In this issue of CJEM, after much consultation and debate, the Canadian Association of Emergency Physicians (CAEP) has published its position statement on Emergency Medicine Definitions.Reference McEwen, Borreman and Caudle ¹ As a “senior” emergency physician and one of the few who is proudly certified in emergency medicine (EM) by both the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada (CFPC), I think this is an important document to set the direction for ongoing improvements in emergency care across Canada. It is important to remember how far we have come on the journey. In the 1980s, a number of young, enthusiastic, and mostly male physicians saw a need for improved care in the emergency rooms as they were called at the time. Care was fragmented, there was no triage, prehospital care was “you call, we haul, that’s all,” and the emergency department was often just a “room” and in some provinces was called “The Outdoor.”

Over the next few years, there were dramatic new innovations in care: early intervention in trauma, recognition of sepsis, rapid diagnosis and treatment of cardiovascular emergencies, and a new specialized body of knowledge in the first 15 minutes of every specialty and the critical link to primary care. A small but committed and visionary group of physicians, together with their nursing and paramedic colleagues, forged a new type of practice, rapidly embraced by the public that now has expanded around the world. CAEP was one of four national societies in EM that founded the International Federation for Emergency Medicine in 1991, which has now grown to over 65 national organizations on all continents. ²

As the specialty developed in the 1980s, both certifying colleges saw a need to support training in this new discipline, and thus the two training programs began to train and certify both practicing physicians and new graduates interested in a career in EM. It is also important to consider the unique geography of Canada and its provincially based healthcare system. Medical care in rural Canada has always been delivered by physicians who are increasingly certified by the CFPC that requires broad generalist skills, of which EM is important but not unique. In Canada’s urban and suburban regions (which continue to see marked population growth), high volumes and increased expectations in the delivery of timely, skilled emergency care have resulted in a gradual increase in the number of emergency physicians trained or certified in either the Certification in the College of Family Physicians in Emergency Medicine (CCFP-EM) or RCPSC program.

As part of the work of the Collaborative Working Group (CWG) on the Future of Emergency Medicine,Reference Sinclair, Abu-Laban and Toth ³ an extensive survey was done of practicing emergency physicians, departmental chiefs, and residents in both training programs. We had an excellent response to the surveys, and many respondents took the time to express many strong and passionate opinions on the future of EM and the role of various training programs. The CWG report was completed in June 2016, and the recommendations were accepted and endorsed by CAEP, the CFPC, and the RCPSC. Both colleges have reflected on this work and are collaborating more closely than ever before to improve both training programs to meet the changing EM needs of the Canadian public.

So, here is what we know about the current practice of EM in Canada. Both training programs produce excellent emergency physicians who are well prepared to practice in the currently challenging healthcare system across Canada. CCFP-EM graduates, since the beginning of the program and at the present time, practice EM almost exclusively. Both RCPSC- and CCFP-EM-certified physicians practice in academic settings and are leaders in the specialty at national and international levels. RCPSC-certified physicians practice more in urban, tertiary care settings. Also, perhaps most significantly of all, there is a cohort of at least 2,900 physicians who are certified in family medicine and spending at least 20% of their practice in EM, mostly in rural and remote settings.

This background is important to understand the purpose of the definitions. This work is aspirational and directionally sound. In the background document, CAEP states that its focus is “to encourage incremental change” and support acquisition of certification “wherever possible.” CAEP also encourages certifying colleges and CPD educators to develop “innovative ways” to assist physicians in rural and remote regions to achieve a certification in EM. CAEP has chosen the year 2020 to achieve the certification goal. A goal of 2025 might be more reasonable and palatable to the EM community, but we know that governments need very current dates to get them to act.

The CWG identified a shortage of 478 full-time equivalents nationally in EM in 2016, which is projected to grow to 1,518 in 10 years. Canada needs expansion of current residency programs as well as innovative plans to support and certify physicians providing EM care in rural Canada.

We all need to use this position statement by CAEP as a vision to move forward in partnership and avoid the often negative discourse that in the past has not served Canada, nor our specialty, to achieve excellence. We need to remember the words of Nelson Mandela: “It seems impossible . . . until it is done.”