Discussion: Impacts of Digital Learning in Rural Communities in Canada

I had the pleasure of discussing impacts of digital learning in rural communities with my MALAT classmate, Chris Henderson. Chris is based in St. Catharines, Ontario and works as Manager of LMS, Library, Policy and Student Resources at Niagara Health. He has deep experience in this domain and it was interesting to learn from him about this broad and far-reaching topic.

While we set out to chat for about 20 minutes, we ended up having about a 40-minute conversation. I have general familiarity with some of the issues concerning smaller centres in Alberta, where I am based. I also conducted some research in preparation of our discussion.

Some highlights and context to our discussion are as follows:

• Distributed medical education (DME) has been implemented in various models across Canadian medical schools where all sites are required to meet the accreditation standards and elements set forth by the Committee on Accreditation of Canadian Medical Schools. (CACMS, 2023; COFM, 2014; Ellaway & Bates, 2018; Bakker, 2018)
• DME was implemented to address capacity issues in Academic Health Science Centres (AHSCs), address workforce issues and increase support to underserved populations, particularly in rural and remote communities. (Ellaway & Bates, 2018; AFMC, 2010)
• The development of DME in Canada was exceedingly difficult and possible only with access to synchronous bi-directional communication tools like videoconferencing. (Ellaway & Bates, 2018; Sargeant, 2005)
• A challenge with DME sites is demonstrating equivalence of opportunity across different sites. (Ellaway & Bates, 2018) Will someone in Okotoks, just south of Calgary, have the same learning opportunity as someone in Cressday, which is 400 kms away? These sites are governed by the Committee on Accreditation of Canadian Medical Schools (CACMS) to ensure equivalency and not sameness to allow for equivalent opportunities in education. (CACMS, 2023)
• Researcher Joan Sargeant, at Dalhousie University, found that when using digital deliveries for education, the temptation is often to focus more on the technology and less on the learners and instructors, often to the detriment of the educational quality (Sergeant, 2005). Chris shared that the opposite can also happen: instructors may wander out of frame, forgetting about the camera and its microphone.
• Adapting pedagogies and teaching behaviours to support success through videoconferencing was an ongoing and iterative process. (MacLeod et. al., 2019a; CFMS, 2011; Veerapen, 2010)
• McMaster developed an online curriculum management platform, Medportal, which mapped to, and facilitated compliance with, the CACMS accreditation standards and elements. Medportal provided an asynchronous platform for students to access lecture recordings, schedules, course information, grades, and evaluations. (CACMS, 2023) 
• Hardware-based lecture videoconferencing was a complicated system of analogue and digital audiovisual and network infrastructure and had many similarities to television broadcast, requiring significant support by technicians at all sites (Macleod et. al., 2017; MacLeod et. al., 2019a; MacLeod et. al., 2019b)
• COVID had a very detrimental impact on learning: hospitals had to restrict learner access, and policies were changing rapidly. At the same time, this did facilitate a transition to a heavier focus on videoconferencing, which has sustained in its use.
• Having simulation manikins is vitally important in the understanding and demonstration of concepts. Even then, it is a much different experience when your hands are on a real person who needs intervention. Modern simulation manikins have remote-administration capabilities, which can allow for trainees based in rural areas to interface with instructors in bigger centres. (Dag, et. al, 2002; Ayaz, 2022)
• McMaster developed mobile apps to digitize in-the-moment essential clinical encounters (ECE Tracker) and directly observed entrustable professional activities (MacDOT EPA). The apps allowed easier recording of in-the-moment learning activities and reduced the paperwork burden of both learners and faculty. (Levinson et. al., 2019)
• In February of this year, the Alberta provincial government cut service at hospitals in nine communities. Eight of those lost their emergency departments. This is driven primarily by a lack of physicians in the communities. In the absence of local capacity, EMS is rerouted to health facilities in surrounding communities. (Siever, 2024)
• When clinics and hospitals are closed, where does the distributed medical education happen? Can digital education backfill that experience? Chris believes that to a certain degree, it will, but these approaches are still being developed.
• Joan Sargeant’s research found that rural locations often experience decreased access to education, due to factors such as distance from a clinical teaching centre, limited availability of current medical information… and that working in isolated environments, like rural areas, where access to peers, education and information is limited, is one of the highest risk factors for physicians’ loss of medical competence. (Sargeant, 2005)
• Sargeant also notes that in “undergraduate and residency education, videoconferencing use is increasing and includes students and residents in rural and distributed sites”. So does the increased use of videoconferencing help to mitigate that loss of competence? Physicians and surgeons have access to libraries, databases, and source materials. They are also required to undergo a certain amount of professional development each year, to maintain their credentials. Videoconferencing is used as a part of this training, alongside other methods.
• There is evidence that learners educated in DME communities stay and practice in the region of training. (Utzschneider & Landry, 2018; Lovato et. al., 2019). However, resolving the gap in rural and community family medicine is complex requiring further incentives and research. (Bakker et. al., 2020; Lovato et. al., 2019)

Conclusion

The impacts of digital learning in rural communities (in Canada and beyond) are influenced by many of the same factors of change as most other locales. Additionally, rural communities face challenges related to resources, geography, recruitment, facilities, and funding. Proactive approaches are in place to foster equitable training opportunities but it is still a work in progress that continues to evolve.

It was a pleasure to have this conversation with Chris and learn more about this field.

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References

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Bakker, D., Russell, C., Schmuck, M.L., Bell, A, Mountjoy, M., Whyte, R., Grierson, L. (2020). The relationship between regional medical campus enrollment and rates of matching to family medicine residency. Canadian Medical Education Journal,11(3): e73-e81. https://doi.org/10.36834/cmej.69328 

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Siever, K. (2024, May 14). 8 rural Alberta hospitals lost ER service last month. The Alberta Worker. https://albertaworker.ca/news/8-rural-alberta-hospitals-lost-er-service-last-month/ 

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