Emergency medicine certification in Canada

Letters

CJEM 2008;10(4):321-322

To the editor: I read with great interest the editorials in the March 2008 issue. I am a graduating FRCPC emergency medicine resident from the University of Calgary with additional training in medical education. I am emboldened by the courageous positions described by Drs. Abu-Laban1 and Rutledge.2 I agree with the authors that the divisive nature of the 2 streams has led to acrimonious feelings on both sides. Ultimately, the rift undermines the professionalism of our specialty. A sole training program mirrored after the specialty programs in internal medicine and pediatrics is an attractive alternative. Following 3 years of general emergency medicine (EM) training, residents would elect to pursue general certification (1 additional year) or specialization (2 or more additional years). EM has many unique niches within the field of medicine, and formal subspecialty fellowships in toxicology, critical care and emergency medicine services (among others) could be developed. These training programs would provide the critical mass of learners in the academic centres that cultivate an environment ripe for the promotion of the specialty and EM specific research.

Dr. James Ducharme at one time argued that EM in Canada is best served by 3 training programs, noting that the FRCPC, CCFP(EM) and the family practitioners (FPs) who practise EM serve a complementary role to one another.3 While I would concede that the preponderance of emergency department (ED) care is delivered by FPs not formally certified in EM, I would argue that the specialty of EM suffers from an identity crisis in part because of these multiple care providers. Physicians who provide care in an ED should not, by default, be referred to as EM specialists. As we move forward, the designation of EM Specialist should be reserved for physicians who have undergone a rigorous training program and demonstrated success on a standardized exam. The designation process should be inclusive, and not discriminate against current emergency physicians (EPs) based on prior training. Practising EPs should be offered the opportunity to grandfather the residency and receive the designation on the basis of clinical experience. The vast majority of CCFP(EM) graduates practise primarily EM and no longer operate as FPs.3,4 Unlike other FP subspecialties such as low-risk obstetrics and GP-anesthesia whose providers remain FPs first and obstetricians or anesthetists second, most CCFP(EM) physicians are emergency physicians first. While none would debate their clinical competence, the specialist designation is confusing and may be misleading. A unified training program would eliminate this confusion.

Calling oneself a specialist in a given field connotes many things, including taking part in a common training program, membership in a professional society and a standardized examination for those who hold the designation. Ultimately, the role of a specialist involves more than providing quality patient care.4,5 Health policy advocacy, medical education and research are important aspects of a recognized specialty. The Royal College of Physicians and Surgeons of Canada has long been the national governing body that certifies physicians as specialists.5 We should aspire to develop a 4-year program that falls under their jurisdiction and meets the needs of all learners.

We are not debating the clinical competence of graduates from any particular stream but are discussing the requirements necessary to be designated an EM specialist. Rather than knee-jerk defensive posturing and protectionist policies, graduates from and administrators for each training program should reflect on what is best for the specialty. We need to band together, focus on the similarities rather than the differences and use the political clout of a unified certification program to advocate for more funding in residency training. With the high career attrition rates prevalent in EM,4 our goals should be to unify our training programs and ensure that there are enough trained EM specialists to provide appropriate care for our increasingly complex patients.

Trevor S. Langhan, MD
FRCPC Emergency Medicine Resident
University of Calgary
Masters of Medical Education Candidate
Calgary, Alta.

References

1. Abu-Laban RB. Emergency medicine certification in Canada: the years march on but the questions remain the same. CJEM 2008;10:101-3.
2. Rutledge T. Emergency medicine training in Canada: learning from the past to prepare for the future. CJEM 2008;10: 108-10.
3. Ducharme J. Preparing emergency physicians for the future. CMAJ 2003; 168:1548-9.
4. Drummond A. How to train emergency docs. CMAJ 2003;169:389-91.
5. The Royal College of Physicians and Surgeons of Canada. Information by specialty or subspecialty. Available: http://rcpsc.medical.org/information/index (accessed 2008 May 26).