The Case Against the Supra-Specialty Model

Published on July 11, 2013
The current specialty model for emergency medicine in Sweden creates an overly costly and inefficient training pathway and dissuades new residents from joining.

{This article was first published in 2010}

Late last year I was recognized as a specialist in emergency medicine in Sweden. The interesting fact about this decision is that Socialstyrelsen (The National Board of Health and Welfare) until now only approved emergency medicine as a “supra-specialty,” meaning emergency medicine is only recognized in conjunction with another “base specialty,” such as internal medicine or family medicine.

As I am trained in the United States where emergency medicine is a specialty of its own, I am not double boarded. I am also recognized as a specialist in Iceland and these credentials where sufficient for specialist approval in Sweden. I hereby urge Socialstyrelsen, in light of this decision, to recognize emergency medicine as a specialty of its own. Otherwise, Swedish emergency physicians will continue to be trained in a more costly and less efficient system compared to European colleges.

Emergency medicine is today an established specialty in most English speaking countries, and indeed in many European countries. In the United States, emergency medicine was recognized as a specialty of its own in 1979 after a decade or more of emerging residency training and organization efforts. The same topics discussed then about emergency medicine as an independent specialty, from curriculum to organizational structure to double boarding, are being debated in Sweden today, 30 years later. Today, there is no real debate to abolish emergency medicine as a specialty, and this competency is taken for granted by the public and the medical community. Emergency medicine in the United States has proven itself with demonstrated competency, research and organization. Emergency medicine today in the United States is one of the most popular specialties, reflected by the large number of highly qualified applications to resident training programs.

In Sweden, a number of hospitals over the last decade have initiated a change towards emergency medicine practice with development of organization and residency programs. Since 2006, Socialstyrelsen has recognized emergency medicine as a “supra-specialty,” meaning physicians have to specialize in a traditional specialty before completing emergency medicine training to gain specialist recognition. This is against the recommendations of both SWESEM (Swedish Society of Emergency Medicine) and EuSEM (European Society of Emergency Medicine), and complicates matters for residency programs and organizational development. The supra-specialty model increases residency time by almost double, and increases costs both for the training hospital and the resident, whose time with resident salary is prolonged. This cumbersome system also sways away potential applicants from emergency medicine, making recruitment more difficult.

Also, the supra-specialty model creates a conflict of interest during training. The training program for the base specialty has little or no interest in training a physician who is only partially going to practice in this field – or not practice at all. This adds to a negative training environment for junior physicians.

I would argue this model produces inferior training of the residents as both specialties have to compromise in regards to supervision, training time and curriculum content.

As mentioned there are substantial reasons for abolishing the supra-specialty model. In addition to the above mentioned reasons, we must now consider the fact that Socialstyrelsen recognizes me as a specialist. This because there is an agreement among the Nordic countries to acknowledge specialists from their respective countries.

Since several countries within the EU recognize emergency medicine as a specialty, these physicians can go through the same credentialing process and ultimately become certified in Sweden like me. It is therefore unreasonable to continue to demand supraspecialty training for Swedish physicians given that European training is indirectly recognized.

In addition, all medicine should be practiced based on the evidence, and according to accepted standards of care. Today there is sufficient international experience suggesting quality and efficiency is augmented with emergency medicine training and organization. To disregard this international experience is no longer valid or appropriate.

I hereby request that Socialstyrelsen analyses the present overall situation and, in fairness, acknowledges emergency medicine as an independent specialty. This would indeed facilitate recruitment and training of emergency physicians. It would also speed up the process of a more appropriate organization, and move the development of Swedish emergency medicine towards an international standard of care. Björn Nicholas Aujalay, MD, was born and raised in Sweden. After completing medical school at Uppsala University and residency training at South Hospital Stockholm, he moved overseas for training at North Shore University Emergency Medicine Program in New York. Dr. Aujalay has been practicing EM in Fairbanks, Alaska for the last five years.

This article originally appeared in issue 2 of Emergency Physicians International

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