Note: This is the fifth installment in a seven-part series Brian Doyle prepared to help colleagues make the most of an emergency medicine rotation Down Under.
Part V:
Advanced Training in Emergency Medicine
In Australia, medical school is for six years commencing after high school.
After this, they do basic training for two years; an internship year and then at least one more year before they can apply to the Australasian College for Emergency Medicine for advanced training. Unlike the USA, training is much more individualized and must be undertaken at multiple different hospitals.
The next step is at least one year of provisional training during which time they must spend 12 months in an accredited ED. (ACEM determines which EDs in Australia can train emergency trainees and for how long; 6, 12, or 24 months.) From this point onwards, the trainee is referred to as an emergency “registrar” similar to an emergency resident in the USA. During this provisional training, they must pass theprimary exam. This exam is similar to USMLE step 1 and a major pain in @%^*. There are four sections; anatomy, pathology, pharmacology, and physiology.
After provisional training comes advanced training. This is at least four years long, but is often years longer depending on the motivation and commitment of the registrar. Often they take “time-off” and get paid quite well doing other things that are not recognized as contributing to their 48 month commitment. (Like being a doctor in Antarctica…) Of the 48 months, 30 months must be in an accredited ED (but 6 months must be done in an urban district or a regional/rural hospital) and 18 months are off service… most registrars will do some anesthetics and other rotations. There is a minimum pediatric requirement and a “4:10.” The 4:10 is a major hurdle in training in EM. It is the research requirement and the college takes this very seriously. I had to perform research, present it at a national conference, and have it formally adjudicated before I could even consider having my USA ABEM qualifications recognized by ACEM. Many trainees actual publish research in a peer reviewed journal.
After all of the above requirements are met, they take the fellowship exam. I believe the pass rate for the fellowship exam is about 60% (but I could be wrong.) I do know that it is very common for people to fail the exam on multiple attempts.
My belief is that the average new FACEM is actually more experienced than the average new ABEM graduate. But after a couple of years, the end product is really the same and boils down to the individual. In some ways the training in the USA is better since it seems to be more comprehensive with formal training in many different environments (surgical, pediatric ICU, ultrasound, EMS, toxicology, etc) but in many ways the FACEM may also be more well rounded. They will often spend at least 6 months in anesthetics, during which time they start all of the large IVs and manage entire operative cases on their own (with back-up of course…) playing around with inhalation anesthetics etc.(hopefully, not on themselves…)
FACEMs… to reiterate
A fully qualified emergency physician in Australia is referred to as a FACEM… Faculty of the Australasian College for Emergency Medicine. ACEM, the Australasian College, administers the fellowship examination (much like ABEM does in the USA, but ABEM is not part of ACEP). The Australians are not really sure what to call a US trained ABEM graduate, so they call us FACEPs. Even though this may not really be correct, it is easier not to try to correct them. Just call yourself a FACEP! (I’m sure that ACEP would understand given the circumstances…)
More on FACEMs and ED Cover
There are only about 1000 FACEMs in all of Australasia. The USA has about 20,000 emergency physicians. This is much fewer per capita then the USA. There are not enough to provide 24-hour coverage of all of their EDs. Therefore, it is very common for Emergency Registrars to be the most qualified doctor in the ED after hours. If you are lucky, a FACEM will be on call. It is an unusual experience being on-call again, but what can you do? If you are called in, it is usually for something quite fun… like putting in a couple of chest tubes and intubating a trauma patient.