Do family physicians with emergency medicine certification actually practise family medicine?

Since 1982 the College of Family Physicians of Canada (CFPC) has offered a certification program in emergency medicine for family physicians. To obtain this designation, most individuals do an extra year of emergency medicine training, while others choose the “practice-eligible” route by accumulating emergency department experience and then taking a clinical competency examination. According to the college, this program aims to help family physicians deepen their skills in an area of clinical practice that is integral to family medicine.1 As such, the emergency medicine certification — CCFP(EM) — is viewed as a complement to family medicine training.

To what extent does this ideal hold true? Do family physicians with emergency medicine certification actually practise family medicine, or do they instead practise as if they were emergency medicine specialists? To answer this question, physician billing data from the Ontario Health Insurance Plan (OHIP) were examined. The OHIP database contains information on fee-for-service emergency departments and selected non-fee-for-service emergency departments that submit shadow (zero dollar) billings to track utilization. Physicians were classified into 4 categories according to the proportion of patient assessments that occurred in an emergency department in the fiscal year 1999/2000: “almost all emergency medicine,” “mostly emergency medicine,” “mostly non-emergency medicine” or “almost no emergency medicine.” Information on physician demographics, practice location and training was obtained from the Ontario Physician Human Resource Data Centre. Twenty-two physicians in non-fee-for-service, non-shadow billing practices were excluded.

Of the 345 family physicians with emergency medicine certification included in the study, 194 (56%) were in the “almost all” or “mostly” emergency medicine categories (Table 1). Overall, 186 (54%) of the physicians derived less than 10% of their annual patient volume from scheduled family practice visits. In a multivariate logistic analysis the physicians in the “almost all” or “mostly” emergency medicine categories were more likely to be younger (odds ratio [OR] 0.90 per year in practice, 95% confidence interval [CI] 0.87–0.94), less likely to be in a rural practice (OR 0.30, 95% CI 0.13–0.67) and more likely to practise in an urban teaching hospital (OR 2.62, 95% CI 1.19–5.75) than the physicians in the other 2 categories. Of the 85 physicians who graduated from medical school between 1989 and 1996, 31 (36%) were in the “almost all emergency medicine” category and 38 (45%) in the “mostly emergency medicine” category in their first year of practice.

This study demonstrates an incongruity between the CCFP(EM) program's objective and the practice choices of its graduates. The objective is to have family physicians with extra emergency medicine skills. The reality is that most graduates practise full-time emergency medicine, with little or no office-based family practice. This is particularly true among young family physicians with a CCFP(EM) entering practice directly from residency training. These findings occur amid evidence that the workforce in emergency departments has become more specialized over the past decade. Family physicians without a CCFP(EM) working part-time in emergency departments are gradually being replaced by those with a CCFP(EM) who tend to have full emergency department workloads.2

Why are family physicians with emergency medicine certification choosing to practise emergency medicine full time? One possibility is that they had no intention of practising family medicine and chose the CCFP(EM) program because it is shorter than the emergency specialist program offered by the Royal College of Physicians and Surgeons of Canada. Alternatively, they may have initially intended to practise family medicine but were drawn to full-time emergency medicine work by hospital administrators who have a strong interest in their skills.3 Another possibility is that family physicians without emergency medicine certification are leaving emergency medicine and those with such certification are being asked to fill the void. The physicians who are leaving emergency medicine may be doing so because of lifestyle reasons, because their emergency skills are not being valued or because the physician population is aging4 and physicians tend to relinquish their emergency medicine practice as they grow older.5 All of these hypotheses deserve further research.