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A survey of Canadians enrolled in American Emergency Medicine residencies22
The Journal of Emergency Medicine, Vol. 18, No. 4, pp. 473– 476, 2000 Copyright © 2000 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/00 $–see front matter
PII S0736-4679(00)00169-4
Canadian Perspectives A SURVEY OF CANADIANS ENROLLED IN AMERICAN EMERGENCY MEDICINE RESIDENCIES Steven J. Socransky,
MD, CCFP, FRCPC,*
Greg Obst,
MD, FAAEM, MSc,†
and Gary Swart,
MD, FACEP‡
*Department of Emergency Medicine, Sudbury Regional Hospital, Sudbury, Ontario, Canada; †Department of Emergency Medicine, Wausau Hospital, Wausau, Wisconsin; ‡Department of Emergency Medicine, Elmbrook Memorial Hospital, Brookfield, Wisconsin Correspondence Address: Steven J. Socransky, MD, CCFP, FRCP, Department of Emergency Medicine, Sudbury Regional Hospital, 700 Paris St., Sudbury, ON, Canada P3E 3B5
e Abstract—Despite the existence of Emergency Medicine (EM) residency programs in Canada, Canadian physicians continue to pursue EM training in the United States. To determine the factors that may influence these Canadian physicians to return to practice in Canada, a survey was sent to all Canadians enrolled in U.S. EM training programs. Seventeen of 22 (77%) post-graduate trainees responded. Residents said they had chosen U.S. training mainly because of the low number of residents in Canadian EM specialty programs, and they also had the perception that U.S. EM training was superior. Lower salaries, restrictions on location of practice, and an inability to obtain Royal College certification were the factors most likely to prevent a return to Canada. Six of the 17 respondents (35%) said they were definitely or probably returning to Canada. Given the limited number of Canadian training positions and the Canadian Emergency Physician workforce shortfall, the U.S. training route appears to be underutilized. © 2000 Elsevier Science Inc.
INTRODUCTION Emergency medicine (EM) has been a recognized specialty in Canada for over 15 years. Many of the early leaders of the specialty in Canada obtained their EM training in the United States. Despite the existence of EM residencies in Canada, Canadian physicians continue to obtain their EM training in the U.S.. Most academic centers in Canada offer an EM training program, either a 5-year Royal College-accredited EM residency (FRCP) or a supplementary year of EM training after a family medicine residency (CCFP[EM]), or both. Despite this, a recent Canadian emergency physician (EP) manpower survey suggests a future shortfall of EM-trained physicians based on Canadian EM training sites alone (1). Canadians who are training in the U.S. may represent a potential resource. The number of Canadians enrolled in U.S. EM residencies is unknown, as are their plans for returning to Canada. This study seeks to answer those questions. It also will examine the residents’ demographics and the factors influencing both their initial move to the U.S. and their possible return to Canada.
e Keywords—Canada; Emergency Medicine; emigration; immigration; health manpower; residency
MATERIALS AND METHODS This is a descriptive study of Canadians enrolled in U.S. EM residencies. An initial screening survey was mailed
All authors are formerly of: Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.
Canadian Perspectives is coordinated by James Ducharme, MD, of the Canadian Association of Emergency Physicians (CAEP) and St. John Regional Hospital, St. John, New Brunswick, Canada
RECEIVED: December 2, 1998; FINAL ACCEPTED: November 10, 1999
SUBMISSION RECEIVED:
October 18, 1999;
473
474
S. J. Socransky et al.
to all U.S. EM residency directors to determine the number of Canadians enrolled in U.S. training programs. The list of residency directors (as of September 1996) was obtained from the Society for Academic Emergency Medicine Internet site. The directors were asked to indicate the number of Canadians who were enrolled in their program as either residents or fellows, and to return the initial survey by fax. Nonresponders received a second mailing. Programs still not responding were contacted by telephone to obtain a 100% response to the initial screening survey. Once the initial survey located the programs with Canadian residents or fellows, a second survey was sent to each program in the winter-spring of 1997 for forwarding to their Canadian trainees. Respondents remained anonymous. The survey asked for information on demographics, experience before EM training, type of EM residency (PGY123, PGY1234, PGY234), and the likelihood of their returning to Canada. Information requested also included legal status in the U.S. Persons on J-1 and H-1B visas are required to return to their home country after a defined period. The holding of a green card generally implies that one is on a path toward U.S. citizenship. Trainees who were potentially returning to Canada were asked to rank a list of factors that might encourage or prevent their return in order of importance. Respondents were also asked to rank factors that had caused them to go to the U.S. for EM training. Finally, space was provided for comments on the future of EM in the two countries. Two mailings of the second survey were sent out, with responses requested by either mail or fax. Telephone follow-ups were also used to maximize the number of responses.
RESULTS The initial screening survey found that there were 22 postgraduate Canadians enrolled in U.S. training programs across all years of training (20 residents and two toxicology fellows). Seventeen surveys were completed and returned by June 1997, including surveys completed by two of the authors (SJS, GO). The average age of respondents was 29.8, with all but one being male. Provinces of origin were Ontario (6), Quebec (5), Alberta (4), British Columbia (2), and Newfoundland (1). Eleven went to medical school in Canada and six in the U.S. Eight had prior internship or residency training, research, or independent practice experience. Seven were enrolled in PGY234 programs, six were enrolled in PGY123 programs, and four were enrolled in PGY1234 programs (including the prior EM residencies of the two fellows). Seven trainees were in the U.S. on a J-1 visa, two were on an H-1B visa, five had green cards, two were U.S.
Table 1. Factors Encouraging a Return to Canada
Factor Family considerations Lifestyle Philosophical preference for Canadia health care system Feelings of loyalty to Canada Preference for Canadian style of practice Salary Visa requirement Fear of U.S. malpractice risk
Average Ordinal Ranking
Number of Times Ranked as Most Important Factor
1 2 3
6 5 0
4 5
1 0
6 7 8
1 2 0
citizens, and one had “other” status. Three stated that they were definitely returning to Canada, three were probably returning, seven were possibly returning, two were unlikely to return, and two were definitely not returning. Of those who were definitely or probably returning to Canada (n ⫽ 6), all were on a J-1 or H-1B visa, all were in a PGY234 or PGY1234 program, and all had gone to medical school in Canada. Five of the six had prior post-graduate training or practice experience. Of those who were definitely not returning or unlikely to return (n ⫽ 4), all had gone to medical school in the United States. Those who were potentially returning to Canada (i.e., all respondents except those who were definitely not returning) ranked factors, in order of importance, that might encourage or prevent their return. The average rankings of all respondents are presented in Tables 1 and 2. The number of times a factor was ranked by a respondent as being the most important also is indicated. Factors influencing the decision to train in the U.S. are presented in Table 3.
Table 2. Factors Discouraging a Return to Canada
Factor Restrictions concerning location of practice Salary Less favorable stature of EM in Canada Lifestyle Inability to obtain Royal College certification Preference for U.S. style of practice Family considerations Lack of opportunity to pursue subinterest in EM
Average Ordinal Ranking
Number of Times Ranked as Most Important Factor
1
3
2 3
4 0
4 5
1 4
6
2
7 8
1 0
Canadians in U.S. EM Residencies
475
Table 3. Factors Influencing the Decision to Train in the U.S.
Factor Preference for U.S. training because of lack of critical mass of EM residents in Canadian programs Limited Canadian training slots Felt U.S. training was better than Canadian training Adventurous spirit No longer eligible for the Canadian Residency Match Already in U.S. because of prior education/move Felt no need/desire to perform 5 years of residency Happy to go anywhere Sought to avoid Canadian medical system
Average Ordinal Ranking
Number of Times Ranked as Most Important Factor
1
1
2 3
2 4
4 5
0 2
6
5
7
1
8 9
0 0
Of the 15 respondents who were potentially returning to Canada, 12 planned on working in a higher-volume ED (⬎40,000 visits/year). All planned on working in an urban or near-urban (within 1 h of a city) hospital; none planned on working in a rural hospital. Eleven anticipated an academic career, with four preferring a community practice. Nine had applied or were planning to apply for the Royal College EM examination. Two were willing to do extra training to become eligible for the Royal College examination. Six others were willing to become eligible for the examination after 2 years of practice in Canada. The rest were, at most, willing to take the examination only if their U.S. training was considered equivalent to a full 5-year Canadian residency.
DISCUSSION The initial screening survey found 22 Canadians enrolled in U.S. EM training programs, 17 of whom responded to the data collection survey. While this represents a small percentage of the over-3,000 EM residents in the U.S., it is a significant number when one considers the number of EM specialists trained in Canada. In each of the last several years, only 10 –20 graduates of Royal College programs obtained specialty status in EM. Though only slightly more than half of Canadians training in the U.S. may return to Canada, this still implies that 3 or 4 specialty-trained EPs per academic year are potentially available to the Canadian workforce—an important number (over 15%) given the production of FRCP programs. These findings are less impressive when one includes the more numerous graduates from CCFP(EM) programs (approximately 45– 60 per year).
The most important factors in the decision to train in the U.S. appear to be related to the low number of residents in Canadian programs, a feeling echoed in the comments section by several respondents. Certainly, many in the Canadian EM community believe that more residency spots should be made available given the EP workforce shortfall (1). In addition, having a critical mass of residents may enhance the robustness of a residency in terms of the general atmosphere, the didactic experience, research productivity, and the education of interns and students. This opinion is echoed by Moore et al. (2). With more residents, a valid demand could be made for the hiring of more staff members to handle the greater academic load, and academic departmental status may be more easily obtained. The next most important factor was the perception that U.S. training is better overall, a point that was also reiterated in the comments section. Though the clinical experience and teaching received in Canada may not be dissimilar from that in the U.S., certainly the academic centers in the U.S. have had an earlier start in the development of trauma centers, EMS systems, ED ultrasound, research expertise, and fellowship training. Many commented that academic EM in Canada needs to be a stronger force and needs more funding. With a majority of respondents being interested in an academic career, certainly their influence may be valuable in this regard. The most important factors encouraging a return to Canada were family considerations and lifestyle. The most important factors preventing a return to Canada were restrictions on location of practice and salary. These findings are not surprising, as they are factors common to many Canadian physicians who have considered a move to the U.S. (3). Interestingly, although ranked only fifth by the average respondent, four trainees said an inability to obtain FRCP certification would be the most important factor potentially preventing their return to Canada. Currently, the Royal College has a strict requirement for 5 years of residency training to become eligible for the EM examination. Many of the respondents who appear more likely to return to Canada have significant prior training and are following a 4-year U.S. residency pathway, perhaps because of the Royal College standards. Nevertheless, many encounter difficulty in obtaining eligibility status. It appears from the survey that many respondents would be willing to take the examination on the basis of practice eligibility after 2 years of working in Canada. However, given the licensure requirements of some provinces, an inability to take the FRCP examination may effectively prevent some Canadians from obtaining a license for independent medical practice in their home province. Conversion of the FRCP program to a 4-year residency, as has been re-
476
cently suggested, might let more of these trainees take the Royal College examination (4). The popularity of EM as a specialty in the U.S. among U.S. medical students has grown considerably over the last 20 years. Concurrently, the popularity of EM training in Canada has also grown. Many qualified CCFP(EM) and FRCP candidates do not obtain positions because of a limited number of training spots. Although the number of Canadians presently training in the U.S. may seem significant at first glance, U.S. training is perhaps underutilized as a training ground by Canadians seeking a career in EM. An increased number of Canadians training in the U.S. would temporarily ease the shortfall of Canadian EPs, while increasing the momentum of the specialty’s development in Canada. This survey has several limitations. Although it may be interesting to find that 22 Canadians are in U.S. EM residencies, this number is too small to allow for definite conclusions. The number is further limited by the 23% nonresponse rate and the facts that 12% of the surveys were completed by authors of this study and that 35% of respondents went to medical school in the U.S. and, therefore, likely have limited knowledge of Canadian EM as reflected by their limited desire to return to Canada. The opinions expressed regarding quality of EM training in the U.S. compared with that available in Canada are likely to be different from those of EM residents in Canada. Our respondents likely began developing their opinions regarding EM in Canada in the early ’90s. Since then, EM in Canada has continued to develop and may no longer engender similar opinions. A similar survey of Canadian-based EM trainees would be interesting and useful. Tools should be developed to serially evaluate the clinical skills of residents so that the adequate EM training period can be determined
S. J. Socransky et al.
with accuracy. Finally, future research regarding the Canadian EP workforce should evaluate the emigration of established Canadian EPs to the U.S. and other countries.
CONCLUSIONS The most important factors encouraging a return to Canada were family considerations and lifestyle. Restrictions on location of practice, salary considerations, and an inability to obtain FRCP certification figured prominently as factors that might prevent a return to Canada. Although Canadians continue to pursue EM training in the U.S., the U.S. training route appears to be underutilized given the limited number of Canadian training positions and the Canadian EP workforce shortfall. Canadian medical students and residents interested in EM should be encouraged to consider U.S. training.
Acknowledgments—We thank Izora Brown for her tireless secretarial support, Dr. Annie Gareau for her advice regarding survey development, and Dr. Chris Bourdon for his helpful review of the manuscript.
REFERENCES 1. Beveridge R, Lloyd S. Manpower survey (II): remuneration and future expectations. CAEP Communique´ 1996;Spring:18 –20. 2. Moore K, Lucky CA. Emergency medicine training in Canada. Can J Emerg Med 1999;1:51–3. 3. McKendry RJR, Wells GA, Dale P, et al. Factors influencing the emigration of physicians from Canada to the United States. Can Med Assoc J 1996;154:171– 81. 4. Etherington J. An immodest proposal: the future of emergency medicine training in Canada. CAEP Communique´ 1997–98;Winter:16 –9.
PII S0736-4679(00)00169-4
Canadian Perspectives A SURVEY OF CANADIANS ENROLLED IN AMERICAN EMERGENCY MEDICINE RESIDENCIES Steven J. Socransky,
MD, CCFP, FRCPC,*
Greg Obst,
MD, FAAEM, MSc,†
and Gary Swart,
MD, FACEP‡
*Department of Emergency Medicine, Sudbury Regional Hospital, Sudbury, Ontario, Canada; †Department of Emergency Medicine, Wausau Hospital, Wausau, Wisconsin; ‡Department of Emergency Medicine, Elmbrook Memorial Hospital, Brookfield, Wisconsin Correspondence Address: Steven J. Socransky, MD, CCFP, FRCP, Department of Emergency Medicine, Sudbury Regional Hospital, 700 Paris St., Sudbury, ON, Canada P3E 3B5
e Abstract—Despite the existence of Emergency Medicine (EM) residency programs in Canada, Canadian physicians continue to pursue EM training in the United States. To determine the factors that may influence these Canadian physicians to return to practice in Canada, a survey was sent to all Canadians enrolled in U.S. EM training programs. Seventeen of 22 (77%) post-graduate trainees responded. Residents said they had chosen U.S. training mainly because of the low number of residents in Canadian EM specialty programs, and they also had the perception that U.S. EM training was superior. Lower salaries, restrictions on location of practice, and an inability to obtain Royal College certification were the factors most likely to prevent a return to Canada. Six of the 17 respondents (35%) said they were definitely or probably returning to Canada. Given the limited number of Canadian training positions and the Canadian Emergency Physician workforce shortfall, the U.S. training route appears to be underutilized. © 2000 Elsevier Science Inc.
INTRODUCTION Emergency medicine (EM) has been a recognized specialty in Canada for over 15 years. Many of the early leaders of the specialty in Canada obtained their EM training in the United States. Despite the existence of EM residencies in Canada, Canadian physicians continue to obtain their EM training in the U.S.. Most academic centers in Canada offer an EM training program, either a 5-year Royal College-accredited EM residency (FRCP) or a supplementary year of EM training after a family medicine residency (CCFP[EM]), or both. Despite this, a recent Canadian emergency physician (EP) manpower survey suggests a future shortfall of EM-trained physicians based on Canadian EM training sites alone (1). Canadians who are training in the U.S. may represent a potential resource. The number of Canadians enrolled in U.S. EM residencies is unknown, as are their plans for returning to Canada. This study seeks to answer those questions. It also will examine the residents’ demographics and the factors influencing both their initial move to the U.S. and their possible return to Canada.
e Keywords—Canada; Emergency Medicine; emigration; immigration; health manpower; residency
MATERIALS AND METHODS This is a descriptive study of Canadians enrolled in U.S. EM residencies. An initial screening survey was mailed
All authors are formerly of: Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.
Canadian Perspectives is coordinated by James Ducharme, MD, of the Canadian Association of Emergency Physicians (CAEP) and St. John Regional Hospital, St. John, New Brunswick, Canada
RECEIVED: December 2, 1998; FINAL ACCEPTED: November 10, 1999
SUBMISSION RECEIVED:
October 18, 1999;
473
474
S. J. Socransky et al.
to all U.S. EM residency directors to determine the number of Canadians enrolled in U.S. training programs. The list of residency directors (as of September 1996) was obtained from the Society for Academic Emergency Medicine Internet site. The directors were asked to indicate the number of Canadians who were enrolled in their program as either residents or fellows, and to return the initial survey by fax. Nonresponders received a second mailing. Programs still not responding were contacted by telephone to obtain a 100% response to the initial screening survey. Once the initial survey located the programs with Canadian residents or fellows, a second survey was sent to each program in the winter-spring of 1997 for forwarding to their Canadian trainees. Respondents remained anonymous. The survey asked for information on demographics, experience before EM training, type of EM residency (PGY123, PGY1234, PGY234), and the likelihood of their returning to Canada. Information requested also included legal status in the U.S. Persons on J-1 and H-1B visas are required to return to their home country after a defined period. The holding of a green card generally implies that one is on a path toward U.S. citizenship. Trainees who were potentially returning to Canada were asked to rank a list of factors that might encourage or prevent their return in order of importance. Respondents were also asked to rank factors that had caused them to go to the U.S. for EM training. Finally, space was provided for comments on the future of EM in the two countries. Two mailings of the second survey were sent out, with responses requested by either mail or fax. Telephone follow-ups were also used to maximize the number of responses.
RESULTS The initial screening survey found that there were 22 postgraduate Canadians enrolled in U.S. training programs across all years of training (20 residents and two toxicology fellows). Seventeen surveys were completed and returned by June 1997, including surveys completed by two of the authors (SJS, GO). The average age of respondents was 29.8, with all but one being male. Provinces of origin were Ontario (6), Quebec (5), Alberta (4), British Columbia (2), and Newfoundland (1). Eleven went to medical school in Canada and six in the U.S. Eight had prior internship or residency training, research, or independent practice experience. Seven were enrolled in PGY234 programs, six were enrolled in PGY123 programs, and four were enrolled in PGY1234 programs (including the prior EM residencies of the two fellows). Seven trainees were in the U.S. on a J-1 visa, two were on an H-1B visa, five had green cards, two were U.S.
Table 1. Factors Encouraging a Return to Canada
Factor Family considerations Lifestyle Philosophical preference for Canadia health care system Feelings of loyalty to Canada Preference for Canadian style of practice Salary Visa requirement Fear of U.S. malpractice risk
Average Ordinal Ranking
Number of Times Ranked as Most Important Factor
1 2 3
6 5 0
4 5
1 0
6 7 8
1 2 0
citizens, and one had “other” status. Three stated that they were definitely returning to Canada, three were probably returning, seven were possibly returning, two were unlikely to return, and two were definitely not returning. Of those who were definitely or probably returning to Canada (n ⫽ 6), all were on a J-1 or H-1B visa, all were in a PGY234 or PGY1234 program, and all had gone to medical school in Canada. Five of the six had prior post-graduate training or practice experience. Of those who were definitely not returning or unlikely to return (n ⫽ 4), all had gone to medical school in the United States. Those who were potentially returning to Canada (i.e., all respondents except those who were definitely not returning) ranked factors, in order of importance, that might encourage or prevent their return. The average rankings of all respondents are presented in Tables 1 and 2. The number of times a factor was ranked by a respondent as being the most important also is indicated. Factors influencing the decision to train in the U.S. are presented in Table 3.
Table 2. Factors Discouraging a Return to Canada
Factor Restrictions concerning location of practice Salary Less favorable stature of EM in Canada Lifestyle Inability to obtain Royal College certification Preference for U.S. style of practice Family considerations Lack of opportunity to pursue subinterest in EM
Average Ordinal Ranking
Number of Times Ranked as Most Important Factor
1
3
2 3
4 0
4 5
1 4
6
2
7 8
1 0
Canadians in U.S. EM Residencies
475
Table 3. Factors Influencing the Decision to Train in the U.S.
Factor Preference for U.S. training because of lack of critical mass of EM residents in Canadian programs Limited Canadian training slots Felt U.S. training was better than Canadian training Adventurous spirit No longer eligible for the Canadian Residency Match Already in U.S. because of prior education/move Felt no need/desire to perform 5 years of residency Happy to go anywhere Sought to avoid Canadian medical system
Average Ordinal Ranking
Number of Times Ranked as Most Important Factor
1
1
2 3
2 4
4 5
0 2
6
5
7
1
8 9
0 0
Of the 15 respondents who were potentially returning to Canada, 12 planned on working in a higher-volume ED (⬎40,000 visits/year). All planned on working in an urban or near-urban (within 1 h of a city) hospital; none planned on working in a rural hospital. Eleven anticipated an academic career, with four preferring a community practice. Nine had applied or were planning to apply for the Royal College EM examination. Two were willing to do extra training to become eligible for the Royal College examination. Six others were willing to become eligible for the examination after 2 years of practice in Canada. The rest were, at most, willing to take the examination only if their U.S. training was considered equivalent to a full 5-year Canadian residency.
DISCUSSION The initial screening survey found 22 Canadians enrolled in U.S. EM training programs, 17 of whom responded to the data collection survey. While this represents a small percentage of the over-3,000 EM residents in the U.S., it is a significant number when one considers the number of EM specialists trained in Canada. In each of the last several years, only 10 –20 graduates of Royal College programs obtained specialty status in EM. Though only slightly more than half of Canadians training in the U.S. may return to Canada, this still implies that 3 or 4 specialty-trained EPs per academic year are potentially available to the Canadian workforce—an important number (over 15%) given the production of FRCP programs. These findings are less impressive when one includes the more numerous graduates from CCFP(EM) programs (approximately 45– 60 per year).
The most important factors in the decision to train in the U.S. appear to be related to the low number of residents in Canadian programs, a feeling echoed in the comments section by several respondents. Certainly, many in the Canadian EM community believe that more residency spots should be made available given the EP workforce shortfall (1). In addition, having a critical mass of residents may enhance the robustness of a residency in terms of the general atmosphere, the didactic experience, research productivity, and the education of interns and students. This opinion is echoed by Moore et al. (2). With more residents, a valid demand could be made for the hiring of more staff members to handle the greater academic load, and academic departmental status may be more easily obtained. The next most important factor was the perception that U.S. training is better overall, a point that was also reiterated in the comments section. Though the clinical experience and teaching received in Canada may not be dissimilar from that in the U.S., certainly the academic centers in the U.S. have had an earlier start in the development of trauma centers, EMS systems, ED ultrasound, research expertise, and fellowship training. Many commented that academic EM in Canada needs to be a stronger force and needs more funding. With a majority of respondents being interested in an academic career, certainly their influence may be valuable in this regard. The most important factors encouraging a return to Canada were family considerations and lifestyle. The most important factors preventing a return to Canada were restrictions on location of practice and salary. These findings are not surprising, as they are factors common to many Canadian physicians who have considered a move to the U.S. (3). Interestingly, although ranked only fifth by the average respondent, four trainees said an inability to obtain FRCP certification would be the most important factor potentially preventing their return to Canada. Currently, the Royal College has a strict requirement for 5 years of residency training to become eligible for the EM examination. Many of the respondents who appear more likely to return to Canada have significant prior training and are following a 4-year U.S. residency pathway, perhaps because of the Royal College standards. Nevertheless, many encounter difficulty in obtaining eligibility status. It appears from the survey that many respondents would be willing to take the examination on the basis of practice eligibility after 2 years of working in Canada. However, given the licensure requirements of some provinces, an inability to take the FRCP examination may effectively prevent some Canadians from obtaining a license for independent medical practice in their home province. Conversion of the FRCP program to a 4-year residency, as has been re-
476
cently suggested, might let more of these trainees take the Royal College examination (4). The popularity of EM as a specialty in the U.S. among U.S. medical students has grown considerably over the last 20 years. Concurrently, the popularity of EM training in Canada has also grown. Many qualified CCFP(EM) and FRCP candidates do not obtain positions because of a limited number of training spots. Although the number of Canadians presently training in the U.S. may seem significant at first glance, U.S. training is perhaps underutilized as a training ground by Canadians seeking a career in EM. An increased number of Canadians training in the U.S. would temporarily ease the shortfall of Canadian EPs, while increasing the momentum of the specialty’s development in Canada. This survey has several limitations. Although it may be interesting to find that 22 Canadians are in U.S. EM residencies, this number is too small to allow for definite conclusions. The number is further limited by the 23% nonresponse rate and the facts that 12% of the surveys were completed by authors of this study and that 35% of respondents went to medical school in the U.S. and, therefore, likely have limited knowledge of Canadian EM as reflected by their limited desire to return to Canada. The opinions expressed regarding quality of EM training in the U.S. compared with that available in Canada are likely to be different from those of EM residents in Canada. Our respondents likely began developing their opinions regarding EM in Canada in the early ’90s. Since then, EM in Canada has continued to develop and may no longer engender similar opinions. A similar survey of Canadian-based EM trainees would be interesting and useful. Tools should be developed to serially evaluate the clinical skills of residents so that the adequate EM training period can be determined
S. J. Socransky et al.
with accuracy. Finally, future research regarding the Canadian EP workforce should evaluate the emigration of established Canadian EPs to the U.S. and other countries.
CONCLUSIONS The most important factors encouraging a return to Canada were family considerations and lifestyle. Restrictions on location of practice, salary considerations, and an inability to obtain FRCP certification figured prominently as factors that might prevent a return to Canada. Although Canadians continue to pursue EM training in the U.S., the U.S. training route appears to be underutilized given the limited number of Canadian training positions and the Canadian EP workforce shortfall. Canadian medical students and residents interested in EM should be encouraged to consider U.S. training.
Acknowledgments—We thank Izora Brown for her tireless secretarial support, Dr. Annie Gareau for her advice regarding survey development, and Dr. Chris Bourdon for his helpful review of the manuscript.
REFERENCES 1. Beveridge R, Lloyd S. Manpower survey (II): remuneration and future expectations. CAEP Communique´ 1996;Spring:18 –20. 2. Moore K, Lucky CA. Emergency medicine training in Canada. Can J Emerg Med 1999;1:51–3. 3. McKendry RJR, Wells GA, Dale P, et al. Factors influencing the emigration of physicians from Canada to the United States. Can Med Assoc J 1996;154:171– 81. 4. Etherington J. An immodest proposal: the future of emergency medicine training in Canada. CAEP Communique´ 1997–98;Winter:16 –9.