Emergency medicine in Canada: a call to arms

Editorials / Commentaries

CJEM 2010;12(1):8-10

All editorial matter represents the views of the authors and not necessarily those of CJEM or the Canadian Association of Emergency Physicians.

VERSION FRANÇAISE À LA PAGE 11

As CJEM senior editors, we have noticed disturbing trends over the past 2 years among the volunteers on whom the journal so desperately relies. Peer reviewers have been declining requests to review manuscripts at an alarming rate, sometimes requiring our editorial staff to contact more than 10 people to secure the requisite 2-3 reviews. Decision editors have been similarly less available, and slower to complete their tasks. Finding associate editors for new initiatives, or to fill increasing vacancies, has been difficult and sometimes impossible. Moreover, response to calls for submissions to new sections, such as the new back page feature Radical Departure, has been luke warm. Now that CJEM is an indexed and internationally established journal for emergency medicine (EM), have all those volunteers lost their sense of urgency or desire? Or do the problems arise from broader and more fundamental issues affecting not just academic EM, but Canadian EM in general?

To understand our current situation requires reflection on our evolution. In contrast to EM in the United States, EM in Canada was established with clinical care and medical education as its founding pillars. The Canadian Association of Emergency Physicians (CAEP) launched its first "road show" in the 1980s, and continues to dedicate considerable energy and resources to continuing professional development (CPD) of this nature. Canadian EM research rapidly developed as a third pillar, facilitated by initiatives such as the research track at the annual CAEP scientific meeting, the establishment of CJEM and an annual funding award program. Canadian EM now boasts internationally recognized individuals in all of these domains.

Clearly, CPD should remain a component of what CAEP provides its members. On the other hand, now that nearly all emergency physicians (EPs) entering practice are residency trained and certified through one of our 2 certification routes, there are strong arguments for why CPD should no longer be such a central focus for CAEP. What should instead become an increased focus for CAEP, and Canadian EPs in general, is the fourth pillar: the political and administrative arena. Our collective lack of development in this area remains a considerable impediment to the advancement of Canadian EM. Although the American College of Emergency Physicians initially lagged behind Canada in research, from the start it has maintained a primary strength in this fourth pillar. This is likely a central reason why EM is flourishing in the United States. Unlike the United States, where several national EM organizations exist to advance and develop different aspects of EM, Canada has only one. This is unlikely to change in the near future. As a result, CAEP faces the challenge of needing clear mandates for all of these areas, and active involvement by physicians in all of these areas. Unfortunately, a minority of physicians who work in Canadian emergency departments (EDs) belong to CAEP, and fewer still have pillar 4 expertise.

Although notable exceptions exist, many academic EPs in Canada shy away from political and administrative activities related to the advancement of EM. In the last 2 decades only a few CAEP presidents have come from university teaching hospitals. Academically active board members have been similarly scarce, despite efforts by CAEP to change this. Given that most major Canadian hospitals are also teaching centres, it is evident that leadership in political and administrative EM activities is essential at such locations. Even among urban groups of full time EPs, CAEP membership rates are far from ideal, however. What organization other than CAEP do we think will represent us? Without a strong and active membership base, and the voice and financial resources that come with it, CAEP will continue to struggle to have the political will and strength to advance our various agenda items. As we have experienced before, the result is we will be dictated to by other, more organized, groups. Although CAEP prides itself on being a national specialty society, it would appear that academic EPs have grown to believe CAEP is irrelevant or will survive without them. Could it be that this journal is also falling victim to misplaced apathy?

It is difficult to consider the challenges in academic EM in Canada without also considering our clinical situation. At the inception of our discipline it was believed that no one could practise EM for an entire career without "burning out." Research and experience has shown this to be false. Recently, however, suggestions that many Canadian EPs are planning their exit strategy have again been heard. Working conditions over the past decade have deteriorated considerably as a result of crowding, wait times and understaffing. Moreover, the scope of what EDs should do remains in flux, creating a disconnect between what we train residents for and what they actually see when they enter practice. Emergency medicine was envisioned to be the safety net for the acutely ill or injured; however, we are increasingly forced to be the safety net for the entire health care system. Just who is defining EM? It seems everybody except us.

Our clinical issues have been well documented and studied; however, they have not yet been meaningfully corrected and continue to deteriorate. This highlights our lack of political progress, particularly our failure to implement meaningful standards against which emergency care can be measured. It is arguably correct to say that CAEP has failed in this regard. But who makes up CAEP and who is responsible for correcting this? Per haps more importantly, who does not make up CAEP? Turning the mirror around, it also merits considering whether CAEP is as clear as it should be on what its mandate is and who it represents. It is striking that nothing in CAEP's current vision or mission statement (available at www.caep.ca) speaks to academic EM, certification in EM, or EM as a specialty.

The structure of our 2 independent training programs may be an additional impediment to the development of political and administrative strength in Canadian EM. In theory, the College of Family Physicians of Canada's CCFP(EM) program exists to produce clinical physicians, and the Royal College of Physicians and Surgeons of Canada (RCPSC) program was designed to produce consultants and leaders in EM. The 1 year EM component of the CCFP(EM) program allows virtually no time for gaining nonclinical expertise. Academic faculty members understandably encourage RCPSC residents to develop a niche or skills outside the clinical domain. Unfortunately, almost no residents use this to increase their understanding of the health care system, or how to successfully work within in it to improve EM. Training in research, education and technical skills is oversubscribed; training in business, change management and operations is rare. It may be that we have collectively subspecialized EM too soon, before establishing the required critical mass of specialist Canadian EPs. Moreover, the development of a niche can result in the option to practise a stand alone specialty, some times one with better working conditions and remuneration. It shouldn't surprise us, particularly when conditions in our EDs are untenable, that the result is with increasing frequency we find ourselves losing valuable new RCPSC graduates from EM altogether.

On the political level, many feel we have no ability to influence health care reform. Our specialty's successful efforts in areas such as gun control, access to diagnostic testing and helmet legislation disprove this myth. Despite this, some of our brightest minds deliberately avoid health care reform — Why? Excellent administrators are among us; however, perhaps few feel suited to this domain. Certainly few have received formal training to ensure their success and career longevity. Residents see an absence of role models in this area, so it's not surprising they rarely enter this realm. If we do not step into the political arena and assert our place, who will speak for us and our patients? Who will initiate the steps required to advance EM into the discipline that it should be?

With a lack of political leaders combined with poor working conditions, it's no wonder there is disaffection on the academic front. Moreover, there is no consistent model for nonclinical funding. Many academic groups still do not have departmental status, and hence have less political influence at the university level. Currently we have no endowed chairs in EM, 1 Canada research chair, a handful of career researchers and few supported departmental chairs. Many groups, including those in teaching hospitals, are struggling. Successful change for such groups can only come from a critical mass of academic EPs with secure funding and leaders who are experts in health administration. We need people with vision and the ability to make their vision a reality, working not just within their own group but also at the national level.

CAEP needs a clearer mandate, one that includes academic EM, if it is to be the rudder we believe our collective ship lacks. But that requires a much larger commitment by academic EPs to CAEP. It's a Catch 22. It takes people with a heartfelt conviction in EM to shepherd us through these difficult times. This is not a time for retreat. It requires that people stay in EM and com mit themselves to make the required changes, not leave because it isn't as much fun anymore. Such people and their successes will energize others. We will all see that we can make a difference and that our efforts matter. Now that we have matured and gained experience as a profession, this is not the time to walk away. It is the time to use that experience to help make innovative changes that improve our working conditions, academic programs and patient care.

Hence this call to arms. We see increasing apathy, less involvement, and many physicians diversifying and focusing on things other than making EM better in Canada. It is time for all of us to recognize that the political and administrative pillar of Canadian EM needs strengthening. Why don't we all take some time to consider how we can help? The success of our 2 Canadian EM institutions, CAEP and CJEM, is critically important to all of us regardless of our location or the nature of our work. To be true advocates for EM and our patients we need to become more involved. Who knows? Maybe then we won't have to worry about the enthusiasm and turnaround times of CJEM reviewers and editors ...