Emergency medicine training in Canada: learning from the past to prepare for the future

Editorials / Commentaries

CJEM 2008;10(2):108-110

Emergency medicine has been recognized as a specialty in Canada for a quarter of a century. But how distinct is our discipline, and how well prepared are we to meet the challenges facing us in the years to come? At this time, it seems appropriate to reflect on what we have learned during our first 25 years and consider some tough questions on how best to meet the future emergency medical needs of Canadians.

It is easy to understand why there is a lack of clarity regarding what defines an emergency physician (EP) in Canada. Our workforce is made up of practitioners from disparate backgrounds with a variety of credentials. There are 2 separate paths to certification in emergency medicine (EM) through different colleges. Furthermore, data from the 2004 National Physician Survey indicates that the majority of physicians who identify the emergency department (ED) as their main patient care setting have no EM certification at all.1 This is not surprising given that our residency programs still do not produce nearly enough graduates to meet the demand. Many EPs have learned on the job and have developed considerable expertise in this manner.

Our dual training system arose more as a result of politics than wise planning. In the late 1970s and early 1980s, both Canadian colleges were lobbied to establish EM training programs and both initially resisted. The Royal College of Physicians and Surgeons of Canada encountered reluctance within its ranks to accept EM as a specialty, and the College of Family Physicians of Canada had concerns that creating a specialty program could lead to fragmentation in family medicine (concerns that continue to this day). A conjoint committee was established to decide on the most appropriate home for the new discipline and the optimal format for its training program (oral communication, Dr. Paul Rainsberry, Associate Executive Director, Academic Family Medicine, College of Family Physicians of Canada, January 2008). After failing to achieve consensus on the issues in the context of misaligned political agendas, both colleges established EM programs with different ideologies and goals.2,3 Advocates at the College of Family Physicians viewed EM as acute primary care and a natural extension of the family medicine residency. The third-year CCFP(EM) program was designed for family medicine graduates to develop special competence in EM, and its first certification exam was held in 1982. With the goal of establishing EM as a discipline on par with other specialties, the Royal College developed a program designed to produce academic emergentologists. The first Royal College FRCP(EM) certification exam was held in 1983.

And so here we are, a quarter of a century later, a discipline divided, with 2 training streams that have ostensibly different goals. What we have learned, however, is that the graduates of the 2 streams do not fit neatly into their intended career paths. The real-world experience has been that EPs from both streams go on to pursue a wide variety of career paths that overlap considerably. It has been suggested that this may be a failure of the 2 programs to attain their objectives.4 In my view, what it really reflects is that people's career paths evolve over time. It would be most unfortunate if our career options were unduly limited by a decision we made in medical school.

I believe it is time we confront a pivotal question: Is there sufficient rationale to continue to have 2 separate training streams for 1 discipline? A number of Canadian EPs have published opinions on this matter, some with considerable passion.2-11 This topic is fraught with sensitive issues that are potentially divisive. In 1998, the Canadian Association of Emergency Physicians (CAEP) struck a task force to consult with Canadian EPs and investigate the desirability of establishing a unified education program.12 The initiative was short-lived, as the task force quickly determined that consensus could not be achieved. I believe that the benefits of reviving this discussion outweigh the risks. A healthy debate on this topic could, and perhaps should, foster collaboration and ultimately strengthen our discipline.

Is there a problem with our current system? On the positive side, the quality of emergency care in this country is generally excellent. Canadian EM scholars have made enormous contributions to the world literature. In general, EPs from the 2 programs have worked well together and have encountered few limitations in their career paths. Scholarly, administrative and political leaders in our discipline have arisen from both training streams.

However, there are clearly downsides associated with being a divided discipline. There are EDs with exclusive recruitment policies. Residents from 1 stream have been precluded from valuable clinical experiences with faculty from the other stream. This is most unfortunate as there are outstanding EM teachers across the country from each stream. The coexistence of the 2 programs inevitably leads to competition for resources and lost opportunities for synergy. Moreover, having 2 streams is confusing for medical students who are considering a career in EM, making it difficult for them to choose the most appropriate program.8 Because both programs have specific goals beyond producing proficient clinical EPs, both are inherently inefficient. In fact, it could be argued that we do not have a program in Canada that specifically aims to produce clinical EPs!

An ongoing dialogue about the optimal structure and function of EM training is required. The practice of EM is growing in complexity. Faced with the looming demographic changes of our population and our workforce, we need an efficient way to produce a significant number of competent clinical EPs. Unfortunately neither existing stream is well positioned to do this. The CCFP(EM) may appear to be the most efficient program. However, the amount of family medicine content provided over the 3 years is considerably more than is required for those residents planning to work as full-time EPs. Policy-makers also have concerns with the collateral effects of this stream, as it tends to divert physicians trained in family medicine away from comprehensive practice. The FRCP(EM) program is long and produces academic EPs who tend to work in tertiary care centres, often with less than a full-time clinical shift load.

What Canada needs is a single EM residency program that efficiently and effectively produces competent EPs. I believe that this could be accomplished with a 3-year program. There should be a route into this program from family medicine and relevant training should be recognized, shortening the program length for family medicine graduates. After completion of the base EM program, an additional 1 to 2 years should be available for those interested in developing a subspecialty or academic focus. The flexibility of this program would support the development of a wide array of career paths while unifying EM training.

It is unclear whether either of our national colleges would be adaptable enough to develop and accredit such a program. This could be an opportunity for the colleges to collaborate on a conjointly accredited program. It may be that our discipline doesn't fit well with the mandate of either college, as we are both specialists and generalists. Thus the possibility of a Canadian College of Emergency Physicians, as suggested previously,2 has merit and could be considered.

Residency programs should be designed with 2 fundamental goals: 1) to meet the educational needs of the trainees; and 2) to produce graduates who will meet the needs of society. Ideally, these goals should be unfettered by the political agendas of colleges or university departments, the needs of educators or the service requirements of teaching hospitals. With these goals in mind, I have 2 other concerns with postgraduate EM training.

First, it is important that we produce EPs for all practice environments in the country and avoid the current trend of training physicians who are best prepared for practice in urban academic centres. Graduates need to be aware of the realities of diverse practice settings. All EM programs should provide core rotations in community and rural centres, where valuable insights and experiences would be gained.

Second, I believe that all EM programs should include family medicine rotations in their core curriculum. Consider how often we advise patients to follow up with their family doctor. Our graduates must have insight into the realities of family practice and what can reasonably be accomplished in a community office setting. This would also provide future EPs with a better understanding of the factors involved in family physicians' decisions to refer patients to the ED. Beyond the valuable system perspectives, there are many important lessons to learn from family medicine educators, particularly their emphasis on a humanistic, patient-focused approach to care. I would add that there is more overlap in the roles of family physicians and EPs than is generally appreciated. I certainly feel that my family medicine training has served me well.

Whatever form our postgraduate training programs take in the future, we need to reach a point where EM in Canada is viewed by all as 1 united discipline. Our education system should foster collaborative and supportive relationships among all physicians who will practise EM. I don't have the answers to all the difficult questions we must tackle, but there is 1 central tenet that seems obvious: emergency medicine is 1 discipline and it should have a unified training program. I believe it is time for a national forum on this matter that should be led by CAEP. As our professional association, CAEP must play a central role in shepherding the formulation of a shared vision of what emergency medicine is in Canada, and what it will be. Our degree of success in addressing these important matters will impact the future welfare of our discipline and, in turn, the broader health care system.

References

1. College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Institute for Health Information and Health Canada. 2004 National Physician Survey. Available: www.nationalphysiciansurvey.ca/nps/2004_Survey/2004nps-e.asp (accessed 2008 Jan 7).
2. Etherington J. An immodest proposal: the future of emergency medicine training in Canada. CAEP Communiqué 1997-98; Winter:16-9.
3. The FRCPC vs. the CCFP(EM) [Letters to the Editor]. See exchange of letters in: CAEP Communiqué 1998;Spring:7-9.
4. Ducharme J, Innes G. The FRCPC vs. the CCPP(EM): Is there a difference 10 years after residency? CAEP Communiqué 1997;Fall:1-4.
5. The FRCPC vs. the CCFP(EM) [Letters to the Editor]. See exchange of letters in: CAEP Communiqué 1997-98;Winter:7-13.
6. Murray M. Challenges for 1998 [President's Letter]. CAEP Communiqué 1997-98;Winter:14-15.
7. On unified training [Letters to the Editor]. See exchange of letters in: CAEP Communiqué 1998;Summer:7-11.
8. Gray S. Emergency residency training [Letter to the Editor]. CAEP Communiqué 1998;Fall:5.
9. Ducharme J. Preparing emergency physicians for the future. CMAJ 2003;168:1548-9.
10. Steiner IP. Emergency medicine practice and training in Canada. CMAJ 2003;168:1549-50.
11. How to train emerg docs. See exchange of letters in: CMAJ 2003;169:389-92.
12. Grunfeld AF. The Task Force on Emergency Medicine Training. CAEP Communiqué 1998;Summer:1-2.