Measuring the Impacts of Medical Schools in Canada - Simon Fraser University August 2021
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Measuring the Impacts of Medical Schools in Canada
Prepared by:
Simon Fraser University
August 2021
Introduction
Simon Fraser University (SFU) is proposing to establish a new medical school in Surrey, which would be
the first established in Canada in over 15 years and the second ever to be established in British
Columbia. The UBC Faculty of Medicine is the only medical school in BC, with campuses in Vancouver,
Victoria, Prince George and Kelowna. As part of this proposal, it is necessary to consider the potential
future economic and social impacts of a new medical school.
Overall, medical schools in Canada have been found to have a positive economic and social impact on
their surrounding cities, as well as on provinces as a whole. There are currently 17 accredited medical
schools in Canada. In addition to solid economic benefits, research has confirmed that medical schools
have had many positive social impacts, including “job creation, high-quality medical care, advanced
research, new business development, and education of medical professionals”. 1
Medical Schools in Canada
The 17 accredited medical schools in Canada are listed below. The most recently established is the
Northern Ontario School of Medicine (est. 2005), which is jointly affiliated with Lakehead and Laurentian
Universities, and features a unique decentralized model of student training sites. Additionally, Ryerson
University received a planning grant from the Ontario government in 2021 in order to develop a
proposal for a new medical school.2
Medical School Established Campus Locations Distributed Sites
McGill University Faculty of Medicine 1829 Montreal, Gatineau 30 locations in
Northern Quebec
University of Toronto Faculty of 1843 Toronto, Mississauga Rural residency stream
Medicine in Midland, Orillia,
Port Perry, Orangeville
Université de Montréal Faculté de 1843 Montréal, Trois-Rivières Unknown
Médecine
Université Laval Faculté de Médecine 1848 Québec City Unknown
Queen's University School of Medicine 1854 Kingston 26 locations across
Southern and
Southeastern Ontario,
including large, mid-
size, small, and rural
locations
Dalhousie University Faculty of Medicine 1868 Halifax, Saint John Annapolis Valley,
Cape Breton-Sydney,
Cape Breton-
Inverness, Fredericton,
Halifax, Moncton,
North Nova, Prince
Edward Island, Saint
John, South West
Nova
1 Tripp Umbach, “The Economic Impact of Canada’s Faculties of Medicine and Health Science Partners” (Association of Faculties
of Medicine of Canada, August 2014), http://www.afmc.ca/sites/default/files/pdf/Economic_Impact_Study_Report_EN.pdf.
2 “Ryerson University Receives Planning Grant for Medical School in Brampton,” Ryerson University, accessed July 23, 2021,
https://www.ryerson.ca/news-events/news/2021/03/ryerson-university-receives-planning-grant-for-medical-school-in-
brampton/.
Western University Schulich School of 1881 London, Windsor Various sites in the
Medicine and Dentistry following regions:
Chatham-Kent, Huron-
Perth, Elgin-
Middlesex, Lambton-
Kent, Grey-Bruce,
Oxford
University of Manitoba Max Rady 1883 Winnipeg Unknown
College of Medicine
University of Alberta Faculty of Medicine 1913 Edmonton Unknown
and Dentistry
University of Saskatchewan College of 1926 Saskatoon Prince Albert, Swift
Medicine Current, Moose Jaw,
North West, La Ronge,
and others
University of Ottawa Faculty of Medicine 1945 Ottawa Cornwall, Hawkesbury,
Pembroke, Winchester
University of British Columbia Faculty of 1950 Vancouver, Victoria, Prince Various mid-size, small
Medicine George, Kelowna and remote
communities across
Vancouver Island,
Northern BC,
Okanagan, and
Chilliwack
McMaster University Michael G. 1965 Hamilton, Waterloo, St. Grand Erie Six Nations,
DeGroote School of Medicine Catharines Burlington, Halton and
Osler
Université de Sherbrooke Faculté de 1966 Sherbrooke, Chicoutimi, Unknown
Médecine et des Sciences de la Santé Moncton
University of Calgary Cumming School of 1967 Calgary Unknown
Medicine
Memorial University of Newfoundland 1967 St. John’s Unknown
Faculty of Medicine
Northern Ontario School of Medicine 2005 Sudbury, Thunder Bay Over 90 communities
in Northern Ontario
Measuring the Economic Impacts of Medical Schools
In general, medical schools yield “a strong return on investment for provincial governments”. 3 A 2014
report for the Association of Faculties of Medicine of Canada found that in the 2012/2013 fiscal year,
medical schools and their teaching hospitals generated $66.1 billion in combined revenue, or 3.5% of
Canada’s GDP. They supported 295 000 jobs nationwide, or 1.7% of Canada’s employment. They also
generated over $13.9 billion in government tax revenue. Nevertheless, it is difficult to quantify all
measures of the economic impact of medical schools, and various methodologies can be used to do this.
3 Tripp Umbach, “The Economic Impact of Canada’s Faculties of Medicine and Health Science Partners.”
Methodologies for Measuring Economic Impacts Methodologies used to measure the economic impact of medical schools can vary. The common approach to measuring the economic impacts of colleges and universities in general 4 is to “sum expenditures of the college community (students, faculty, staff and visitors) created by the presence of the institution and apply multipliers to account for the interdependency of economic activity in a local economy”.5 Siegfried et al. (2007) outline several challenges to accurately measuring the economic impact of higher education institutions: accurately defining counterfactual scenarios, defining the local area, double-counting, and adequately quantifying spillover. 6 There are methodological challenges in measuring the economic impact of any medical school. Lemky et al. provide a review of five quantitative methodologies that can be used to measure economic impact of medical schools in the unique Canadian context.7 They divide economic impact into direct spending by medical schools, indirect spending by their employees, and induced spending in the local economy as a result of the first two types of spending. Lemky et al. find five mathematical methodologies that have been used to determine economic impact of medical schools. The most popular model used is the Input- Output (I-O) model, which can be sub-divided into the Canadian I-O Model (developed by Statistics Canada), IMPLAN (developed by the U.S Department of Agriculture), ACE (developed by the American College of Education), and Simplified ACE (developed by Sudmant). Less commonly used are models based on economic base theory. The following includes several examples of the above methodologies used to measure the economic impact of medical schools in Canada and beyond. Example of Simplified ACE Model The 2014 report for the Association of Faculties of Medicine of Canada, conducted by consulting firm Tripp Umbach, uses the Simplified ACE model. It quantifies direct economic impact with the following measures: operational, capital, research, visitor and student spending, the number of employees, and salaries and benefits. The report explicitly leaves out other measures, such as research commercialization, attraction power, knowledge and expertise, and even arts and culture, which can also have an economic impact.8 The consulting firm used a customized data collection form to gather data from the medical schools and built linear cash flow models to understand the indirect, or “multiplier” impact of medical schools on the economy. Data was double-checked with medical schools directly. 4 Based on: Caffrey, John, and Herbert H. Isaacs. Estimating the Impact of a College or University on the Local Economy. Washington, D.C.: American Council on Education, 1971. 5 John J. Siegfried, Allen R. Sanderson, and Peter McHenry, “The Economic Impact of Colleges and Universities,” Economics of Education Review 26, no. 5 (2007): 546–58. 6 Siegfried, Sanderson, and McHenry. 7 Kim Lemky et al., “A Review of Methods to Assess the Economic Impact of Distributed Medical Education (DME) in Canada,” Canadian Medical Education Journal 9, no. 1 (March 2018): e87–99. 8 Tripp Umbach, “The Economic Impact of Canada’s Faculties of Medicine and Health Science Partners.”
Example of Economic Base Theory Model In 2009, the Centre for Rural and Northern Health Research conducted a study measuring the economic and social impacts of the Northern Ontario School of Medicine (NOSM).9 This school exists in a unique geographic and social context, with main campuses in Sudbury and Thunder Bay, as well as many decentralized teaching sites in remote communities in Northern Ontario. The research team developed a local economic model using economic base theory. Economic data came from NOSM administrative and financial records and from the Ontario Ministry of Health. The data included “administrative, office, research, travel, salary or wages and benefits paid to NOSM employees, preceptors and to Family Medicine Residents as well as any other spending directed to a specific community.”10 A counterfactual approach was used, comparing the actual economic impact of the school to what would have taken place in its absence. 59 qualitative interviews and two focus groups were also used during the study. Example of Methodology Used for DME Measuring the economic impact of distributed medical education (DME) presents particular challenges. As well, methods used in the US may not entirely translate to the unique context of Canadian academic medicine, and to rural/remote settings. Lemky et al conclude that the best methodologies for measuring the economic impact of DME are the Canadian I-O and the Simplified ACE models. 11 Hogenbirk et al. also conducted a study assessing NOSM’s distributed economic activity in the medically and economically disadvantaged Northern Ontario region in 2019. This study used a cash-flow model clustered in eight economic zones, which allowed them to see the economic impact in individual communities.12 Another example of measuring the economic impacts of DME on specific communities is Tripp Umbach’s report on the Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) program. 13 Example of Canadian I-O Model While not specific to medical schools, the economic impact reports from the University of New Brunswick (2002)14 and the University of Toronto Mississauga (2013)15 both use the Canadian I-O model. 9 Centre for Rural and Northern Health Research, “Exploring the Socio-Economic Impact of the Northern Ontario School of Medicine” (Lakehead and Laurentian Universities, November 2009), https://www.nosm.ca/wp- content/uploads/2018/06/FINAL_Report_NOSM_Socioeconomic_Impact_Study-2009-11.pdf. 10 Centre for Rural and Northern Health Research. 11 Lemky et al., “A Review of Methods to Assess the Economic Impact of Distributed Medical Education (DME) in Canada.” 12 John C. Hogenbirk, David R. Robinson, and Roger P. Strasser, “Distributed Education Enables Distributed Economic Impact: The Economic Contribution of the Northern Ontario School of Medicine to Communities in Canada,” Health Economics Review 11, no. 1 (December 2021): 1–10, https://doi.org/10.1186/s13561-021-00317-z. 13 Tripp Umbach, “Montana’s Medical School: The Economic Aan Social Impact Of The Montana WWAMI Program” (Montana State University, February 14, 2011). 14 Van A. Lantz, John R. G. Brander, and Yigezu A. Yigezu, “The Economic Impact of the University of New Brunswick: Estimations and Comparisons with Other Canadian Universities” (University of New Brunswick, September 2002), https://www.unb.ca/rpb/_resources/pdf/factspublic/economicimpactunb.pdf. 15 KPMG LLP, “University of Toronto Mississauga: Economic Impact Report” (University of Toronto Mississauga, April 12, 2013), https://www.utm.utoronto.ca/sites/files/default/public/shared/UTM%20Economic%20Impact%20Report%20- %20Final%20Report%20-%20Apr%2012%202013%20v15.pdf.
Example of Other Input-Output Model (Abroad) In their 2008 article, Davies & Bennett present a different, more holistic model for measuring the economic, as well as social, impacts of medical schools and their clinical partnerships in the UK. 16 Their model contains five categories of impacts: economic, human capital, social capital, knowledge, and place, which are measured using quantitative and qualitative methodologies. To measure economic impacts, the authors created an input-output model informed by the literature. They measured direct impacts by calculating employee wages as well as goods and services purchased. The “multiplier” effect of these direct impacts was calculated using an input-output model. Data was verified through numerous qualitative interviews. Measuring the Social Impacts of Medical Schools Although they have strong economic impacts, the positive social impacts of medical schools cannot be discounted. A recent study on the Schulich School on Medicine & Dentistry’s Windsor Regional Medical Campus shows that the establishment of a medical campus in this underserved, mid-size city yielded economic, healthcare, education, political, and community benefits. 23 participants interviewed for this study affirmed that the establishment of the campus improved healthcare, community reputation, training opportunities, and even community engagement.17 Likewise, two studies on UBC’s Northern Medical Program (NMP) found that establishing a DME site in an underserved community led to increased social capital, in the form of “pride and status; partnership development; community self- efficacy, and community development.”18 19 Both the Windsor and the NMP studies used semi- structured interviews with key stakeholders to gather data and identified key themes from the resulting transcripts. Methodologies for Measuring Social Impacts The above examples used semi-structured qualitative interviews with key stakeholders. The first study to be conducted was a 2005 pilot study in Prince George, which sought to understand the social impacts of UBC’s Northern Medical Program (NMP) on the community. Researchers interviewed eight senior leaders in the health, education, business, economy, media and political sectors.20 Following, another study was conducted in Prince George in 2007, evaluating the social impacts of the NMP. Researchers interviewed 23 leaders from the following sectors: Aboriginal health services, social services, allied health, and community development. The interview was semi-structured and consisted of eight-opened ended questions (see Appendix A).21 16 Stephen M. Davies and Anita Bennett, “Understanding the Economic and Social Effects of Academic Clinical Partnerships,” Academic Medicine 83, no. 6 (June 2008): 535–40, https://doi.org/10.1097/ACM.0b013e3181723033. 17 Gerry Cooper et al., “Impact of an Urban Regional Medical Campus: Perceptions of Community Stakeholders,” Canadian Medical Education Journal 12, no. 1 (February 2021): e46–59, https://doi.org/10.36834/cmej.69951. 18 Chris Lovato et al., “Evaluating Distributed Medical Education: What Are the Community’s Expectations?,” Medical Education 43, no. 5 (2009): 457–61, https://doi.org/10.1111/j.1365-2923.2009.03357.x. 19 Patricia Toomey et al., “Impact of a Regional Distributed Medical Education Program on an Underserved Community: Perceptions of Community Leaders,” Academic Medicine 88, no. 6 (June 2013): 811–18, https://doi.org/10.1097/ACM.0b013e318290f9c7. 20 Lovato et al., “Evaluating Distributed Medical Education.” 21 Toomey et al., “Impact of a Regional Distributed Medical Education Program on an Underserved Community.”
In the Windsor study, researchers also interviewed 23 individuals. They targeted five interviewees from each of the following sectors: health, education, business, and political.22 Interviews were one hour in length and consisted of eight open-ended questions based on those in the NMP study (see Appendix A).23 Finally, a 2009 report measuring the economic and social impact of the NOSM also conducted interviews with community members. Three distinct groups of interviewees, including senior university officials, senior hospital management and clinical staff, and community leaders, were each asked a unique series of questions (see Appendix A). A total of 59 individuals were interviewed. Local Business and Medical Education An article by the President of the Oklahoma University Tulsa campus notes the potential for strong collaboration between the University’s College of Medicine and their local Chamber of Commerce. Clancy’s experience in collaborating with the Tulsa business sector yielded important mutual benefits including access to legislators, support for the school’s work in healthcare and poverty reduction, as well as accelerating local economic development.24 Indigenous Health and Medical Education It has also been recognized that medical schools play a large role in Indigenous health, both in terms of recruiting and training Indigenous students and teaching Indigenous medical education within the curriculum. While some positive developments have been made, there remain many challenges that must be solved by existing and future medical schools.25 In Plain Sight, the 2020 report published as part of the Addressing Racism Review in BC, provides 24 recommendations. In particular, recommendations 18, 21, 23, and perhaps others, could provide direct opportunities for a newly established medical school to meet those community needs. Case Study: The Northern Ontario School of Medicine (NOSM) This school exists in a unique geographic and social context, with main campuses in Sudbury and Thunder Bay, as well as many teaching sites in remote communities in Northern Ontario. It serves large Indigenous and Francophone populations, which have been historically medically underserved and suffer from a higher rate of certain medical conditions than the rest of the province. 26 In recent years, a new practice has emerged in Canada called “distributed medical education” (DME), where medical students are taught in diverse settings outside of their medical school and its associated teaching hospitals. DME has been important for addressing health inequities and providing medical services to underserved communities. A small amount of DME exists at most Canadian medical schools, but the NOSM is an interesting case study as it trains students in over 90 communities, including rural 22 Cooper et al., “Impact of an Urban Regional Medical Campus.” 23 Cooper et al. 24 Gerard P. Clancy, “Commentary: Linking Health Equity With Economic Development: Insights From My Year as Chairman of the Board of the Chamber of Commerce,” Academic Medicine 87, no. 12 (December 2012): 1665–67, https://doi.org/10.1097/ACM.0b013e318272113f. 25 Marcia Anderson, Barry Lavallee, and Linda Diffey, “Indigenous Medical Education,” AFMC: 75 Years of Legacy, 2018. 26 Roger P. Strasser et al., “Canada’s New Medical School: The Northern Ontario School of Medicine: Social Accountability Through Distributed Community Engaged Learning,” Academic Medicine 84, no. 10 (October 2009): 1459–64, https://doi.org/10.1097/ACM.0b013e3181b6c5d7.
and remote locations.27 It has been argued that in the Northern Ontario context, DME has also brought about distributed economic impacts in the form of bringing people, increasing spending, and introducing knowledge-based economic activities to a region that had seen largely resource-based economic activity.28 A 2009 report estimated NOSM’s economic impact on Northern Ontario to be between $67-82 million yearly and funded 232.5 full-time equivalent positions in the 2007/2008 fiscal year. Additionally, NOSM also pays honoraria to Indigenous Elders, committee members, and preceptors for medical students. 29 Conclusion A variety of articles and reports covering local and national Canadian contexts have demonstrated that medical schools have strong positive economic and social impacts. It is also clear that the positive impacts of medical schools reach beyond those that can be easily quantified. As DME continues to expand in Canada, the distributed economic and social impacts of medical schools will also continue to expand. When measuring the impact of medical schools on their surrounding communities and on the province as a whole, it is important to accurately define variables and to use appropriate quantitative and/or qualitative methodologies for each measure. The medical school’s geographic location and unique local context should be considered when determining measures and methodologies to be used. Engaging with diverse stakeholders is also important. 27 Rachel Ellaway and Joanna Bates, “Distributed Medical Education in Canada,” Canadian Medical Education Journal 9, no. 1 (March 27, 2018): e1–5. 28 Hogenbirk, Robinson, and Strasser, “Distributed Education Enables Distributed Economic Impact.” 29 Centre for Rural and Northern Health Research, “Exploring the Socio-Economic Impact of the Northern Ontario School of Medicine.”
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Appendix A Interview Questions Used for the NMP Study (Toomey, Patricia, Chris Y. Lovato, Neil Hanlon, Gary Poole, and Joanna Bates. “Impact of a Regional Distributed Medical Education Program on an Underserved Community: Perceptions of Community Leaders.” Academic Medicine 88, no. 6 (June 2013): 811–18. https://doi.org/10.1097/ACM.0b013e318290f9c7.) Interview Questions Used for the Windsor Regional Medical Campus Study (Cooper, Gerry, Maher El-Masri, Mars Kyle De, Nathan Tam, Nicole Sbrocca, Mark Awuku, and Lawrence Jacobs. “Impact of an Urban Regional Medical Campus: Perceptions of Community Stakeholders.” Canadian Medical Education Journal 12, no. 1 (February 2021): e46–59. https://doi.org/10.36834/cmej.69951.)
Interview Questions Used for the NOSM Study
(Centre for Rural and Northern Health Research. “Exploring the Socio-Economic Impact of the Northern Ontario School of Medicine.” Lakehead and Laurentian Universities, November 2009. https://www.nosm.ca/wp- content/uploads/2018/06/FINAL_Report_NOSM_Socioeconomic_Impact_Study-2009-11.pdf.)
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