Emergency medicine training in Canada

Education

CJEM 1999;1(1):51-53

Abstract

Résumé

Introduction

Canada is the only country with two colleges governing certification in emergency medicine (EM). Does this serve the specialty of emergency medicine appropriately or does it divide the specialty and its resources?

To address this question we reviewed the emergency medicine accreditation guidelines of the College of Family Physicians of Canada (CFPC)¹ and the Royal College of Physicians and Surgeons of Canada (RCPSC).² In addition, we interviewed key representatives from both colleges, compared Canadian accreditation guidelines to those of the American Board of Emergency Medicine and reviewed the literature on EM accreditation, certification and training.

The two colleges

It is admirable that, in 1982, the CFPC introduced a certification of Special Competence in Emergency Medicine - the CCFP(EM). The CFPC's Accreditation and Certification Guidebook¹ expressed the desire to optimize Canadian emergency care delivery and noted that much emergency care was [and still is] provided by family physicians, especially in nonurban environments.

In its accreditation guidelines, the CFPC recommends that during the extra year of training: 1) family physicians provide a significant portion of the clinical care and take direct responsibility for residents' education and teaching; 2) experience in a rural setting be available; and 3) residents be trained to assume leadership roles in improving services and monitoring the quality of community-based emergency medical care.

The stated goals of the CCFP(EM) program are: to improve the standards and availability of emergency care from practising family physicians; to establish guidelines for the development and administration of emergency medicine training programs; and to ensure the availability of preceptors in emergency medicine.

According to 1997-98 CFPC figures, there are 734 physicians registered as CCFP(EM), of whom 486 were practice eligible and 445 residency trained. The Canadian Medical Protective Association (CMPA) states that between 1500 to 2000 Canadian physicians are registered as full-time emergency physicians. The RCPSC states that, between 1987 and 1996, 138 physicians graduated from Royal College emergency medicine residency programs. Of 374 graduates of the Royal College certification process, 360 are fellows and 307 are practising in Canada.

The CFPC should review their special competency guidelines and consider the product that they are creating and certifying. If the result is physicians who practise only EM with little or no rural experience and few family physician preceptors, then the stipulated objectives are not being met. Reform in the certification of Special Competence in Emergency Medicine may be necessary. It would appear that Canadian emergency medicine practice is becoming a specialty that is in need of re-evaluation of its residency programs and certification processes.

Canada is the only country with two colleges governing certification in emergency medicine.

At present, the specialty of family medicine "hyphenates" itself with other specialties such as emergency medicine, anesthesia and surgical obstetrics, thereby creating a parallel to RCPSC programs. The ongoing discussions regarding EM training reflect directly on the overall goals of the CFPC. Will there be continuing expansion of the current CFPC accreditation process or will this stop with the realization that family medicine is a specialty with a need for more than two years of training? Special Competence training could be coordinated and certified with the RCPSC disciplines. This would diminish bureaucracy and administrative expense. More importantly, it would give family medicine the respect that it is due as a specialty.

A decision on this matter would also help resolve the issue of dual EM training pathways. If the CCFP(EM) process is creating, in the vast majority of cases, full-time emergency physicians, then noble intentions need to be revisited. On the other hand, the RCPSC must also evaluate its residency training program to see whether it is meeting the requirements of the American Graduate Medical Education Directory for Emergency Medicine.³

US EM programs have existed since 1972. Currently, there are 119 US emergency medicine residency programs, with 3239 residents in training.^4,5 In contrast, RCPSC emergency medicine training programs have a total of 87 residents, with 5 in their 5th post-graduate year and 24 in their 4th post-graduate year. This year, the CFPC expects 61 residents and 70 practice-eligible candidates to sit their CCFP(EM) exam.

Each US program requires a minimum of 6 residents per year of train-ing in order to: 1) achieve a major impact in the emergency department; 2) assure a meaningful conference schedule; 3) provide progressive responsibility and; 4) foster a sense of residency program and department identity. US residency programs are 3 years, and any program that extends beyond this must present a clear educational rationale. Why should the RCPSC training program differ? And further, do any of the current Canadian programs truly achieve the 4 US objectives listed here? With respect to faculty, a minimum of 6 physicians should be devoted to providing leadership and resident supervision. Amalgamating the teaching faculties from the current two tracks in Canada may help meet this requirement.

Training and certification

Some authors recommend re-evaluating the length of EM training in Canada,^6-8 and some suggest moving to a shorter program with the option of postresidency fellowship years in areas of special interest, such as trauma, research, disaster medicine, toxicology or administration. Shortening the length of training would allow more residency positions to be created, thus advancing the goal of providing optimum delivery of emergency care to the Canadian public. Creating a separate college for emergency medicine is an option, but the question remains whether it is cost efficient to create another bureaucracy. The RCPSC is the certifying body for specialists in Canada and should be maintained as the certifying body for EM, but change is necessary.

The certification process should be open to practice-eligible candidates. In Canada, EM can still be practised by a physician with a general licence, and, based on the figures discussed above, there may be up to 1000 physicians who are not certified by either college delivering full-time emergency care. In spite of this, neither the provincial colleges nor many of the hospital credentialling committees, although entrusted to promote quality care for the public, have set definite or specific standards for EM providers.

Organizations such as the RCPSC, the CFPC, the Canadian Association of Emergency Physicians (CAEP) and the provincial colleges should meet to discuss the certification process. This would be a way of establishing minimum knowledge standards and ongoing CME requirements. Physicians could have portability of certification across Canada, and the public could expect to receive care from qualified emergency physicians who have achieved a specified level of competence.

The current debate regarding the future of EM residency training is very important if we are to assure the delivery of certified, appropriately trained physicians to Canadian emergency departments. We must acknowledge the fact that most physicians who provide emergency care in this country belong to neither college. Whatever process we develop, it must include these noncertified physicians and must encourage them to participate in the decision-making process. In the interest of quality care for Canadians, certified emergency physicians should be magnanimous; they should be willing to accept and certify practice-eligible physicians who are not "formally trained." Canadian citizens have a right to certified emergency care; until the number of graduating EM residents equals or surpasses the number of physicians leaving the field, this will not be the case. This raises the issue of manpower needs and begs the question: Should further EM residency positions be made available?

Models could be developed to predict the number of residents necessary to maintain a steady-state work force. The eventual standard for entry into an emergency medicine position should be residency training and EM certification. If we plan appropriately and maintain high-quality patient care as our goal, emergency medicine can rise above the current political debate and agree upon common guiding principles.

Conclusion

Emergency medicine is a specialty. One voice should represent Canadian EM at all levels. Currently, CAEP best represents this voice. There are over 1000 CAEP members, representing every province and territory. CAEP must maintain its focus on optimal patient care in the emergency departments of this country and on the emergency health care needs of the Canadian public. Our citizens deserve one standardized, certified, accredited EM training program that produces the highest quality emergency physicians. While the RCPSC and CFPC discuss reforms, we should not lose sight of this goal.

References

1. Residency program accreditation and certification. Mississauga (ON): College of Family Physicians of Canada; July 1997.
2. Objectives of training and specialty training requirements in emergency medicine. Ottawa: Royal College of Physicans and Surgeons of Canada; 1998.
3. Specialty requirements for residency training in emergency medicine. Graduate medical education directory for emergency medicine. American Board of Emergency Medicine; 1998.
4. Moorhead JC. A study of the workforce in emergency medicine. Ann Emerg Med 1998;31:595-607.
5. Hoffman GL. Report of the Task Force in Residency Training Information, American Board of Emergency Medicine. Ann Emerg Med 1998;31:608-25.
6. Murray M. Challenges for 1998. CAEP/ACMU Communiqué 1997-98;Winter:14-5.
7. Ducharme J, Innes G. The FRCPC vs. the CCFP(EM). Is there a difference 10 years after residency? CAEP/ACMU Communiqué 1997;Fall:1-4.
8. Grunfeld AF. The Task Force on Emergency Medicine Training. CAEP/ACMU Communiqué 1998;Summer:1-2.