May 15, 2017 via email to: ksharma@cpso.on.ca Kavita Sharma Project Coordinator, Quality Management Division The College of Physicians and Surgeons of Ontario 80 College Street Toronto, Ontario, M5G 2E2 Dear Sirs/Mesdames, Re: CPSO request for feedback on Expectations of Physicians Not Certified in Emergency Medicine Intending to Include Emergency Medicine as Part of Their Practice Thank you for the opportunity to review and comment on the draft framework, Expectations of Physicians Not Certified in Emergency Medicine Intending to Include Emergency Medicine as Part of Their Practice. As the voice of family medicine in Ontario, the Ontario College of Family Physicians (OCFP) represents more than 10,500 family physicians caring for patients across communities throughout the province. The mission of the OCFP is to improve the health of all Ontarians by promoting excellence in family medicine through education, leadership, research and advocacy. Our members provide care within various models and work in centres of diverse sizes in both urban and rural settings. We are all aware that untrained medical professionals performing certain procedures can lead to tragic outcomes. Robust regulatory oversight is crucial to public protection and we commend the efforts of the CPSO to ensure consistency in managing changes in scopes of practice. However, it is crucial that any efforts to improve the delivery of care by physicians in hospital emergency departments be based on evidence and that new guidelines truly address the realities in which our physicians practise. To our knowledge, there is no existing evidence to suggest that the care being provided in Ontario s rural emergency departments (EDs) is currently leading to poor outcomes. We note that, compared to rural EDs, urban EDs are relatively well staffed with Royal College- and CFPCcertified emergency physicians. Urban EDs have funding structures that include formal seconds on call and may also have payment structures that allow for several physicians and this may give one physician who is involved in less urgent cases the capacity to act as mentor. Further, since most urban ED positions are full time, new physicians in this setting may focus on one aspect of family practice emergency medicine (EM) rather than addressing the larger, comprehensive scope of the rural generalist practice. Given these realities, we have fewer concerns about the potential negative ramifications of the current proposals on urban EDs. We believe that if we can make the guideline work in a rural setting for the generalist physician who is practising emergency medicine some of the time, then it will work in an urban setting with the conditions we describe above.
It is not only reasonable for our rural citizens to expect the same high standard of care as those who live in urban centres, it is necessary that we enable physicians who practise in rural settings to have the necessary skills and competencies to provide this level of care. It is important that the CPSO has identified the practice of rural generalism, inclusive of emergency medicine, as a highly demanding domain of care which remains isolated in terms of both geography and system support within our healthcare system. Skilled family physicians are a critical component of healthcare delivery in rural communities and it is crucial that barriers to recruitment are not created. In this response to your request, we have focused on approaches to supporting high-quality emergency care and the unintended consequences that may result from the CPSO s proposed framework. We have also taken this opportunity to outline how educational programs, institutional standards and mentoring can support proficiency, skills and competence among family physicians currently, and how these existing approaches may help inform efforts to enhance care for rural Ontarians. Working in the Public Interest We believe the question of whether the draft guidelines protect the public interest may be better considered as, What harms and what benefits would our rural citizens experience from the proposed guidelines?. While it is absolutely reasonable to articulate an expectation that all patients will receive high-quality care, including in the rural emergency department we are apprehensive that, contrary to your intentions, the expectations outlined in the proposed guidelines could lead more physicians, and in particular new grads, to turn away from rural emergency medicine. In doing so, the human resource available to patients in rural communities to provide comprehensive, family medicine, which has historically included emergency care, risks being diminished to an even greater degree than is already the case. The experiences of our colleagues in other Canadian jurisdictions bear out these concerns. As has been the case in Québec, Saskatchewan and British Columbia, the introduction of competency requirements based on numbers and checklists can lead to reduced access to much-needed services such as OB and anaesthesia in rural areas, and can lead to a loss of human resource, then not only from the hospital setting, but from the community as a whole. As we know, insufficient health human resources lead to significant gaps in patient care. For a healthcare system that is already precarious and arguably nowhere more fragile than in the remote areas of our province reducing the number of physicians who are seen to be able to provide care in rural communities, including qualified EM practitioners, could have serious consequences for care for the whole community. Ensuring Proficiency, Skills and Competence We appreciate the acknowledgement in the CPSO s draft guidelines that a physician s prior training and/or practice experience in EM would be considered on an individual basis in devising a training program. Nonetheless, we stress that months, hours and numbers of procedures do not ensure page 2
competence. In addition to the significant administrative challenges that would come with managing multiple categories of EM certification, we are doubtful that the additional training and supervisory requirements you outline (Pathway 3) can be achieved. Specifically, we note that the checklist of critical skills in your recommendations in particular, the target numbers for experience is generally unobtainable in any reasonable timeframe given the reality that emergency care in a rural environment involves low volume of high-acuity cases. Additionally, if the cost of the lengthy supervision is to be borne by the physician who wishes to retrain to EM as is likely to be the case such retraining is unlikely to be undertaken. Newer family physicians, whether they choose to work in a rural community practising OB, EM or any other specific area, will receive informal support and advice from physician colleagues and from their senior associates in nursing and allied health. It is this support as one enters practice that facilitates the development of confidence in the competencies one has developed as a resident. Family medicine residents may well be deterred from practising as comprehensive generalists in rural communities if guidelines imply that they must have an emergency medicine focus in order to work in the ER or risk scrutiny under the Changing Scope of Practice policy. It would be appropriate for the CPSO to recognize the efforts of local hospitals and credentialing committees to ensure that those who work in the rural hospital setting both ER and the acute care ward where critical illness is often managed for a brief pre-transfer time have the appropriate competencies to undertake that work safely. It is also important that the local systems support those new to the practice of emergency medicine in the community. Rather than the MRP for CTAS 1,2,3 approach noted in the CPSO draft, a formalized mentor for both second on call for any case in which the new practitioner has questions and for formal case review would be more appropriate and would reflect the rural reality from a human resource standpoint as well as the historical practice in most settings. In addition, it s notable that many of the items in the CPSO checklist are now highly supported skills in the age of reliable technology. Questions about EKGs and x-rays, as examples, can now be immediately shared from rural settings to expertise remotely in order to support accurate interpretation and diagnosis. Across Northern Ontario (the NW LHIN and the NE LHIN) virtual ICU brings intensivists into the ER to support the management of critically ill patients in ways that have not been possible in the past. These rapidly evolving technologies serve as supports to rural physicians that make several of the noted items on the checklist seem out of step both with current clinical reality, as well as educational best practice. We further note that specialist certification, while it represents education and can be important to public confidence, cannot be considered the best indicator of competence and must not lead to unwarranted diminishment of the value of the generalist family physician. A physician living in a rural community best serves that community by working in the hospital and the community, competently delivering comprehensive care with a rich set of skills that includes emergency, palliative and other care. Working with colleagues, undertaking education opportunities, practising simulations, and ensuring a local system that is well set up to support the physician to manage the occasional critical skill are all pieces of the challenge of supporting the generalist physician to both develop and maintain competency in the ER setting. page 3
Enhancing Care by Building on Existing Models Your request for feedback asked whether there was anything missing. While not directly related to the changing scope of practice issue, the need to ensure that there are ways for physicians in rural settings to maintain their competence is very important. Any contemplation of physician competencies and skills must consider existing means, measures and mechanisms for not only ensuring that one is prepared to enter a practice domain, but also to ensure that proficiency is maintained. Some of these solutions might be extended to further address competency concerns and human resource challenges. We will take this opportunity to highlight how our rural physicians are effectively overcoming such barriers and providing excellent patient care. Enhanced skills development and continuing professional development. Residents pursuing family medicine in Ontario must meet rigorous requirements of clinical competence, now in a revised Triple C curriculum. These high standards help ensure they are competent and prepared for the breadth of generalist family practice in many settings in Canada. This base of high proficiency is supported by the ongoing training and education offered by the OCFP, the SRPC and other providers. The OCFP s educational mandate aligns well with how physicians in small communities effectively use CPD that matches their clinical needs and helps close skills gaps. It has become increasingly challenging for rural physicians, who work largely in underserved areas, to be able to access hands-on CPD which is often available in large centres. There is a role for the CPSO to advocate for kinds of educational opportunities that make it easier for rural doctors to develop and maintain their skills ensuring that they are not only a resource for clinical care in their ER department, but also a resource to their local colleagues who also must maintain their skills. Systemic clinical support and use of technology. Physicians in low volume settings need to be confident in managing the procedures that can t be delayed in emergencies airway, breathing and circulation (the ABCs ). We know from our members that physicians in small communities routinely draw on the expertise of other local physicians in emergencies. Cooperation such as this enables the physician community to maintain their collective skills in infrequent but challenging procedures both within and outside of the emergency room setting such as central lines, chest tubes, intubations, preterm deliveries and UVC lines. As we note above, increasingly, technology plays a role in these collaborations, including digital transmission of electronic records for urgent interpretation and virtual ICU to help manage critical patients prior to transfer. Consideration must be given to adding as a competency, the ability to effectively use technology to communicate virtually with remote specialists, including through digital imaging and videoconferencing. In addition to technological support, it is clear that it is not just the clinical skills of the physician that matter, but also the capability and effectiveness of the local team, local ER department and the regional system that supports care delivery. A dedicated focus on building and maintaining a system of clinical support is important to the challenge of rural emergency medicine both for new physicians and those more seasoned in practice. page 4
The CPSO may have a role to play with partner organizations like the OHA, LHINs, and the MOHLTC to ensure that adequate local and regional supports are in place to support physicians in the delivery of rural emergency care. The Rural Road Map for Action points to some of the opportunities for regulators to help ensure excellence in rural health care. Mentorship and the OCFP mentoring networks. The principle of mentoring is implicit in the team-based system of clinical support described above. The OCFP s MainPro+-certified Collaborative Mentoring Networks (CMN) formalize this concept, linking family doctors with other more experienced family physicians and specialists in formal arrangements that build confidence and competence among mentees. (We distinguish here between the close clinical supervision described in the Training Options you outline in your draft guidelines which represent one form of mentorship and the formal mentoring networks being led by the OCFP.) Current efforts by the OCFP focus directly on supporting the work of physicians in small and rural communities. Introduction to Ontario of the BC Rural Emergency Care Course is one aspect of this work. A current OCFP proposal to the Ministry of Health and Long-Term Care is to pilot the Course in three northern rural communities, then evaluate and determine how to build an ongoing program in Ontario. The course is an established program that brings together emergency room doctors, paramedics and nurses in a multi-disciplinary approach to rural emergency medicine. Further, while the two existing OCFP-led mentoring networks address mental health, addictions and pain, the second part of our proposal to the Ministry includes expansion of our current mentoring programs to other key areas, including a new network focused on rural medicine. (Other networks in our proposal are leadership, early years in practice, palliative and end-of-life care, and MAiD.) Conclusion The CPSO s draft proposal to address issues of concern for the practice of emergency medicine, particularly in rural settings is well intentioned: The public must be confident that doctors regardless of where they practise in Ontario have the necessary skills to provide high-quality patient care. It is, however, not clear that imposing another level of certification of skills will improve the system. It is also not at all clear that Pathway 3 is tenable, particularly in rural settings, either from the standpoint of attainment of the checklist demands, nor from the standpoint of the financial viability of the longterm supervisory relationship that would be required to undertake the checklist. The determination of competency for those entering emergency medicine must be grounded in sound educational theory and the practical reality of those on whose shoulders that work would rest. Our collective obligation is to ensure Ontarians have access to high-quality medical care when they need it and regardless of where they live. There is a need to ensure that skills are maintained and that skills development is provided in a way that is accessible to rural physicians and the teams with which they work. Through a coordinated multi-pronged approach, including mentorship, higher skills training and page 5
professional development, greater reference to hospital proficiency requirements, and a recognition of the opportunity that technological innovations present, the educational needs of rural physicians to develop and maintain their broad generalist competencies can be met, and the health human resources requirements of rural communities can be supported. We trust that our comments and the solutions we have outlined for discussion are helpful. We urge further consultation on this important topic and would be pleased to further discuss our submission with you. Respectfully submitted by, Glenn Brown, BSc, CCFP(EM), FCFP, MPH OCFP President cc Dr. Tom Smith-Windsor, President, Society of Rural Physicians of Canada Dr. Stephen Cooper, Chair, Rural Expert Panel, Ontario Medical Association page 6
June 7, 2017 Kavita Sharma Quality Management Division The College of Physicians and Surgeons of Ontario 80 College Street Toronto, ON M5G 2E2 Sent via email at: ksharma@cpso.on.ca Re: For Consultation: The CPSO Policy of Changing Scope of Practice: Expectations of Physicians Not Certified in Emergency Medicine Intending to Include Emergency Medicine as Part of Their Practice Dear Ms. Sharma, Thank you for sharing the CPSO s draft policy statement entitled: Changing Scope of Practice: Expectations of Physicians Not Certified in Emergency Medicine Intending to Include Emergency Medicine as Part of Their Practice, with the College of Family Physicians of Canada (CFPC). As the voice of family medicine in Canada, the CFPC strives to ensure that all in Canada have access to timely, equitable and high quality health care. We have consulted with our Emergency Medicine Committee and the Working Group on the Assessment of Competence in Rural and Remote Family Medicine to review the document and render feedback. The policy, while well intentioned, may have unintended consequences that will not serve the interests of Ontarians living in small towns and rural areas. We would like to offer the following feedback for your consideration. Firstly, there is an absence of evidence demonstrating that there is a quality issue with rural emergency medicine care being delivered by non-emergency medicine certified physicians. The CFPC believes the overall result of this policy will further reduce the availability of emergency medicine services in small towns and rural settings, and create barriers to rural generalism and broad-based family practice, which includes emergency medicine. Secondly, the policy does not adequately consider the distinct context of the rural health care system, and the uniqueness of rural health care providers. As noted in the letter submitted to you by the CFPC s Ontario Chapter, the Ontario College of Family Physicians (OCFP), the rural context of emergency medicine practice brings unique challenges and solutions that are not captured in this policy, and cannot be solely understood or resolved by looking at physician skill sets in a static way. The adaptive expertise of rural generalists allows them to interact with the available support systems to ensure that they provide safe and quality care, even when faced with challenging and dynamic situations. The same is true of those who
practice in small towns. With regard to urban emergency practice, we support the views expressed by the OCFP. Thirdly, the practice of emergency medicine does not represent a change in scope, as the CFPC considers it a core element of generalist training and practice. The CFPC is not aware of any reason why there is a specific focus on emergency medicine, as opposed to any other facet of generalist care also considered inherent in the accredited formal scope of family practice and competencies linked to CCFP certification. As such, the requirements indicated in Paragraph 4 of the Definitions / Examples section in the Changing Scope of Practice policy are already being met with respect to emergency medicine. While the CFPC understands the need for individualized assessments of competence for all domains of care, this policy will not effectively assess the competence of physicians wanting or needing to provide emergency care in small towns and rural areas. The stated approach of assigning arbitrary training months, specific numbers of observations, and naming certain rotations does not necessarily imply competence. This is especially true where family medicine trainees are subjected to the competencybased assessment of the Triple-C curriculum. For example, there may be residents trained in rural settings who may not have been exposed to the minimum numbers suggested in each category, but because of other experiences, would be able to manage cases appropriately. It is recommended that specific competencies be defined and having potential applicants demonstrate their preparations and previous experiences. By creating barriers in certain areas, particularly in rural Ontario, it will limit the supply of physicians that meet the requirements, or are willing to sacrifice time and income to meet them in the future. This is especially true for physicians who may have had previous experience, but would need to re-justify their competencies. The consequence of deterring physicians from practicing emergency medicine in rural communities may further decrease an already small pool of potential candidates. Thank you once again for providing the CFPC with the opportunity to provide feedback on this draft policy, which will surely affect current and future family physicians practicing in rural communities. If you have any further questions or comments, please feel free to contact Mr. Eric Mang, the CFPC s Executive Director for Member and External Relations at emang@cfpc.ca. Regards, Francine Lemire, MD CM, CCFP, FCFP, CAE Executive Director and Chief Executive Officer cc: Dr. David White, President, CFPC Mr. Eric Mang, Executive Director, Member and External Relations, CFPC Dr. Eric Wong, Director, Certification and Examinations, Certification and Assessment, CFPC