A survey of one CCFP-EM program's graduates: their background, intended type of practice and actual practice

Education

CJEM 2005;7(5):315-320

Abstract

Résumé

Introduction

In 1982, the College of Family Physicians of Canada launched the certification of Special Competence in Emergency Medicine - the CCFP-EM program. One of the primary objectives of this program is to enhance the emergency medicine skills of practising family physicians (FPs).¹ Twenty years later, Chan reviewed billing records from 345 FPs with emergency medicine certification and found that 56% were practising "almost all" or "mostly" emergency medicine.² There are no other published studies looking at the practice patterns of CCFP-EM graduates.

Our primary objective was to survey all graduates of the University of Western Ontario's (UWO) CCFP-EM residency program with respect to anticipated versus actual medical practice. We hypothesized that the majority of the graduates have been practising emergency medicine exclusively rather than combining it with family practice, and that they intended to do so from the start of their residency. A secondary objective was to determine if specific demographic factors influenced practice choices in this group.

Methods

Survey design

We developed a survey using a modified Dillman method³ consisting of 9 multiple choice questions and 9 "fill in the blank" responses. An outline of the survey is displayed in Fig. 1. The survey was designed to collect information about the graduates' practice positions for all of the positions that they had held over time since graduating, up to a maximum of 8 positions. The full questionnaire is available from the corresponding author (L.G.S.).

Survey distribution

The survey was distributed to all 83 physicians who completed a CCFP-EM residency year at UWO from 1982-2004 inclusive. Addresses were obtained from the Canadian Medical Directory and the College of Physicians and Surgeons of Ontario Web site. Each physician received an introductory letter and self-addressed stamped envelope. Each survey was assigned an identification number for tracking purposes only, and confidentiality of responses was assured. Reminder cards were mailed 2 weeks after the first mailing to non-responders. A second survey was sent 2 weeks after the reminder card to the final group of non-responders.

Data analysis

Data were entered into Microsoft Excel 2002. Cross tabulation tables for all combinations of 2 characteristics/factors from the data set were calculated. Chi-squared tests of independence were applied as the primary analysis tool.

Results

We received 72 survey responses for a response rate of 87.0%. Of the 72 respondents, 51 were male and 21 were female. Demographic data are summarized in Table 1. Additional training following the CCFP-EM year was undertaken by 9 of the respondents. One physician completed a pediatric fellowship, 5 completed additional sports medicine training and 3 completed a CCFP(Anaesthesia) special competence year. (One graduate completed both sports medicine and anesthesia training.)

At the start of their CCFP-EM residency training, 50% of respondents indicated that they had intended to practise exclusively emergency medicine and 47% intended to undertake a blended practice of family medicine and emergency medicine. The remaining 3% were unable to decide or could not recall their intention. None of the respondents intended to enter solely family practice following completion of the program. There were no significant relationships found between intended practice type and any demographic data examined, including gender, size of childhood community, or medical school attended.

Fig. 2: Percent of respondents by practice type in the first 4 employment positions.

For each employment position, the majority of respondents were practising emergency medicine only, ranging from 72% in position 1 to 53% in position 4, while the number of respondents with a blended family medicine/emergency medicine practice never exceeded 20% (Fig. 2). The majority of respondents in all positions chose to practise in regional centres, which for the purposes of this investigation was defined as having a population between 10 000 and 200 000 (Fig. 3). There were no significant relationships demonstrated between actual practice type and demographic variables studied.

Fig. 3: The number of respondents practising in urban, regional and rural locations for each employment position number

The factors influencing the graduates' choices of employment positions are listed in Box 1. The relative importance of the factors for each position was determined by a ranking based on the number of individuals who indicated a particular factor was "influential" or "very influential" and is summarized in Table 2.

Discussion

This is the first published census of one CCFP-EM residency program describing the intended practice types and actual practice patterns of its graduates. The response rate of 87% was excellent and allowed valid interpretation of responses from the survey.

As predicted, the majority of graduates are working exclusively in emergency medicine. We suspect the production of emergency physicians via UWO's CCFP-EM program can be generalized to many if not all other programs in Canada -- a situation that generates more questions than answers. These questions differ dramatically depending upon which side of the lens you are located. When viewed through the eyes of an FP, these CCFP-EM physicians are certainly much needed to ease the manpower crisis in emergency medicine and yet their defection only serves to increase the arguably even greater deficit in family medicine. Are these physicians occupying valuable CCFP residency positions for 2 years with little intent of ever becoming practising FPs?

Through the eyes of an emergency physician, the CCFP-EM graduates are desperately needed throughout the country and they are unapologetically encouraged to practise full-time emergency medicine. Ducharme states that most clinical positions in major centres can and should be filled by CCFP-EM physicians, with the Royal College of Physicians and Surgeons of Canada trained physicians absorbing more of the non-clinical roles.⁴ In 2000, the number of Royal College residency positions was 5 times lower (per capita) than the number of US emergency medicine positions, and this situation has changed little in the past 4 years.⁵ Steiner and colleagues suggest that this situation has caused the CCFP-EM program, by default, to become a major training route for full-time urban emergency physicians -- a situation that is unlikely to change in the foreseeable future.⁵

From either perspective, the need for further study -- both prospectively and nationally -- is warranted. Examination of where all emergency medicine graduates practise and why they make their choices is integral for future planning and development of the specialty.

Less than one-half of physicians entering this CCFP-EM program intended to engage in a blended emergency and family practice. A literature search revealed one other study examining the difference between Canadian family medicine residents' intended and actual practice type. The Ontario Family Medicine Residents Cohort Study⁶ looked at all residents starting family medicine residency programs in Ontario over a 2-year period and the factors affecting their decisions to practise obstetrics. At entry into the residency programs 52% of the respondents expressed an intention to practise obstetrics, but only 16% were actually delivering babies 2 years later. Clearly, significant shifts occur during residency that shape the decisions about type of practice, and this warrants further study. We asked the graduates to recall their intended type of practice when they were starting their CCFP-EM year. However, a prospective look at what their intended type of practice was at the start of their family practice residency might yield some interesting results, particularly about changes occurring throughout the residency training.

How are, and how should, the candidates for the CCFP-EM program be selected? Should they be the strongest applicants or those most likely to engage in a blended family/emergency medicine practice? What caused the drop from 47% of graduates who, at the start of their CCFP-EM year, intended to maintain a blended practice, to less than 20% in actual practice? Can this be explained by a lack of role modelling in the CCFP-EM year? In our program at UWO, teachers almost exclusively practise emergency medicine. Arguing against this is the finding of Godwin and colleagues, who noted that delivering babies with FPs was not related to family medicine residents' intention of whether or not to practise intrapartum obstetrics.⁶

Nearly three-quarters of the graduates from UWO's CCFP-EM program since 1982 were men (71%). Interestingly, the number of women attending medical school in Canada is now approximately equal to the number of men,⁷ and thus one might expect that the numbers of men and women graduating from UWO's CCFP-EM program would have begun to approach a 1:1 ratio. However, looking at the most recent 5 years of graduates, an identical 71% (22/31) of the respondents were male.

Woloschuk and Tarrant found that family medicine resident graduates who had a rural background were 2.5 times more likely to be involved with rural practice compared with their urban-raised peers.⁸ We did not find a significant relationship between the size of our graduates' childhood communities and the size of the cities in which they practised. However, due to the small size of our study population, a larger study may reveal a significant relationship.

Study limitations

A significant limitation to our study was the small data set. Despite our excellent response rate we were only dealing with 72 responses, which was often insufficient for robust statistical conclusions. We were retrospectively asking for recall of respondent's intent, which is clearly subject to recall bias. As in any survey, the question of self-selection bias is raised. The 11 non-responders were not different from the responders in the demographic characteristics that we could measure. Nine of 11 were male. They completed the CCFP-EM program in the years between 1982 and 2003, with no clustering in either the early or later years. However, we cannot know for sure if their intended and actual practice patterns were different. Many responders held concurrent positions and were forced by the survey design to separate these into position numbers. This may have influenced our practice pattern results to some extent. Finally, a technical glitch prevented us from examining "partner influence" as a factor of influence in choosing a position. This was inadvertently left off the final copy of the survey. In other studies,⁹ partner or spousal influence has been shown to influence location of practice.

Conclusions

The majority of graduates of the UWO CCFP-EM program have worked in emergency medicine only positions since graduation, and most intended to do so from the start of their special competency year of their training. No demographic factors surveyed had significant correlation with intended or actual practice. Most positions of employment were in regional and urban centres. Understanding the practice patterns of the graduates of the various emergency medicine programs is an important consideration in creating solutions to the current manpower crisis in both emergency and family medicine.

References

1. College of Family Physicians of Canada. Standards for accreditation of residency training programs. Toronto: The College; 2003. Available: www.cfpc.ca/education/education.asp (accessed 2005 July 26).
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