Emergency medicine as a primary specialty—French emergency medicine residents’ attitudes

Abstract

Emergency medicine (EM) has been a fellowship program (supra-specialty) in France since 2004. Even though the program can be accessed after completion of one of several primary specialties, the vast majority (97%) of its residents enter the program after having completed training in family medicine. A change to develop a primary EM specialty is being discussed. Our objective was to assess French residents and young EM physicians’ attitudes toward EM as a primary specialty. We conducted a brief cross-sectional online survey among young EM physicians and trainees in November and December 2012. There were 288 respondents to the survey. Forty-nine percent (n=142) of respondents would have chosen EM if it was a primary specialty, but 73% (n=209) prefer maintaining the status quo, offering EM training as a supra-specialty fellowship program. Work-related quality of life was the main reason for those not choosing EM as a primary specialty.

Résumé

La médecine d’urgence (MU) est un programme d’études postdoctorales (surspécialité) en France depuis 2004. Bien qu’il soit possible de suivre le programme après la fin des études dans une des nombreuses spécialités de base, la plupart (97 %) des résidents s’inscrivent au programme après avoir terminé leur formation en médecine familiale. Il sera donc question d’un changement visant à faire de la MU une spécialité de base. L’étude avait pour but d’évaluer l’attitude des résidents et de jeunes urgentologues français à l’égard de la MU comme spécialité de base. Une brève enquête transversale a été menée en ligne parmi de jeunes urgentologues et des stagiaires, en novembre et en décembre 2012; il y a eu 288 répondants. Quarante-neuf pour cent (n=142) d’entre eux ont indiqué qu’ils auraient choisi la MU si elle avait été une spécialité de base; néanmoins, 73 % (n=209) des répondants ont déclaré préférer la situation actuelle, c’est-à-dire considérer la MU comme une surspécialité et suivre la formation en programme d’études postdoctorales. La qualité de vie liée au travail était le principal motif invoqué pour ne pas choisir la MU comme spécialité de base.

Introduction

Every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine (EM). ¹ In 2004, EM became a supra-specialty in France. Even though the program can be accessed after completion of one of several primary specialties (including anesthesiology and intensive care, cardiology, general surgery, gastroenterology, internal medicine, nephrology, neurology, pediatrics, pneumology, and psychiatry), the vast majority of its residents enter the program after having completed training in family medicine. ² Ninety-seven percent of French EM residents’ training includes 3 years of family medicine and 2 years of EM supra-specialty. Because the last year of family medicine and the first year of EM can be done in parallel, fully qualified EM physicians complete 4 years of residency but train only 2 years in EM. Therefore, 50% of EM resident training is in another specialty. French EM leaders have been advocating for recognition of EM as a primary specialty, as is already the case in nine European community countries ³ and others around the world. A curriculum proposing a 4-year residency with eight rotations in various clinical departments, including a set of core competencies for a certified EM specialist, has been developed. ⁴ To assess attitudes of young French EM physicians and residents toward the change of EM training to a primary specialty, we performed a two-question cross-sectional online survey.

Methods

The survey was developed, tested, and distributed by email to young EM physicians and residents from November to December 2012, via the Association des Jeunes Médecins Urgentistes (AJMU) national network (Association of Young Emergency Medicine Practitioners). The AJMU network comprises the majority of EM physicians trained since 2004. At the time of the survey, almost 500 residents or physicians in their first decade of practice were part of the AJMU database: 80% residents and 20% young professionals. Residents were equally distributed as either first- or second-year supra-specialty residents. The participants were invited to answer an online survey (SatisFactory, http://www.satisfactory.fr/). The authors monitored the response rate and sent two reminders by email, 2 weeks and 1 week before the end of the survey period. EM residents and young physicians were asked two questions: If EM were a primary specialty, would you have chosen it? and If you could choose between EM as a supra-specialty and EM as a primary specialty, which would you have chosen? Participants were also invited to comment on the subject.

Results

The response rate was 59% (n=288, total=489). Forty-nine percent (n=142) stated that they would have chosen EM if it were a primary specialty. A majority of respondents, 73% (n=209), prefer maintaining the status quo, offering EM training as a supra-specialty fellowship program. More than 31% of the participants (n=92) left a comment to express how they felt about this issue.

There were enthusiastic comments from participants in favour of the primary specialty. They indicated that a primary specialty would offer a better, more complete, practical, and theoretical training. It would promote the specialty’s academic aspects and encourage research in the field. Most expressed that EM becoming a primary specialty would be a necessary step in EM evolution, allowing students to directly begin their careers and remain specialized in this field.

Among the participants who favoured the supra-specialty system, the comments were mostly apprehensive. Most stated that they were currently working exclusively in an EM department, but they were concerned about their abilities to work in EM for many years, citing quality of life, fatigue, and sleep loss as concerns. In most of the comments, maintaining a stable family life while practicing EM appeared to be difficult, if not impossible. These individuals would like EM to remain a supra-specialty, and thus be able to work as EM physicians and/or family doctors.

Discussion

Our study provides a current view of French EM residents and young physicians’ attitudes toward EM becoming a primary specialty. Half of today’s young EM physicians would have chosen it, if it were a primary specialty. Seventy-three percent prefer the supra-specialty system, if they were given both choices. The main reason for those against EM becoming a primary specialty was related to perceived EM physicians’ quality of life, especially related to professional age and family life. Our results are in line with those published ⁵ in a survey among French medical students. Within that pre-resident population, 52% thought that working in an emergency department (ED) was not compatible with a stable family life. In a study on medical specialty, prestige, and lifestyle preferences of Australian medical students, EM ranked 16th out of 19 specialties, ⁶ on lifestyle. These results may have reflected a difference between perceived lifestyle by medical students and actual lifestyle according to EM physicians. To our knowledge, there was no objective measure of lifestyle friendliness or work-related quality of life used in these trials. In other publications, EM is described as a very attractive specialty among medical students, ⁷ largely because of clinical factors (e.g., diversity of clinical pathology and emphasis on acute care) and because it allows for a controllable lifestyle. ^{8 , 9} EM is considered a lifestyle specialty ^{8 , 9} with predictable hours and a balance among clinical work, administrative duties, organizational commitments, teaching, and/or research. Offering this vast range of activities is only possible when a specialty has reached its critical mass of practitioners, allowing them some “off clinical” time. The number of EM-trained physicians has been consistently rising since 2004, ² and, in the coming years, we will hit that critical mass. Once achieved, the image of EM in France will probably change and will be more comparable to that of other countries around the world.

The results of our work have several limitations. The first is inherent to surveys; they provide a good tool to evaluate attitudes and opinions, but they can suffer from selection bias because those with passionate feelings on the topic tend to participate more than the rest of the target population. The second limitation is the anonymity of our survey, which does not allow us to distinguish the responses in our sample between residents and young emergency physicians. Even if the working conditions were similar in the two populations, we might have identified different rates of preference.

As a consequence of a large consensus among EM academics, physicians, and a favourable national political window, ¹⁰ establishing EM as a primary specialty is currently being examined. Some questions remain, such as how should an ED be staffed? Should all of the physicians working in an ED be specialists in EM? How can family life and professional life be reconciled? We should grasp the opportunity offered by the primary specialty discussions to answer these questions and be able to offer attractive career prospects to our new colleagues. We should be enthusiastic about its evolution as a primary specialty, and see it as a way to improve work-related quality of life and not as an obstacle. Building a primary specialty will put EM physicians in charge of defining their future. Young doctors and residents must be involved in this process, in order to pinpoint and tackle what could prevent medical students and future EM doctors from choosing our specialty. Making EM a primary specialty should lead to improving EM physicians’ training, clinical skills, quality of life, research and publications, and, at the end of the day, allow the best possible care for our patients.