Call for family doctors to have more emergency medicine training sparks debate

The emergency room is where you go when you need immediate expert care. It may surprise many Canadians to learn that most doctors providing that care aren’t certified formally in emergency medicine.

Whether they ought to be, and what qualifications they need, is a matter of debate within the profession. It recently came to a head in Ontario, after the College of Physicians and Surgeons of Ontario (CPSO) issued a new framework for rural emergency care, outlining what doctors uncertified in emergency medicine needed to do to expand their scope of practice to include it. Last week, however, much of the substance of the document was rescinded.

“The CPSO has essentially retracted its position that some family medicine residents may not be prepared for rural emergency medicine,” says Dr. Alecs Chochinov, president of the Canadian Association of Emergency Physicians (CAEP). “We’re not going to stop pushing the need for additional training for family medicine residents who want to work as emergency physicians.”

Many doctors in emergency rooms have limited training in emergency medicine.

Image courtesy of JazzIRT/iStock

In the original document, the CPSO called on all physicians uncertified in emergency medicine or lacking in on-the-ground experience to go through up to a year of mentoring and evaluation by someone more seasoned. The revised version suggests that only established Canadian doctors without emergency medicine certification or experience and foreign-trained doctors will be required to undergo this vetting. All new Canadian-trained family doctors will automatically have emergency medicine within their scope.

Dr. Guillaume Charbonneau, president of the College of Family Physicians of Canada (CFPC), says all current medical graduates have attained the competencies necessary to work in emergency medicine. Emergency medicine, he points out, is one of the core competencies of family medicine, along with primary, hospital, maternal and long-term care.

The CFPC, along with the Ontario College of Family Physicians and the Society of Rural Physicians of Canada, argued in a letter to the CPSO that instituting the framework would make it even harder to recruit family doctors to work in rural and remote areas. It would also tax the already over-worked doctors in those areas, who would have to do the monitoring. “The loser would have been the population of Ontario,” says Charbonneau.

Emergency medicine is a relatively new specialty; it has been a recognized discipline in Canada for less than 40 years. There are two separate ways to become certified. One route is to specialize in emergency medicine for five years through the Royal College of Physicians and Surgeons of Canada. The other is to add one year of specialization in emergency medicine to family medicine training through the College of Family Physicians of Canada.

There has long been debate about whether one year is enough to equip a physician for life in the emergency room. But more contentious is that about half of doctors staffing Canada’s emergency departments have only one month of specialized training. “One month isn’t a long time,” says Chochinov. “That’s sixteen shifts, at most.” The Canadian Association of Emergency Physicians has been pushing for the amount of emergency training for family doctors to be increased.

But Charbonneau counters that today’s graduates are assessed on competence, not time spent focusing on a specialty. It was after additional consultations that the CPSO last week amended its framework. “The CPSO listened,” says Charbonneau. Other areas of medicine, such as cosmetic surgery, fertility medicine and psychotherapy, still have prerequisites before a physician’s scope of practice can be expanded to include them, and the CFPC does not contest those.

Dr. Howard Ovens, who trained as a family doctor but spent 36 years in emergency medicine, says the real problem is the chronic shortage of emergency doctors. This summer, cottage country emergency care will once again be depending on young locum doctors to hold things together. “Staffing is so thin; you’d be in trouble without them,” he says. He estimates Ontario needs about 250 more emergency physicians.

Although CAEP wants more training, it also recognizes the burden the framework was placing on rural areas and had called for the CPSO to delay implementation. “We are relieved for our rural colleagues,” says Chochinov, “but we have to get moving on this.”