the less controlled pre-hospital environment. Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, the fluctuating trends began to diminish, being replaced by outcomes-based research. This research then drove further evolution of the practice of both paramedics and the emergency physicians who oversaw their work, with changes to procedures and protocols occurring only after significant research demonstrated their need and effectiveness (an example being ALS). Such changes affected everything from simple procedures such as CPR, to changes in drug protocols. As the profession grew, some paramedics went on to become not just research participants, but researchers in their own right, with their own projects and journal publications. In 2010, the American Board of Emergency Medicine created a medical subspecialty for physicians who work in emergency medical services. Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the early days medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. While this still occurs in some jurisdictions, it has become increasingly rare. Day-to-day operations largely moved from direct and immediate medical control to pre-written protocols or standing orders, with the paramedic typically seeking advice after the options in the standing orders had been exhausted. Canada While the evolution of paramedicine described above is focused largely on the US, many other countries followed a similar pattern, although often with significant variations. Canada, for example, attempted a pilot paramedic training program at Queen's University, Kingston, Ontario, in 1972. The program, which intended to upgrade the then mandatory 160 hours of training for ambulance attendants, was found to be too costly and premature. The program was abandoned after two years, and it was more than a decade before the legislative authority for its graduates to practice was put into place. An alternative program which provided 1,400 hours of training at the community college level prior to commencing employment was then tried, and made mandatory in 1977, with formal certification examinations being introduced in 1978. Similar programs occurred at roughly the same time in Alberta and British Columbia, with other Canadian provinces gradually following, but with their own education and certification requirements. Advanced Care Paramedics were not introduced until 1984, when Toronto trained its first group internally, before the process spread across the country.