FRCPC or CCFP-EM: What is best for you?

FRCPC or CCFP-EM: What is best for you?

FRCPC or CCFP-EM? (FRCPC = Fellow of the Royal College of Physicians of Canada; CCFP = Canadian College of Family Physicians – Emergency Medicine certificate.) This is a question that EM mentors spend a lot of time discussing with their mentees. Why are there two EM designations in Canada? What’s the difference? Which route is right for you?

These are great questions. Unfortunately, as with many important decisions, you’ll probably get as many answers to them as people you ask. Everyone in the Canadian EM world seems to have an opinion on this topic and today I am going to share mine. “Why would you want to get into this potentially thorny topic?” you may ask?

Two reasons: First, because I think it is important for medical students make an educated decision. The only way that to do that is by hearing a lot of opinions and deciding what is best for their personal situation and career goals. And second, because I will be sitting on a panel at CAEP13 and discussing this issue and writing blogs is how I prep myself to speak in front of people these days. After writing and revising a post like this, I generally have my thoughts on an issue quite well organized and I can direct the audience to my blog for a fully drafted opinion.

There are a lot of things in my background that have coloured my thoughts on this issue. The most obvious of these is that I chose the FRCPC route. My opinion has also been shaped through my program in Saskatchewan where a significant portion of my training has come from CCFP-EM physicians (there were 0 FRCPC EM physicians in the province when I started medical school and there are only 4 now). Finally, I was the President of the CAEP resident section last year and sat on the CAEP board through the tail end of its discussions about the Montreal Task Force (aka Dual College/Dual Certification (DC/DC)) on Canadian EM credentials. I learned a lot about the historical context of this issue as a result. All in all, I think that background gives me a fairly good knowledge base on this topic.

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Why are there two EM designations in Canada?

This is a very difficult question to answer. While it was likely discussed even earlier, the first mentions I found about it came from back in 1997. Drs. James Ducharme and Grant Innes started some controversy that year with an editorial in a CAEP Communique published in the Fall of 1997 titled “The FRCPC vs the CCFP(EM): Is there a difference 10 years after residency?” (Edit: This article and a history of publications and letters to the editor that address this issue has been made available by CAEP since the last time I looked. Thanks to Danica Kindrachuk and Chris Byrne for pointing me to it!). In it, they gave their take as to how the two streams of training came to be. As I was -7 years old back in 1977, I figure I should take their word for it. Here it is:

Almost 20 years ago two groups perceived the importance of emergency medicine (EM) and saw the need for advanced EM training. The Royal College of Physicians and Surgeons viewed emergency medicine as a new specialty with a distinct body of expertise, while the College of Family Physicians viewed it as a critical aspect of primary care. As a result of disparate philosophies and divergent political agendas, 2 distinctly different training programs for EM arose and flourished in Canada.

Their editorial went on to speculate about the differences (or lack of differences) between the graduates of the two training streams. It raised quite a furor. If the letters to the editor published in response were representative of the feedback, many CCFP-EM physicians took offence from their conclusion that the FRCPC program was intended to provide “proper academic training” that would allow its residents to provide “academic leadership” to EM and that a CCFP-EM program “could not possibly teach” that in 1 year.

Over the subsequent 16 years it seems to me that the situation has not been altered dramatically. There are still two training programs, every once in awhile someone proposes modifying/unifying them in some way, and every time their efforts are rebuffed. Most recently, CAEP went through a DC/DC process with its Montreal Task Force that, thus far, has failed to produce meaningful results. I’m way too much of an EM baby to provide any insight into where this process is headed (although based on historical precedent  I’d guess nowhere) so I’d suggest asking some of the Big Shots at CAEP.

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What’s the difference?

When I compare programs the first thing that I like to look at are their goals. This is where they tell you, very clearly, their purpose.

From the CFPC Red Book:

The goals of Certification in Family Medicine with added competency in Emergency Medicine [CCFP(EM)] are as follows:
1. To improve the standards and availability of emergency care from practicing family physicians
2. To establish guidelines for the development and administration of training programs in emergency medicine for family physicians
3. To ensure the availability of teachers for training programs in family medicine/emergency medicine

The Red Book describes CCFP(EM) graduates as follows:

The family physician/emergency physician is a family physician who acquires additional skills in emergency medicine to augment family medicine training. The goal of this training is to prepare family physicians to integrate the principles of family medicine into their emergency practice.

From the Royal College Objectives of Training:

Upon completion of training, a resident is expected to be a competent specialist in Emergency Medicine capable of assuming a consultant’s role in the specialty. The resident must acquire a working knowledge of the theoretical basis of the specialty, including its foundations in the basic medical sciences and research.

The Specialist Emergency Physician employs pertinent methods of prioritization, assessment, intervention, resuscitation and further management of patients to the point of transfer. Appropriate procedural and pharmacotherapeutic manoeuvres are central to these abilities.

The Specialist Emergency Physician possesses organizational skills in Emergency Department and disaster management and the ability to interface with and play a leadership role in the development and organization of Emergency Medical Services and prehospital care.

The Specialist Emergency Physician possesses the knowledge, skills and attitudes for effective patient-centered care and service to a diverse population with attention to age, gender, culture, ethnicity and ethics. The Specialist Emergency Physician has the ability to incorporate these perspectives in research methodology, data presentation and analysis.

I think it is important for a medical student considering which route to EM practice they would like to take to compare their career goals to the goals of the program that will train them. Which description sounds like it is more for you?

To give a bit more insight into the differences between the programs, I made a table that outlines some of the differences between the two routes:

FRCPC CCFP-EM
Years of residency 5 3
Years of EM residency 5 1
Pay scale Equivalent$ Equivalent$
Family Medicine License No Yes
Fellowships Yes Some^
Integrated subspecialty/fellowship time 1 year* No
Internationally Recognized EM Credential Yes No%
Job prospects Good+ Good+

$ I have confirmed that FRCPC’s get paid more than CCFP-EM’s in Quebec with the disparity being ~$46,000/year as of 2010. However, the number of specialist (FRCPC) positions in each region is limited by work permits. (Edit – huge thanks to Nina Nguyen, a med student from Sherbrooke, for this information!). Of course, in all provinces CCFP-EM’s would begin earning Attending wages 2 years prior to their FRCPC colleagues.
^ CCFP-EM’s may be eligible for some informal fellowships but would generally not have funding for them. They are unable to do Peds Emerg, Toxicology or Intensive Care.
* Most FRCPC programs allow at least 12 full months of funded electives to develop a subspecialty interest in EM. This time is often used to complete the first year of a fellowship, complete a Masters degree, etc. Nothing would stop a CCFP-EM from developing a similar niche after finishing their training.
% It is possible that EM experience may be considered to allow a CCFP-EM to work internationally as an emergency physician, but from what I understand, the CCFP-EM credential is not considered equivalent to the emergency medicine specialty credential internationally.
+ While this may change in the future, anecdotally, job prospects seem good for both CCFP-EM and FRCPC grads. I have not spoken to graduates of either program that have had difficulty finding a job. One of our CCFP-EM graduates from this year will begin working in the fall at Sunnybrook in Toronto. The myth that CCFP-EM’s can’t get jobs in major centers seems to be just that from what I have seen.

In terms of what type of practice EM residents have after they complete their training, there is not much data. I am not aware of studies regarding the location of practice of FRCPC EM physicians, although anecdotally they largely continue to work in tertiary care centers. However, a recent study at the University of Toronto surveyed graduates of their CCFP-EM program from 1982-2009 and found that they largely practice in EM (~75% spend >80% of their practice in EM) and almost none work in rural areas (94% urban or suburban with 39% specifying an academic affiliation). While this was a relatively small single-center study, it’s interesting to note that these results parallel those of a previous study at the University of Western Ontario.  In this 2005 study 72 participant survey of graduates from 1982-2004 they found that approximately 72% started their career working exclusively in EM while ~16% described their practices as “blended.” <10% described their practice location as rural. So what’s the bottom line? Both FRCPC’s and CCFP-EM’s are very likely to work in urban/suburban centers. As most urban centers also serve as academic centers these days to some degree, you’re also likely to have as much academic responsibilities as you are willing to take on regardless of your route of training.

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Which route is right for you?

I hope this information has helped you consider some of the important aspects of that decision.

The question that tipped me from being unsure to 100% certain that the FRCPC route for me was “Do I really want to train for family medicine for two years?” As I had no interest in training to be a family physician, I decided that I was not interested in pursuing the CCFP-EM route. I also found the possibility of fellowship training appealing and, three years into my residency, I am quite happy with my decision.

Conclusion

Those of you that will be attending the CAEP13 medical student day will have the opportunity to see this discussed by a panel including attending and resident representatives from both the FRCPC and CCFP-EM programs. I may update this post with additional insights after I hear the insights of the discussion. If you’ll be there, please do come and say hi :)

Thanks for reading!

This post was peer-reviewed by: Paul Olszynski (CCFP-EM), Nadim Lalani (FRCPC) & Eve Purdy

Brent Thoma

Brent Thoma

Editor in Chief at BoringEM
Emergency Medicine Resident at the University of Saskatchewan, wannabe Medical Educator, Blogging Geek. + Brent Thoma
Brent Thoma
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  • Melody

    Very insightful post Brent, as usual! Hopefully can meet you at CAEP!

    • http://boringem.org Brent Thoma

      :) See you this weekend!

  • Todd Raine

    Nice summary Brent.

    Let me give you a slightly different perspective. I too, for the reasons you cite and one other, decided that the FRCP route was right for me. The ‘other’ reason was the general disregard to CCFP anything during my training. The vast majority of specialists (not EM specialists though, interestingly) were disparaging of Family Medicine. Academic Family Medicine was hung up on the ‘warm and fuzzy’ side of medicine when it came to the specialty’s interactions with med students.

    This paralleled the Generalized angst that was running through the Family Medicine community at the time (FM popularity was waning year to year, there was much rending of clothing and gnashing of teeth about whether FM should be considered a ‘Specialty’ or should cling to the ‘Generalist’ label – even whether ‘Family Medicine’ was the best name or if a return to ‘General Practice’ was in order).

    The CCFP(EM) training slots were far fewer as well, so someone committed to EM seemed to be taking a big risk by choosing the EM route. Plus the prospect of a second competitive match seemed (& still does) incredibly daunting.

    So, I ranked onlyFRCP programs, and then went unmatched… Zero fun. For perspective, there were ~100 students who ranked EM first, and 17 residency spots available that year (2001), so a lot of people were unhappy that year.

    So, I matched to FM (in Saskatoon!). I was upfront with the Program that my intent was to pursue EM as a career, and the FM was a stepping stone for me. They were open to my goals, but also did they’re level best to ensure I was steeped in the FM ethos and Pt centred philosophy. It sounds awful to many, but that training serves me everyday, both in pt care and in how I deal with colleagues and consultants (FIFE is a great tool when dealing with the EM bugbear of vague complaints).

    9 years into practice I work (and always have) at a busy ~75 000 visits a year) inner city Academic ED, I am a Clinical Associate Professor, and I am developing a neat niche sub specialty that rolls together my interests in Education and IT/Technology.

    Anyway, a different perspective as I said.

    • http://boringem.org Brent Thoma

      Absolutely! Thanks for the input.
      With the consistently competitive state of the match for emergency medicine (not as bad as you describe, but certainly >110 CMG’s for 60some spots) I’m sure your story parallels that of many others.
      The ‘secret curriculum’ take on generalism is really too bad.
      Thanks again.

    • http://www.want2bemd.tumblr.com Danica

      I think if you were a student today, you would find it is nearly the opposite attitude toward family medicine than the one you describe (at least officially anyway). In fact, I have experienced exponentially more distate toward specialty physicians from family doctors than vice versa.

      I began a blog post on the topic but have yet to finish it…your reply reminded me I should get on it once exams are over!

  • http://www.want2bemd.tumblr.com Danica

    Great post as always Brent, and a nice overview for those thinking of emergency. I wish I could be at the medical student/resident day to hear the discussion as I’m sure it will be interesting.

    I’d be interested to know how many of those who go the
    CCFP(EM) route would have wanted to go the FRCPC route instead but for whatever reason, didn’t match to it. I know it is certainly one of the more competitive residencies to match to. There just aren’t enough spots for those interested. And I can’t imagine governments (who fund PG training) wanting to fund more 5 yr positions when they likely see the two “products” as equivalent, whether they are or aren’t (I’m certainly in no position to make any sort of judgement on the matter)!

    Also, the paper is available by Googling the title. It should be the top result.

    • http://boringem.org Brent Thoma

      Danica,

      Thanks for the tip. Interestingly, the file that you find that way is the exact file that I used to read up on this topic. It’s a synopsis of the history of the discussion around this that CAEP created 1-2 years back and shared with their board (that’s how I had access to it). At that time I couldn’t find the article anywhere else and I never thought to do a quick google search to see if CAEP itself had posted it (turns out they had!). Whoops! I’ll add a link to it.

      As you note, that’s a very complicated question. If you bring in confounders like matching for location rather than specialty it would be even more difficult to get a clear picture.

      I certainly think the products of the two programs are different (as they should be after receiving different training!), but discussing how is a matter of extremely controversial opinion!

      • http://www.want2bemd.tumblr.com Danica

        Adding in location in the match is another whole ball of confounding that I hadn’t even considered!

        • http://boringem.org Brent Thoma

          Yep! If you need to be a certain place for whatever reason (most often family), an EM/EM/EM/EM rank list can quickly change into an EM/FM/IM/etc rank list. It’s probably the most difficult situation to be in!

  • Bozo Jones

    I applied for FRCP EM a few years ago, failed, and backed up into some specialty that is about as far away from EM as one can get. Given the circumstances I did what I had to do(I needed to work), but I would not say I am happy with the outcome.

    I often wonder whether I should have backed up with family and gone for CCFP EM. I have rationalized that it probably would have been an even worse choice than the one I made, since I have no inclination nor interest in learning family medicine, and do not buy in to the philosophy of it. To have to sit through two years of that would have been torturous, and to very likely come out the back end not matching in CCFPEM would have made the situation way worse than I’ve made it at present. Picking between the bad option and the worse option is certainly not ideal.

    The data you have above seems to indicate that most of the Toronto and UWO CCFP EM grads practice what looks like exclusively EM. Why have these guys do a CCFP residency at all? Why not just open up more FRCP spots, or combine them or something. The family medicine training in CCFPEM seems extraneous; those grads would have been better off learning 3 years of EM rather than 1 year and 2 years of well-baby checks and smoking cessation counselling.

  • http://www.thechartreview.blogspot.ca Elisha Targonsky

    Brent,

    Very insightful piece that touches upon a lot of the similarities and differences between the FRCP and CCFP-EM routes. As a grad of the CCFP-EM, and someone who works in a busy urban community hospital of >100,000 visits per year, I can speak to the utility of this route and how it should/could play into the decision making thought process.

    My opinion is of the following:

    1) Those who apply to CCFP-EM should enjoy family medicine. This is essential if you are going to be spending 2 years training in FM, and also if your pursuit of the EM fellowship/designation falls short. The program is incredibly competitive with more and more applicants yearly. FM also gives a lot of flexibility and career subspecialization if FM alone doesn’t give you enough excitement.

    2) If you live and die by EM and that is all you want to do, probably better to roll the dice with applying to the FRCP program and take your chances with a program that guarantees EM but is also extremely competitive.

    I have seen many CCFP-EM grads pursue careers that blend EM with FM, but it is true that the majority do mostly EM, and mostly urban/suburban EM. A lot of CCFP-EM grads are key contributors to academic EM, and many hold admin roles (ED chiefs, etc). Both routes allow this, although perhaps research is more strongly represented by the FRCP grads.

    My FM training was great prep for a career in EM. So much encountered in the ED is routine family practice content (knowledge of normal well-baby behaviours, medication adverse effects, DDx of rash, working in collaboration with consultants). The fellowship year is only pursued by the EM keeners, whose drive to learn is very high. Self-directed learning that addresses knowledge gaps and skills gaps is the rule and generally prepares graduates well for independent practice.

    Just some thoughts.

    Keep up the excellent work, Brent.

  • Rob Sedran

    Nice blog Brent, and all those that have replied.
    I was one of those who applied to the FRCPC program exclusively, mostly because all of my early mentors in clerkship were RC docs. I also did not have any desire to do family practise, and wanted the five years to learn the specialty.
    These blogs are helpful, especially to medical students applying to residencies, but also to our colleagues within EM. How do you pick CCFP-EM vs FRCPC-EM. Difficult to answer for many reasons, mostly personal bias, but also because the answer is difficult. Politically difficult. More blogs are helpful to generate more discussion. I think we as an organization (CAEP) should advocate for more training positions in both streams, and try to get more credentialed docs in our emerg departments. Stop with this unsupported rumour that after five years of clinical experience the two are indistinguishable the same. Likely not true and untestable and besides, why do we have to argue equivalence. How about enjoy our differences and skills. Both streams have much to offer.
    I gave a seminar the other day to 12 students interested in emerg med as a career. My first question was how many ways are there to train as a specialist in Emergency Medicine in Canada. Half the group answered two. The basic facts of how to differentiate one residency from another is lacking. They are missing the point altogether. It a personal choice between on or the other. If you want to practice family and emerg, do the CCFP-EM. If you want exclusively emerg med apply to the FRCPC residency training programs. Remember there is in specialist designation for EM in this country and that is given through the Royal College. If you want to be a Family Physician with a special competency year in EM, then the CCFP-EM residency is the way to go. I work with both residency`s learners and work in a completely blended practice group with both types of docs.
    We need to stop saying the two are the same and celebrate the differences. The country is served well

    As always, long live the Royal College.

    • http://boringem.org Brent Thoma

      Rob & Elisha,
      Thank you for those exceptionally well thought out replies! I think you responded to the previous comments better than I ever could have.
      While I never intended for this to become a forum for this discussion, as mentioned in the original post I think the diversity of opinions is important to see. Thanks to everyone for contributing!

  • https://twitter.com/cbyrne2014 Chris Byrne
    • http://boringem.org Brent Thoma

      Chris,
      Thanks for the link! I had access to that document from my time on the CAEP board and I used many of the articles to inform my opinions. When Danica pointed out that it was available I added a link for it into the article. It’s definitely worth a read for anyone interested in more information on this topic.
      Thanks!

  • http://www.want2bemd.tumblr.com Danica

    Something that I’m actually surprised hasn’t come up yet is what about the (usually older) docs who are working in EDs who are “just” family docs, with no specialization in EM at all? Probably mostly in rural(er) areas, but I know even in my hometown of ~30,000 (up until a few years ago anyway) the ED was staffed by FMs who rotated through on a schedule. They had no extra “EM year”.

    I think this has been changing over time and they have a few EMs there now, but many have simply been grandfathered in.

    • http://boringem.org Brent Thoma

      Danica,

      I never thought to mention it, but you’re very correct. EM as a specialty isn’t that old (based on the article from Ducharme & Innes ~30-35 years) and I doubt there were a lot of positions in the early days. There are tons of family physicians and general practitioners (pre-family med there was just the rotating internship year) with no specific EM training working in emergency rooms across the country. This is especially true in rural and regional areas as implied by 94% of the CCFP-EM’s (and virtually all of the FRCPC’s) working in urban/suburban areas. In Saskatchewan I don’t know too many CCFP-EM’s that work outside of Saskatoon and Regina.

      More than just grandfathering, there does not seem to be enough EM physicians trained in the programs combined to fill the ED’s of all non-major cities. Saskatoon still has CCFP’s that graduated relatively recently working in our ED’s who are planning to challenge their EM exam but have not yet. We’d like to hire some more folks with EM credentials, but Saskatoon and Regina have been working short for the last few years because there are not many available.

  • Sandy Dong

    Wow, way more comments here than on FB! Danica, there are indeed non-credentialed EPs out there, working in tertiary care centres (including mine). As I pointed out in the FB thread, the free-market supply/demand model of EPs is so lopsided that non-credentialed physicians are still being hired in full-time EDs in urban settings! Your readings of the CFPC Red Book and the RCPS Objectives of Training (sound like political ideology?) reflect how the two colleges approach the practice of EM. The CFPC, at least in theory, views FM-EM (as well as FM-Anesthesia, OB, geriatrics) as Enhanced Skills to the FP skillset. In my experience, and that of your surveyed institutions, the truth could not be further. The Red Book, in fact, prescribes, as an accreditable standard, that EM teaching be done by community FPs. In my setting, all the CFPC-EM residents learn EM learn from full time EPs, none of whom have a mixed office practice, from both training streams. (Don’t tell the surveyors!) I doubt many CFPC-EM programs would meet that standard today. Interestingly, there is a program (Dal) that offers a direct entry CFPC-EM from CaRMS, as well as a RCPS-EM program. Interesting to see if this model will spread, and how the CFPC feels about an FM training program that will, statistically, graduate only EPs.

    • http://boringem.org Brent Thoma

      Thanks for the great comments Dr. Dong!

  • Jay

    Good post, Brent. Quite fair, I thought.

    I jumped to the Montreal Task Force Update in 2010 (which is now three years old) and it was interesting to see they thought the current programs are inadequate or unsuitable to suit the current population. Any idea what they have brewing? There’s always talk of the 4-year “hybrid” but it seems like that record has been on repeat for years…

    • http://boringem.org Brent Thoma

      Jay,
      While I’m not involved at any level with CAEP, the CFPC or the RCPSC, based on what I heard from CAEP last year around this time there is not much appetite from either of the latter two bodies to take this anywhere. CAEP’s going to look into a few more things, but I don’t think there is a proposal that would satisfy the needs/wants of both colleges.
      I doubt we’ll see change any time soon, but the big-wigs would have a more up-to-date and educated opinion!
      -brent

    • Rob Sedran

      The Montreal task force has been neutralized. Their purpose now is to explore commonalities in the two programs to exploit opportunities. The RC-EM and the CCFP-EM PD’s had no interest in a common program. The country is well served by a two training stream system approach and both programs lead to a diverse EM approach. Once again we should be pointing out our diversity and not saying we are all equivalent.

  • Justin Kopp

    When I did my ER rotation in medical school I asked a preceptor which route was the best one. His advice was, “If you just want to work in the ER a CCFP(EM) will suffice, if you want to have a serious career in academia and research then go through the FRCP. (I should mention he was an EM).

    I wouldn’t say his statement is 100% true, but I do think it holds some validity. When one has five years to establish themselves at an academic emergency hospital during their training I imagine it does make transitioning into a similar institution far easier. Our hospital (USask) had/has mostly CCFP(EM)’s and they do provide a wealth of teaching and do some great research, but it’s not clear to me if this is the case in the larger centers.

    That said I think the general sentiment on this site is the correct one; that is if you like family medicine then the CCFP route is the way to go otherwise do the FRCP. I think it is also fine to backup with the CCFP (unless you really hate family medicine). Keep in mind that even if you do not match with the CCFP, there are opportunities out there to challenge the exam after five years of emergency experience. Many rural providers do it this way… and some busy “rural” emergency care centers provide a decent level of acuity and patient mix to keep things very interesting (for example Prince Albert).

    I personally only chose CCFP programs during the matching process because I enjoyed my family medicine rotations, specifically my rural ones. In fact since I didn’t match to EM until I had worked a year as a GP, I almost opted to decline the match and continue working as a family doc (although I’m glad that I took the chance as I’m having a lot of fun)!

    I think the table you posted is probably the most salient point. Really just reference the table and it gives a person enough information to make an informed choice. If you’re like me and enjoy family med then do the EM, if not do the FRCP. I will say, though, not to chose it based on program length because if you hate family medicine those two years of training are going to feel like four.

  • Merna Adel

    Thanks for the great blog…really helpful
    I just have a question please if anyone could help..is there a difference in the job opportunities offered post residency for both tracks?
    is there any preference or they’re treated equally and the preference is based on the CV?
    another question, for CCFP-EM route…do they take their EM training in university hospitals or large tertiary care centers? or just restricted to community hospitals?
    thanQ

    • http://boringem.org Brent Thoma

      Merna, I responded to this question on the facebook post you made. To reiterate:
      I think I answered most of those questions in the post. Anecdotally, the job market for EM doctors graduating from either program is great right now. I have no idea what it will be like in the future. While I anticipate that in the majority of cases a Royal College trained doctor would get hired before a CCFP-EM trained doctor if both were fresh out of residency and there was only 1 job, that’s hypothetical and right now they both have great job opportunities everywhere. You’d have to look at the specific CCFP-EM program to see where they train.
      -bt