Emergency medicine training in Canada: a different perspective

Letters

CJEM 1999;1(2):91

To the editor:

In the last issue of CJEM, Moore and Lucky argued for a unified emergency medicine (EM) training pathway.¹ But the matter may be more complex than it seems. Concerns revolve around manpower problems, postgraduate training issues and national certification, and we must consider both sides of the argument.

EM, like Pediatrics, is not practised exclusively by FRCP(C) specialists. Based on geographic, medical, fiscal and political realities, family physicians and CCFP(EM) certificants will continue to provide much of Canada's emergency care. Interestingly, ED directors² do not identify either training path as the sole desirable one.

A 1996 manpower study suggests that by 2001 Canada will face a shortage of 562 trained emergency physicians.² Demand for individuals with any type of EM training will be high, and the majority of graduates (from both programs) will be recruited into full-time urban EM practice. Contrary to opinions held by some, this does not reflect a failure of either College in terms of educational philosophy or certification process. It is simply a reflection of marketplace reality.

One solution is to expand Royal College training programs and make smaller increases in CCFP(EM) programs. This would address urban needs but would not provide solutions for small towns or rural areas. The ongoing review of rural family physician training, however, is a step in the right direction that will help clarify and remedy rural problems. In addition, the urban (family physician) curriculum requires re-examination: it is important for all primary care physicians to attain a level of emergency care competence. I agree with Drs. Moore and Lucky that, in comparison with other English-speaking countries, our two-year family medicine training program is too short, but this should not prevent others from respecting family physicians. It is a matter of professional courtesy and simple decency.

Moore and Lucky suggest that, in terms of educational objectives and accreditation processes, both colleges have failed to meet objectives. But the evidence these authors provide is less than convincing. Their conclusion that the Canadian College of Family Physicians (CFPC) needs to review its objectives and certification process was based on two clauses taken (out of context) from the Residency Program Accreditation and Certification book.³ A careful reading of the reference does not support the conclusion made.

The educational model they suggest for Royal College programs is similar to the US model, both in scope and length, but this is not a realistic solution for Canada, where workloads differ, where system resources are limited, and where the supervision provided by attending physicians is unlike that in the US. Nor is it feasible to blend the two Canadian educational tracks; the funding formula for postgraduate medical education precludes this. There is an obvious need for monitoring of educational parameters such as training objectives, training duration and educational outcomes, and these expectations are included in the mandate of both colleges. The implementation of the joint accreditation survey of emergency programs is a step in the right direction. The Canadian Association of Emergency Physicians (CAEP), the national body representing all practising emergency physicians, has a limited role in this educational process. Another proposed solution is the establishment of a separate college for emergency medicine. However, this is impractical, and there is neither the need nor the political will.

Most would agree that practising emergency physicians, including those without residency training, should be eligible for national certification. Since 1995, the CCFP has implemented a formal process that addresses this problem. This avenue for national certification of family physicians will remain open for the foreseeable future, and the role of CAEP and the emergency physician community in this area is limited.

Clearly we all have a keen and sincere interest in the advancement of emergency medicine in Canada. Some of us perceive the manpower, educational and national accreditation issues differently. The coin does have two sides.

Ivan Steiner, MD
University of Alberta
Edmonton, Alta.
ivan.steiner@ualberta.ca

References

1. Moore K, Lucky C-A. Emergency medicine training in Canada. CJEM 1999;1(1):51-3.
2. Beveridge R, Lloyd S. Manpower survey (III): emergency physician supply and demand. CAEP Communiqué 1996; Fall:7-9.
3. The College of Family Physicians of Canada: Residency Program Accreditation and Ceritification. 1997;July:25-7.