A Canadian fellowship training program in emergency medical services

Education

CJEM 2005;7(6):406-410

Abstract

Résumé

Introduction

This paper describes development, current status, and future directions of the first Canadian emergency medical services (EMS) fellowship program. This program was established in 2001 at the University of Toronto, and may serve as a template for the development of similar programs elsewhere in Canada and internationally.

Background

The growth of medical knowledge was a major factor in the development of specialty and subspecialty training programs. In 1980, the Royal College of Physicians and Surgeons of Canada accorded specialty status to emergency medicine. Concurrently, the College of Family Physicians of Canada created a program of special competence in emergency medicine for family physicians. Since then, the scope of practice and knowledge base that defines emergency medicine has grown considerably.

Many subspecialities exist within emergency medicine. These include hyperbaric medicine, toxicology, critical care, pediatric emergency medicine, and EMS. Prior to 2001, no Canadian fellowship or post-graduate training programs existed for EMS.

Rationale for a Canadian EMS fellowship

EMS is increasingly recognized to be an integral part of the health care system. As the focus of health care has shifted to the outpatient setting, with a resulting promotion of community care and regionalized delivery of hospital services, the importance of EMS has increased. Paramedics function as physician extenders and EMS systems as an extension of emergency medical resources into the community. As the role of EMS in the health care system has become more defined and complex, the need for physician involvement in EMS administration, education and medical oversight has increased. Given the expanding role and scope of EMS, there is also an increasing need for structured education of emergency physicians interested in the subspeciality of EMS.

The Accreditation Council for Graduate Medical Education and the Society for Academic Emergency Medicine (SAEM) recognize and promote EMS fellowship training programs in the United States. However these programs do not address the unique aspects of the Canadian health care and EMS systems. A central objective of the Canadian EMS Fellowship Program we describe was to specifically address the characteristics of Canadian and other non-US EMS systems.

Program development and prerequisites

In 2001, the Divisions of Emergency Medicine at the University of Toronto established a 1-year Fellowship Program at Sunnybrook and Women’s College Health Sciences Centre and St. Michael’s Hospital in Toronto. The 4 tracks of this program are EMS, trauma, research and clinical. Fellows spend approximately 12–16 hours per week working clinically as a junior attending in the emergency departments of the sponsoring hospitals, and spend their remaining work week in activities related to their fellowship track.

The purpose of the EMS fellowship track is to prepare fellows for a leadership career in EMS, not only at the local level, but also regionally and nationally. The fellowship provides trainees the opportunity to participate in all aspects of EMS system medical direction. These include treatment of clinical problems in the prehospital environment, management of the EMS system as a public health resource, education of EMS personnel and the public, supervision of EMS personnel in care delivery and provision of medical leadership. To standardize expertise and educational experiences within the program, criteria were established for fellows, the fellowship director and the sponsoring institution (Fig. 1).

Program goals and objectives

A group of academic emergency specialists with expertise in land and air EMS systems was responsible for the researching and developing the Fellowship Program goals, objectives and defined skills. This group compiled and reviewed existing core content, curricula, and guidelines from other institutions with EMS fellowship programs. The didactic, clinical and administrative core content established for the University of Toronto Fellowship mirrors that developed by the American College of Emergency Physicians¹ and the SAEM,² with modifications to meet the unique needs of Canadian and international trainees (Fig. 2). Beyond this, curriculum refinement is made at an individual level to accommodate the career goals of each fellow.

Evaluation of fellows

Fellows meet quarterly with the program director to ensure they are meeting goals and objectives. As with other fellowship trainees at the University of Toronto, formal evaluation is carried out using Canadian Medical Education Directions for Specialists (CanMEDS) methodology.³ Each fellow is evaluated on clinical performance, teaching, and involvement in land and air EMS operations. Fellows are evaluated by medical faculty, paramedics, paramedic educators, EMS management staff and staff from collaborating agencies (e.g., fire, police, public health).

Funding and support

Stipends and benefits for EMS fellows are consistent with other fellowship trainees at the University of Toronto, and are supported by the University of Toronto and the emergency medicine academic practice groups of the participating hospitals. Fellows receive funding to attend the National Association of EMS Physicians’ Medical Directors’ course, and a conference of their choice. Fellows also receive administrative and infrastructure support (e.g., cell phone, pager, office space, computer resources) from the EMS agencies involved in the program. The Fellowship Director receives a stipend from the emergency medicine academic practice groups. The participating emergency departments provide administrative support for the fellow and the Fellowship Program.

Overcoming obstacles to developing an EMS fellowship

There are several obstacles that were overcome in the development of the University of Toronto EMS Fellowship. The first was establishing a critical mass of EMS expertise that crossed academic and service-provider boundaries. Academic EMS expertise exists in many emergency medicine residency locations, but the experts are not always involved in medical direction and oversight of the local EMS agency. In addition, medical directors of local EMS agencies are not always affiliated with academic teaching programs. The University of Toronto Program owes part of its success to a core group of physicians with expertise and protected time to carry out EMS operations, education and research. Bringing together all local and regional experts is the first step in developing the necessary critical mass.

Another obstacle the University of Toronto EMS Fellowship overcame was funding. Universities, base hospitals, governments and EMS agencies have limited or no discretionary funding for the stipends of post-residency trainees. Potential funding sources include academic practice groups, university competitions, granting agencies and partnerships with EMS agencies. Most universities have competitive funding for post-residency trainees. In addition, academic emergency medicine groups may have discretionary funding to support academic initiatives. These aforementioned 2 final sources were cornerstones to funding the University of Toronto Fellowship. Finding local, regional and national funding sources is an important subsequent step in developing a sustainable program.

The final obstacle overcome by the University of Toronto EMS Fellowship was global competition for suitable applicants. The global number of EMS fellowship positions has increased by over 100% during past 5 years. To be competitive a program requires an institution and EMS agency with suitable educational resources and a niche. The University of Toronto is able to attract strong candidates because of the combination of a critical mass of EMS expertise, a successful prehospital and transport medicine research program, and one of the largest air and land EMS systems in Canada. In addition, it is the only Canadian EMS Fellowship available. Promoting local strengths and unique resources is essential in developing a successful program.

Current status and future directions

The Fellowship attracts many Canadian and international applicants annually. In the 2005–2006 and 2006–2007 academic years applications were received from candidates in Australia, Ireland, Great Britain, Singapore, Saudi Arabia, the United States, the Philippines and Canada. The first EMS fellow commenced training in July 2003, and the first Canadian-trained fellow started in July 2005.

In 2003, the Fellowship was modified to accommodate resident trainees during a 12-month "subspecialty year" in the 4th year of the Royal College of Physicians and Surgeons of Canada emergency medicine (RCPS-EM) training program. This was in response to an identified need for comprehensive EMS subspecialty training within the RCPS-EM program. Subspecialty residents have a similar role to fellows, with the exclusion of some administrative and direct medical oversight responsibilities. Clinical responsibilities are commensurate with the resident’s training stage. The first resident completed a subspecialty year in June 2004, and there is ongoing interest in the subspecialty year among Canadian RCPS-EM residents.

The Fellowship has been productive both academically and professionally. The first EMS fellow and subspecialty resident played key roles in developing the EMS contingency plan for a large mass gathering, provided medical oversight for several quality management projects, and authored a number of peer-reviewed publications.^4–8 The latest graduate from the program tailored his curriculum to focus on EMS system design and administration, and was a working group member and author for the 2005 International Liaison Committee on Resuscitation task force on acute coronary syndromes and myocardial infarction. The current fellow is tailoring her curriculum to focus on paramedic education and research in simulation-based training.

EMS fellows interested in research have the opportunity to participate in a well-established prehospital and transport medicine research program. The program includes both land and air EMS systems, and is actively involved in multicentre prehospital clinical trials. Fellows also have the opportunity to participate in EMS education and education research involving high-fidelity simulation. The education program is affiliated with the Wilson Centre for Research in Education at the University of Toronto and provides the opportunity for research projects pertaining to paramedic certification and maintenance of competence, and the development of leading-edge curricula using human patient simulators.

The Fellowship now has a 2-year option available that incorporates the EMS education with a graduate degree in science, public health or health care administration at the University of Toronto. This program also has sufficient resources and infrastructure to accommodate 2 EMS fellows or additional subspecialty residents.

Currently the RCPSC does not recognize EMS as a subspecialty, however the potential for program recognition and accreditation exists within the SAEM. A future application for SAEM accreditation of the University of Toronto EMS Fellowship is planned. This accreditation would provide external benchmarks for the program and allow subsequent applications to US funding agencies for accredited EMS fellowships.

Conclusions

The EMS Fellowship Program at the University of Toronto is a highly sought after, successful and unique program designed to deliver necessary and relevant subspecialty education in EMS. This Canadian academic training program provides medical leadership in EMS, and may serve as a template for the development of similar programs elsewhere in Canada and internationally.

References

1. Krohmer JR, Swor RA, Benson N, Meador SA, Davidson SJ. Prototype core content for a fellowship in emergency medical services. Ann Emerg Med 1994;23:109-14.
2. Marx JA, on behalf of the SAEM Task Force and the SAEM Board of Directors. SAEM emergency medical services fellowship guidelines. Acad Emerg Med 1999;6:1069-70.
3. Frank JR, Jabbour M, Tugwell P. Skills for a new millennium: report of the societal needs working group, CanMEDS 2000 Project. Ann R Coll Physicians Surg Can 1996;29:206-16.
4. Lukins JL, Feldman MJ, Summers JA, Verbeek PR. A paramedic-staffed medical rehydration unit at a mass gathering. Prehosp Emerg Care 2004;8:411-6.
5. Feldman MJ, Lukins JL, Burgess RJ, MacDonald RD, Schwartz B. Half a million strong: the EMS response to a mass gathering. Prehospital Disaster Med 2004;19:287-96.
6. Feldman MJ, Lukins JL, Verbeek PR, Summers J. Paramedic role and patient outcomes at a medical rehydration unit during a mass gathering [abstract]. Prehosp Emerg Care 2004;8:104.
7. Feldman MJ, Lukins JL, Verbeek PR, Burgess RJ, Schwartz B. Use of treat-and-release medical directives for paramedics at a mass gathering. Prehosp Emerg Care 2005;9:213-7.
8. Feldman MJ, Lyons D, Verbeek PR, Chad S, Craig A, Schwartz B. Which dispatch protocols accurately triage high-acuity calls? A comparison of the medical priority dispatch system to a validated prehospital acuity score [abstract]. Prehosp Emerg Care 2005;9:118.