Believe it or not, CCFP graduates provide the majority of emergency care in Canada. I don’t mean CCFP physicians with an emergency medicine (EM) designation – I’m referring to regular non-EM family physicians. From the very northern settlements of Canada to southern border cities, family physicians have been working in emergency departments since their earliest days in Canada.
This begs the important question: what is the value added through a recognized college competency in emergency medicine [CCFP(EM)]?
1. For starters, it boosts your job prospects. It is an almost universal requirement at academic emergency departments to have an additional credential in emergency medicine.
2. It standardizes care: The college states that the added certificate of competence exists to standardize the quality of emergency care from family physicians. To the credit of the CCFP program, there is a great deal of variance in the curriculum of any family medicine training program in Canada. This variance serves well for family medicine being a specialty that fits the needs of its community. With this variance there may be a difference in emergency care competencies. For example, a graduate from a large academic hospital versus a smaller is likely to have had less exposure to emergency teaching and practice.
Canadian Emergency Medicine certifications of ED Chiefs (%) From CWG-EM Survey 1
3. For CCFP physicians who are already practicing in an ED, the added recognized certification from “challenging the exam” may allow them to climb the ranks in their own ED by allowing them to take on administrative roles. Most ED Chiefs in Canada who completed the 2016 collective working group in emergency medicine (CWG-EM) survey who held an EM certification were CCFP(EM). That being said, less than half of ED chiefs who participated in the surveyed held an EM certification at all. Please note however that the majority of responding chiefs were from a rural or regional centre.1
Challenging the Exam
So how does a family physician go about adding the ‘EM’ designation to their CCFP title? The ‘EM’ designation is based on completion of the “examination of added competence in Emergency Medicine”. To sit in to write the exam you need to be a college member who holds CCFP status in good standing and has either:
- Successfully completed an approved residency training program in emergency medicine (PGY-3)
- Met the criteria for practice eligible candidates as determined by the National Board:
- Candidate must be engaged in emergency practice in Canada at a rate of 400 hours/year for a four-year period immediately prior to the date of application
- Candidate must have competencies in procedural skills related to emergency medicine including cardiac and trauma life support. Skills must be documented by the director of their hospital emergency department or their medical staff superior.2
Do job prospects for a CCFP(EM) physician change depending on their route to the additional certification?
The short answer is no. There is no distinction in opportunities for employment or salary between the two routes.
A practical consideration is that if you do choose to go through the practice eligible route you take a gamble on the location of your practice for the four years that are required to accumulate hours in emergency medicine. Job opportunities for physicians who have recently completed a family medicine residency in emergency departments are scarce in big cities. However, opportunities are frequently available in smaller to mid-size communities depending on job turnover and changes in human resources.
How do I know what certification route is right for me?
If you’re a family medicine resident who knows you want to work in an emergency department and feel you could use some extra training after graduation, the PGY3 year may be best for you. The PGY3 year was created to expose residents to critical care. The concentrated critical care experiences in the PGY3 year may make the provider more comfortable early in practice compared to the practice eligible route. Even this view is nuanced with the great deal of variance in family medicine training and CME opportunities available to family physicians. In a structured residency setting the PGY3 resident has an opportunity to implement emergency skills early so that they are more comfortable working in an emergency department as a consultant.
The intended candidate for the practice eligible route is a physician who ‘falls into’ emergency medicine. This is the family physician who provides comprehensive primary care for their community which includes some emergency care. Through the inclusion of emergency care in their practice, the physician may find that they have an affinity for the practice and search for certification of added competency. Practice eligible applicants are self-starters and advocates for self-directed learning. The candidate who enters practice eligible practice often feels confident after graduating from their CCFP accredited residency to provide emergency care in a relatively low acuity setting.
Confidence may be a function of actively seeking emergency medicine CME, elective patterns or a rural/community based residency with a strong focus on critical care and procedural skills. The 2016 CWG-EM found that CCFP (non-EM) graduates felt smaller training centres to be a more effective route to develop EM competencies.1 It should be explicitly advised, if you do choose to go through the practice eligible route please consider the type of community you hope to practice in, the resources available to you, and how easy it is for you to organize a CME plan for yourself. Be honest with yourself about the gaps in your family medicine residency program and how wide these gaps are so that you can create realistic CME goals for yourself that are supported in the community you hope to practice in.
Level of agreement for the CCFP (non-EM) program to be rated as an effective route to develop competencies in EM From CWG-EM Survey 1
What is the practice pattern like for a family doctor providing EM care?
The collaborative working group (CWG) EM survey indicates that the majority of graduates from the CCFP(EM) program practice or intend to practice full-time EM and not a combination of EM and clinical family medicine.1
Depending on location and where they work it may be up to 18% of CCFP(EM) graduates that continue to do some family medicine (more often in rural settings). 4% of CCFP(EM) graduates working in large urban non-academic centres continue to provide family medicine care.
The CWG-EM survey also illustrated that 51% of CCFP(non-EM) physicians currently practice EM predominantly in a rural setting. CCFP(non-EM) physicians were also more likely to devote a higher percentage of their clinical practice to Family Medicine compared to CCFP(EM) physicians. On average CCFP(non-EM) participants devoted 47.9% of their clinical practice to EM and 39.6% to family medicine.1
All of this to suggest that CCFP(EM) graduates practice substantially less family medicine than CCFP(non-EM) graduates.
Anticipated breakdown of clinical practice of EM residents (%) From CWG-EM Survey1
The Case about ‘Specialist’ Family Medicine
The CCFP has made it clear that the college’s priority is to produce generalist comprehensive family physicians.3 Recently there has been debate around whether the “primary care advantage” is being threatened by family physicians who opt to increasingly focus their practice. It can be argued that certificates of added competence are a distraction from the importance of comprehensiveness and continuity. By creating family physicians with focused practices, are we performing a disservice to Canadians?4
A deep dive into this issue reveals that the topic is very nuanced. Enhanced skills programs are not created to undermine or threaten the work of office based family physician. There is an argument to be made that graduates choosing to focus on emergency care, hospitalist care, and palliative care are choosing demanding practices that are filling a gap in healthcare responsibly. “There is estimated to be a shortfall of 478 emergency physicians in Canada which is estimated to be equivalent to the student body size of an entire Canadian medical school.” This shortfall is projected to be 1518 emergency physicians by 2025.1 Interestingly, this shortfall is not exclusive to rural locations in Canada and is seen even in large non-academic urban centres.
Projected emergency physician shortfall (Large Urban Non-Academic) From CWG-EM Survey1
An important principle of family medicine is that it is community based. What is more responsive to community need than filling a necessary healthcare gap?
Emergency care is important care, despite the lack of continuity. The care provided is 24/7 and resolves to provide care to the most complex and often the most marginalized.
With respect to graduates of PGY3 programs, a study published in 2012 looking at practice patterns of 86 graduates of the University of Toronto CCFP(EM) program from 1982 to 2009 reported that graduates practiced EM on average for 7 years before ending their EM practice. Notably, 43% of respondents had practiced EM in under serviced areas at some point in their careers.5
One real issue that continues to merit evaluation is the disparate geographical distribution of PGY3 graduates in emergency medicine with the majority opting to practice in large urban centres.1
Overall, the enhanced skills program in EM is an interesting crown jewel in the CCFP program, albeit sometimes in the eye of controversy.
There are multiple routes to a fulfilling career in emergency medicine. Choosing the right route often means identifying your level of comfort, interest in fellowship opportunities, where you hope to practice, and what your learning style is. The matter of choosing between working in an emergency department as a CCFP or completing the CCFP-EM credential through is hotly debated.
The post was informed by content interviews with Dr. John Foote, program director of the PGY3 enhanced skills program in EM for the University of Toronto, and Dr. Aaron Orkin, who completed the practice eligible route to CCFP(EM). Prior to its publication, it was reviewed by Drs. Paul Das, John Foote, Aaron Orkin, Howard Ovens, and Brent Thoma.