approach even further through its emphasis on the competencies that francophone students have to acquire in order to meet societal needs. The innovations that were developed for that purpose now inspire the Faculty to improve the entire curriculum by developing similar learning activities for the English-language stream.
Other Major Outcomes
Besides having a significant impact on the existing medical program, the creation of the French-language stream for the undergraduate medical program has had further outcomes, both within and outside the Faculty.
Within the Faculty, the project has been highly stimulating. A lot of creative thinking was needed to put forth such a vast project with scanty resources. Anglophone faculty who were sceptical of the community-oriented approach taken in developing the program now see this move as both feasible and pedagogically sound. Faculty development activities that are offered to francophone faculty members have fostered a renewed interest in medical education within that group. Many have since taken major educational responsibilities in the program, and a few have registered in a master's degree program in medical education. Francophone medical students enjoy their community-based experiences and speak of the program with pride. They feel well prepared for providing clinical care during their residency training, and their performances on qualifying examinations are comparable to those of their peers in the English-language stream.
The program has also had some impact outside the Faculty. Francophone community groups show great interest in the new program. They welcome the partnerships that have developed with the Faculty when organizing promotional tours or enrichment courses locally and in remote areas of the province. Francophone community members are grateful that their health care needs are being addressed. They are happy to collaborate with promotional activities that aim to increase the number of applicants to the program. Another major outcome of the program took place in January 1999. The French-language program was recognized by the federal government as an important resource for the medical training of candidates coming from francophone minority groups in provinces outside Ontario and Quebec. The University of Ottawa received a grant to train 30 medical students and 60 health science students for these minority population groups by the year 2003. With this expansion of the program, the Faculty of Medicine received a national mandate with respect to undergraduate medical education in the French language.
The project has served as a stimulus for creative thinking and for pedagogic innovation at our school. While the original mandate of the French-language stream of the medical program was restricted to the francophone population of Ontario, the focus of the program has now become broader and includes francophone minority groups in all of Canada. Further community-based learning activities need to be developed in regions both within and outside Ontario to accommodate the needs of the students in the entire program.
We hope that medical schools that serve linguistic minority groups will benefit from the experience gained at the University of Ottawa. The success met in developing, with scanty resources, several innovations that make the curriculum more responsive to societal needs of a minority population group could inspire these medical schools to set up similar programs.