• Apr 19, 2018
  • Insights

Hamilton’s new heart, or how McMaster Med cured the God Complex

By Captain108 - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=65239516

Written by Yaroslav Baran. Published by Policy Magazine.

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That gritty and industrial perception of Hamilton continues to this day, though largely based on outdated stereotypes.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 post-industrial 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, Problem-Based 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 research-intensive 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.