Progress, frustration and controversy
Rocco Gerace, MD; Bill McCauley, MD
CMAJ 1997;157:1683-4
Dr. Gerace is Chair of the Division of Emergency Medicine and Dr. McCauley is Director of the Residency Program in Emergency Medicine at the University of Western Ontario, London.
© 1997 Canadian Medical Association
mergency medicine was the last discipline granted designation as a primary specialty by the Royal College of Physicians and Surgeons of Canada. Despite the controversies that surrounded this bold move in 1980, the discipline has matured and prospered in the intervening years. Although the specialty is now entering its adolescence -- the first Royal College certifications were granted in 1983 -- and progress continues, emergency medicine is still dogged by frustration and controversy.
The greatest frustration lies in the inability to secure enough training positions to meet demand. A comprehensive survey conducted for the Canadian Association of Emergency Physicians (CAEP) identifies demand for emergency physicians over the next 5 years. In Canada's 998 hospitals, the preferred number of new emergency physicians required is 862.
Each year the country produces 45 new emergency physicians with certification from the College of Family Physicians of Canada, along with 15 who have Royal College certification. This indicates a 5-year total of 300 new emergency physicians, resulting in a production shortfall of 562 doctors. This is quite dramatic, given the overall physician surplus that is said to exist.
Coupled with the shortage of training positions is the growing popularity of emergency medicine as a career. Data from the 1997 match of the Canadian Resident Matching Service indicated that, based upon available positions, emergency medicine ranked a close fourth (after dermatology, plastic surgery and cardiac surgery) in terms of first-choice career selections. Although no national data are available concerning the number of applications received for each position within family medicine's emergency medicine programs, at the University of Western Ontario there were 35 applications for 5 positions during the last residency match. This combination of need and career interest should surely be compelling enough to prompt a re-examination of the distribution of residency positions by both the governments that fund training and the faculties of medicine that provide it.
The interest in emergency medicine extends beyond medical students. The success of the television program ER -- emergency medicine is the only discipline with its own program on prime-time television -- helps to demonstrate the popularity of this specialty with the public at large. Could the dynamism and compassion of the physicians we see on ER, who no doubt portray the discipline accurately because one of the associate producers is an emergency physician, be a factor in encouraging its popularity as a preferred career choice?
Progress within emergency medicine is evident with the international acceptance of the "Ottawa ankle rules," developed by Dr. Ian Stiell and colleagues for doctors to use when determining the need for ankle radiography in patients presenting with an acute ankle injury. Stiell is also lead investigator for the Canadian CT Head and C Spine (CCC) Study, which involves 8 Canadian hospitals and is currently collecting data on patients with acute head and/or neck injury. The goal is to generate a clinical decision-making rule for obtaining computerized tomography in patients who have experienced minor head trauma and plain film radiography of the spine in patients with blunt neck trauma.
Another ongoing multicentre study, the Emergency Diagnosis and Investigation of Thromboembolic Diseases (EDITED) trial, is looking at the utility and safety of d-dimer testing and physician clinical judgement in the diagnosis of thromboembolic diseases. Ongoing recruitment is taking place in Halifax, Ottawa and London, and patients with possible thromboembolic disorders are placed in low-, moderate- and high-risk categories based on predetermined criteria.
Preparations are well under way for Canada to host the International Conference in Emergency Medicine in Vancouver in March. This conference, held every 3 years, is a joint meeting of CAEP, the American College of Emergency Physicians, the Australasian College of Emergency Physicians and the British Association of Emergency Medicine. One highlight will be a live address by emergency physician Dave Williams, an astronaut with the Canadian Space Agency. The speech will be more exciting than most because the speaker will be orbiting the earth at the time!
Controversy in emergency medicine can arise in the form of professional boundary definition. Emergency medicine utilizes knowledge and skills from many other specialties, and the use of these specialties' skills can lead to disputes. In the US, for example, emergency physicians have been performing ultrasonography and employing the results as a diagnostic tool for several years. Its use in the US is now so widespread that training in ultrasonography has become a required element of American residency programs in emergency medicine.
In Canada, however, emergency physicians' use of this simple and inexpensive tool has been slower to develop. Drs. Barry McLellan and Bernard Boulanger of the Sunnybrook Health Science Centre in Toronto have been using ultrasound successfully to detect the presence of free intraperitoneal fluid in victims of abdominal trauma.1 The use of ultrasound by emergency physicians may yet evolve here, as it already has south of the border.
The year's most controversial publication concerning emergency medicine in Canada appeared in CMAJ in September. It concerned the sexual involvement of Ontario emergency physicians with patients.2 Although the report suggested that 8.7% of physicians were aware of a colleague who had become sexually involved with a patient, the likelihood that there were multiple reports of the same sexual encounter was not reflected in the lay press. Further, the lay press reported that "6% [of emergency physicians] admitted to having sex with patients" but did not point out that these were former patients.
Although the report called for the need to clarify the ethics of boundary issues concerning relationships with patients, this message seemed to have been lost beyond the boundaries of CMAJ. In a letter to the editor published in the Toronto Star Sept. 25, the study's authors noted that Ontario's former minister of health had called the report "shocking" and that the premier, although he had not read the report, found the results "unacceptable." In their letter, the authors summarized things appropriately by noting that "the only thing shocking is how this study has been sensationalized and used to embarrass the profession."
For emergency medicine, the frustration associated with becoming a new specialty is largely a thing of the past. The ever-increasing presence of emergency physicians as researchers, educators and leaders within our profession will undoubtedly help this discipline move from being new kid on the block to leader of the pack.
References
- Wherrett LJ, Boulanger BR, McLellan BA, Brenneman FD, Rizoli SB, Culhome J, et al. Hypotension after blunt abdominal trauma: the role for emergency abdominal sonography in surgical triage. J Trauma 1996;41(5):815-20.
- Ovens HJ, Permaul-Woods JA. Emergency physicians and sexual involvement with patients: an Ontario survey. CMAJ 1997;157:663-9.
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