Practice profiles of physicians currently practicing EM

• ∙ The primary practice settings for physicians with an EM certification are typically large and small urban settings. FRCPC-EM and dual certificants almost exclusively practice EM in large urban academic settings, while the primary practice setting of CCFP(EM) certificants are more varied across large and small urban settings. These results were consistent with the findings from EM residents, with the majority of FRCPC-EM and CCFP(EM) residents indicating a desire to practice full-time EM in an urban setting.

• ∙ The proportion of CCFP(EM) certificants with a component of Family Medicine in their practice is extremely low across all ED settings. EM practice makes up the majority of the clinical practice distribution of all physicians with an EM certification.

• ∙ CCFP (non-EM) certified physicians are most likely to provide emergency care in rural settings, and make up the large majority of physicians providing emergency care in remote and rural settings.

Alignment of training and practice

• ∙ The majority of respondents who currently practice EM (FRCPC-EM, CCFP(EM), CCFP) feel adequately prepared for clinical practice by their training route.

• ∙ The effectiveness rating of the CCFP (non-EM) program for EM practice is more likely to be rated positively in smaller centres.

• ∙ There is a strong sentiment amongst certified physicians and ED chiefs outside rural and remote settings, and trainees in both programs, that CCFP (non-EM) training alone is insufficient to gain competencies for the practice of EM. ED chiefs outside rural and remote settings and certified physicians indicated their greatest concern was with regard to CCFP (non-EM) training alone for the practice of EM in larger centres.

• ∙ Qualitative responses of survey respondents indicated that preparation for practice after graduation is dependent on training route and intended practice setting.

Reflections on the current approach to EM certification in Canada

• ∙ Survey respondents identified strengths and challenges of the dual college, dual certification approach for EM residency training. Many respondents advocated a single unified EM training program, however this was not considered feasible at this time by the CWG-EM.

• ∙ A qualitative analysis of the survey data revealed four key strengths and four key challenges of the current approach.

  1. o Strengths: The current approach fulfills Canadian needs, is responsive to Canada’s vast geography and population distribution and is appropriate for diverse contexts, includes roles for each practitioner type, and both routes produce capable emergency physicians.

  2. o Challenges: The current approach has insufficient content exposure for both training routes, inappropriate length of training programs, inequalities between the certification routes, and misalignment of program goals with practice.

Physician distribution and staffing needs

• ∙ Current physician staffing needs are not fully covered in any ED setting type.

  1. o Dependent on ED setting, approximately 40% (large urban academic) to 62.5% (remote) of ED Chiefs from different ED settings indicated that their staffing needs were not fully covered.

  2. o The most significant hours of shortfall were reported in large urban academic (11.3 hours coverage/day/ED short) and large urban non-academic (15.4 hours coverage/day/ED short) settings.

• ∙ The majority of ED Chiefs anticipate an increase in annual patient volume and a critical staffing shortage.

Current shortfall of certified emergency physicians and projected increase in the HHR deficit over the next decade

An HHR model was constructed by the CWG-EM in order to determine the current and projected shortfall of emergency physicians over the next decade. This concluded there is a current estimated shortfall of 478 emergency physicians in Canada. In the absence of expansion of EM residency training capacity, this shortfall is projected to rise to 1071 emergency physicians by 2020 and to 1518 emergency physicians by 2025. The methodology, limitations, and assumptions of this model can be found on page 66 of the final report.

Misalignment of the intent of the FRCPC-EM and CCFP(EM) training routes and the reality of Emergency Medicine practice for program graduates

The surveys of physicians with an EM certification and EM residents indicated that a substantial proportion of respondents report discontent regarding the current approach to EM training and care in Canada. This undercurrent of dissatisfaction conveyed by survey respondents appears to arise from a complex multitude of factors that act to divide the EM community. Within a relatively small discipline like EM, this division is pervasive enough to potentially result in animosity between certificant types and may present significant challenges to an effective system of care.

Our survey data suggests concern exists within the EM community that some physicians are placed into a clinical role they are not prepared for upon graduation. Issues regarding preparedness for practice in a variety of settings for both CCFP(EM) and FRCPC-EM graduates appear to stem from a misalignment of the intent of training with the reality of practice.

Preparing for practice: Supporting a standard of care for “patient zero”

A major consideration that guided the CWG-EM’s review of the data and subsequent recommendations is the concept that a central component to the practice of EM is that “patient zero” (the first patient a graduate from a training program cares for post-graduation as an attending physician) merits excellent care in all settings, irrespective of the certification of the care provider. The following set of consensus statements informed the vision and recommendations of the CWG-EM.

Assumptions

1. 1. Both EM training routes in Canada are high-quality and are effective educationally.

2. 2. Both EM training routes attract high-quality trainees.

3. 3. Canada currently needs a variety of training routes to serve the emergency care of Canadians effectively across all settings.

4. 4. Canada also needs focused rural EM training to effectively meet the needs of patients in this context.

5. 5. The two EM training programs are not identical, due to design, time, educational experiences, emphasis, and duration of training.

6. 6. Differences and distinctions between graduates of the two programs evolve over time, just as every professional changes their scope of practice and depth of knowledge during their career.

Proposed Concepts

1. 1. The two programs do not and cannot produce identical graduates.

2. 2. There are qualitative and quantifiable differences between graduates of the two programs upon completion of training.

3. 3. CCFP(EM) graduates, due to their Family Medicine (FM) background and competencies, have additional ability in clinical presentations that overlap with ambulatory FM care including but not limited to holistic communication skills, integration with the community, ambulatory psychiatry and obstetrics.

4. 4. FRCPC-EM graduates, due to their longer dedicated training in EM, have additional abilities, including but not limited to: critical care experience, advanced resuscitation skills, advanced toxicology, pediatric EM, research and a higher level of experience with the management of critically ill patients.

5. 5. The qualitative and quantitative differences in #4 listed above are most evident in the sickest patients and in the context of more complex and unusual emergency patient presentations and conditions.

6. 6. Due to curriculum differences, FRCPC-EMs have additional training in some areas, including EM administration, research, and pre-hospital care.

7. 7. Despite these significant differences, inter-College collaboration in developing competencies to provide care for all common ED presentation is required for all trainees in order to safely meet the needs of “patient zero”. It is understood that FRCPC-EM program graduates, as EM consultants, will exceed these in some areas. At the same time, the standard of care required to be clinically competent in the provision of EM care must be equivalent for both CCFP(EM) and FRCPC-EM graduates for ED presentations that are common to the settings in which they work.

8. 8. With experience, the sophistication of EM care will exceed the aforementioned competency minimum for graduates of both EM training programs, however, FRCPC-EM graduates benefit from greater formal education and exposure upon graduation than CCFP(EM) graduates.

In moving forward, decision-makers must strive to advance approaches that serve both the EM and ED patient communities. The current reality of Canadian EM practice is that graduates of both the CCFP(EM) and FRCPC-EM programs work side by side clinically in a variety of ED settings, most commonly large urban centres. The two colleges have the ability to positively impact patient care by collaboratively developing parallel foundations of training for EM care delivery.

Health human resources shortfall

There is a current estimated shortfall of 478 emergency physicians in Canada. This deficit is roughly equivalent to the student body size of an entire Canadian medical school. In the absence of expansion of EM residency training capacity, this shortfall is projected to rise to 1071 physicians by 2020 and to 1518 physicians by 2025 (Figure 1).

Figure 1 National emergency physician shortfall estimate and future projections (excludes remote settings)

We recommend that CAEP, the CFPC, and the Royal College work collaboratively to advocate for the significant EM residency training slot expansion necessary to address the large current and projected future shortfall of certified emergency physicians in Canada. CAEP, CFPC and the Royal College are encouraged to work in collaboration in order to address the current and future HHR deficit in Emergency Medicine, consider the right balance of physicians needed to fill this deficit, and advocate for growth in the programs as defined by the types of graduates needed for a variety of ED settings. In addition, in consultation with both colleges, provincial Departments of Health must also work with the postgraduate offices of medical schools within their jurisdictions to increase the number of EM postgraduate training positions in Canada.

In line with its mission to promote the interests of emergency physicians and the specialty of EM in Canada, CAEP must also advocate for the growth of EM certification programs, as well as hold influential groups accountable to move this issue forward.

Alignment of the CFPC and Royal College Emergency Medicine residency training programs

Patient needs have been met with the current approach to EM certification in Canada; however, some improvements are felt to be necessary to improve efficiency and effectiveness and thus enhance care and educational resource utilization. It is envisioned that there will be a continuum of physicians from CCFP(EM) and FRCPC-EM programs staffing various types of Canadian EDs, with each physician’s practice context being aligned with the competencies of the individual.

The CWG-EM is not recommending a single certification stream for EM practice, however the substantial support for this that continues to exist in the EM community underscores the need to make meaningful improvements to the status quo. We recommend that the CCFP(EM) and FRCPC-EM programs reform their objectives of training with the following goals:

HHR needs in rural and remote settings

HHR needs in rural and remote areas are complex, and it is unlikely that the full breadth of EM staffing needs can be filled in these locations by CCFP(EM) and FRCPC-EM certified physicians in the near future. HHR planning for rural and remote areas needs to consider many more aspects of medical care than solely emergency care. A review of the CCFP (non-EM) program and the issues of EM care in rural Canada were outside of the mandate of the CWG-EM, however general recommendations related to the CCFP program and provision of EM care will be briefly communicated.

The CFPC is encouraged to review the rural/remote findings in detail and, as many CCFP certified physicians fulfill critical ED staffing needs in these settings, consider modifications to the CCFP program in order to ensure that required competencies for provision of emergency care are attained by program graduates intending to work in these settings. We recommend that the CFPC, the Society of Rural Physicians of Canada, and other key stakeholders continue to work collaboratively towards solutions for the provision of optimal emergency care in rural Canada.

Future collaboration of the CCFP(EM) and FRCPC-EM programs

Collaboration between the two colleges with respect to the CCFP(EM) and FRCPC-EM residency programs must be implemented and actioned towards the goal of achieving clinical competence for every resident, for their ultimate practice trajectory and setting, at the completion of training.

We recommend the two Colleges make specific and meaningful changes to collaborate on issues related to their EM training programs and the future evolution of Canadian EM education and certification, including but not limited to:

• ∙ Collaboration between the CFPC and the Royal College in order to clarify, co-develop, and distinguish the goals of each program, highlight their distinctions, and ultimately ensure that clinical competencies for “patient zero” are met, non-clinical competencies are achieved, and both programs are efficient and effective at meeting their goals.

• ∙ Optimizing patient care by collaboratively developing parallel foundations of EM care for both training routes, as well as the co-development of competency-based clinical care milestones for common clinical presentations.

• ∙ Establishing observer status appointments for one-another on EM relevant committees including but not limited to the Royal College Specialty Committee in Emergency Medicine and the CCFP(EM) Program Committee.

CWG-EM Data Access for Future Research Activities

The quantitative and qualitative results of the CWG-EM National Survey of EM represent a significant collective resource for the Trilateral Partners (CAEP, CFPC, and the Royal College), as well as the Canadian EM community, both today, and in the future.

The opportunity to access the data collected by the CWG-EM should be made available for future research initiatives by any of the trilateral partners or members of the EM research community.

Access to the CWG-EM survey data should be granted exclusively for the purposes of research and improvement to the emergency care of Canadian populations, and not for any commercial purposes. A formal application process should be developed and the CWG-EM should be continued (or a new trilateral partner committee should be established) to review any requests to access raw CWG-EM survey data. Permission to access the CWG-EM survey data would require the approval of all three Trilateral Partner organizations, and approval from a Canadian Research and Ethics Board (REB). Additional factors involving access to CWG-EM survey data such as project mechanics, intellectual property, and confidentiality, would need to be defined in advance by the trilateral partners.

Examples of potential future research questions that could be answered or facilitated through the use of CWG-EM survey data are provided in Figure 23 of the final report.