Emergency medicine training in Canada: learning from the past to prepare for the future.

Emergency medicine has been recognized as a specialty in Canada for a quarter of a century. But how distinct is our discipline, and how well prepared are we to meet the challenges facing us in the years to come? At this time, it seems appropriate to reflect on what we have learned during our first 25 years and consider some tough questions on how best to meet the future emergency medical needs of Canadians. It is easy to understand why there is a lack of clarity regarding what defines an emergency physician (EP) in Canada. Our workforce is made up of practitioners from disparate backgrounds with a variety of credentials. There are 2 separate paths to certification in emergency medicine (EM) through different colleges. Furthermore, data from the 2004 National Physician Survey indicates that the majority of physicians who identify the emergency department (ED) as their main patient care setting have no EM certification at all. This is not surprising given that our residency programs still do not produce nearly enough graduates to meet the demand. Many EPs have learned on the job and have developed considerable expertise in this manner. Our dual training system arose more as a result of politics than wise planning. In the late 1970s and early 1980s, both Canadian colleges were lobbied to establish EM training programs and both initially resisted. The Royal College of Physicians and Surgeons of Canada encountered reluctance within its ranks to accept EM as a specialty, and the College of Family Physicians of Canada had concerns that creating a specialty program could lead to fragmentation in family medicine (concerns that continue to this day). A conjoint committee was established to decide on the most appropriate home for the new discipline and the optimal format for its training program (oral communication, Dr. Paul Rainsberry, Associate Executive Director, Academic Family Medicine, College of Family Physicians of Canada, January 2008). After failing to achieve consensus on the issues in the context of misaligned political agendas, both colleges established EM programs with different ideologies and goals. Advocates at the College of Family Physicians viewed EM as acute primary care and a natural extension of the family medicine residency. The third-year CCFP(EM) program was designed for family medicine graduates to develop special competence in EM, and its first certification exam was held in 1982. With the goal of establishing EM as a discipline on par with other specialties, the Royal College developed a program designed to produce academic emergentologists. The first Royal College FRCP(EM) certification exam was held in 1983. And so here we are, a quarter of a century later, a discipline divided, with 2 training streams that have ostensibly different goals. What we have learned, however, is that the graduates of the 2 streams do not fit neatly into their intended career paths. The real-world experience has been that EPs from both streams go on to pursue a wide variety of career paths that overlap considerably. It has been suggested that this may be a failure of the 2 programs to attain their objectives. In my view, what it really reflects is that people’s career paths evolve over time. It would be most