Is this really the right time for an identity crisis?

Letters

CJEM 2008;10(4):320-321

To the editor: I was struck by the contrast of my recent attendance at the International Federation for Emergency Medicine (IFEM) meeting and the arrival of the latest issue of CJEM in the mail.

At IFEM, I listened with great interest to the immense struggles of many Western nations to establish the specialty of emergency medicine in their respective countries. As a Canadian, I felt a strange sense of pride in reflecting on our own experience. The traditional Canadian values of inclusiveness and acceptance of diversity have been reflected in the way we approach the training and credentialing of emergency physicians and the manner in which we staff our departments. Yes, we are an international anomaly, with our 2 routes to certification and our generous acceptance of family physicians working collaboratively with specialists in the same department, but for the most part it works. We work collaboratively, we deliver excellent care and our citizens in a wide variety of ED settings are well served. Sitting in the audience at IFEM, I felt we could be a model for the rest of the world. Then I returned home and opened my copy of CJEM and my prideful vision of the Canadian approach to emergency service delivery was directly assailed.

In CJEM, there were 2 editorials1,2 calling for a common training program and a common certification process, and the justification for change represented, in my view, a repudiation of what many would consider to have been a successful experiment.

I have no real problem with the concept of a unified training program. I have been a quiet supporter in 2 of the 3 previous debates. The idea largely makes sense, with a family medicine component strengthening the elements of communication, comprehensiveness and continuity of care required for effective practice in this increasingly complex health care environment, and the specialty component providing a strong academic and research basis for the growth of the specialty.

The concept of a single unified training program was not so much the issue; it was the justification for same, the exquisitely poor timing for the proposal and the potential diversion it represented to more pressing issues of the day.

Both authors advocate the need for a unified specialty and a unified voice if the specialty of emergency medicine is to develop to its full potential, inferring we are being held back by our current approach.

The experience at IFEM suggested to me that Canadians have developed a mature specialty, with both academic and research excellence, and a typically pragmatic Canadian way of covering the emergency health care needs of our geographically diverse population. We should take a back seat to no one internationally.

Having been involved with the politics of emergency health care for at least 2 decades, in regional, provincial and national spheres, I simply do not recognize or accept the "divided voice" and the "discipline divided" suggested by the 2 editorialists. We who love and practise emergency medicine, whatever our training and whatever our practice milieu, are not divided. We have a common purpose and goal in pursuing exciting and fulfilling careers, achieving excellence in patient care and participating in the well-being of our individual communities and our nation.

Furthermore, with respect to patient-centred emergency health care, emergency physicians do speak with one voice and that voice belongs to CAEP, not the College of Family Physicians and not the Royal College. There are no 2 separate and divisive masters; there are no 2 solitudes.

The call for a debate about program unification also represents exquisitely poor timing, politically speaking.

It is extremely worrisome that at the exact moment that all provincial governments are attempting to introduce/ force nurse practitioners, physician assistants and paramedics to replace emergency physicians as low-acuity providers, we should now declare an identity crisis of our own. We are not sure if a family physician working in a community ED with 20 000 patient visits should call him or herself an emergency physician? An incredible and sad suggestion to be sure, given that about one-half of the emergency care in Canada is delivered by family physicians, but equally, it is politically naive and ill-timed. If we declare, as suggested, that we are no longer sure who has the right credentials to work in an emergency department, you can be sure that government will help us all find the answer, with all manner of alternative health care providers thrust on our department while we struggle with this artificial and fabricated identity crisis.

Lastly, if the issue behind the call for a unified training and certification program is providing and guaranteeing a unified standard of excellence in emergency health care for all Canadians, then why this particular focus at this particular point in time? It represents an unnecessary distraction when there are so many more pressing issues, and so few emergency physicians with enough stamina left to contribute extra time to their resolution. There is, after all, only so much energy available to tackle the myriad of issues that are affecting the availability and quality of emergency health care in Canada. Is this really the time to reignite a long dormant, and for the most part forgotten, family feud about turf?

And where is the patient in all of this?

If we want to have a direct and immediate impact on the availability of quality care offered to our citizens, here are a few suggestions that may be more meaningful. How about an increased and renewed emphasis on adequately preparing the family physician for emergency service? How about we rededicate ourselves to developing a system of care? How about aggressively seeking adequate compensation for those who staff the nation's EDs so that we avoid the ebb and flow of doctors in and out of the ED depending on the discrepancy between family and emergency medicine fee schedules? How about finally getting serious about emergency physician wellness and career sustainability, and in so doing prevent our best and brightest from leaving the specialty to work in travel clinics or on ocean liners? How about a uniform national insistence on providing us all with adequately supported EDs in which to better serve our patients?

Or perhaps we could just talk, yet again, about a unified training program.

Canadians deserve our full attention on the most pressing issues that affect our ability to deliver premium emergency care. While we should, perhaps in time, consider a modification of our approach to training and certification, this is not the right time or the right place in our history to consider adopting a US model. Let's celebrate our uniquely Canadian way.

Alan Drummond, MD, CCFP(EM)
Perth, Ont.

References

1. Rutledge T. Emergency medicine training in Canada: learning from the past to prepare for the future. CJEM 2008;10: 108-10.
2. Abu-Laban RB. Emergency medicine certification in canada: the years march on but the questions remain the same. CJEM 2008;10:101-3.