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.
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.
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:
|Years of residency||5||3|
|Years of EM residency||5||1|
|Family Medicine License||No||Yes|
|Integrated subspecialty/fellowship time||1 year*||No|
|Internationally Recognized EM Credential||Yes||No%|
$ 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.
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.
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!