RAMS Global Emergency Medicine Roadmap

GLOBAL EMERGENCY MEDICINE Global Emergency Medicine is a growing subspecialty bridging the gap between global health and emergency care.

It encompasses a broad range of knowledge and skills, ranging from building emergency systems to the delivery of humanitarian aid, anywhere in the world.

MED STUDENT (MS3/4)

JUNIOR RESIDENT

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Senior RESIDENT

Resources

AUTHORS: Cindy Bitter, MD, MPH; O. Agatha Offorjebe; Shama Patel, MD, MPH; Kate Douglass, MD, MPH; Nehal Naik, MD; Wei David Hao, MD, MS; and Brian Rice, MD, MS, DTM&H Welcome to the Global Emergency Medicine Career Pathways Roadmap. This exciting sub-specialty bridges the gap between global health and emergency care, and here we provide a guide to finding your way through this global adventure. Don’t know where to start? Click on “Background” or select your training level above. A full list of fellowships, conferences, publications can be found in “Resources”. For pearls of wisdom from faculty and residents in the trenches, click on “Insider Advice.”

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insider Advice

1 - MEDICAL STUDENT Medical School Years 1 and 2: Develop your thoughts on why you want to work in global health and think about the kind of global health opportunities you are interested in, whether clinical, research, education, health systems development, etc. If you have had a prior experience in one area, it could be beneficial to gain exposure to something different during this time. Try to find opportunities at your medical school in longitudinal and/or short-term global health projects.

• R each out to global health mentors. We cannot emphasize enough the importance of good mentorship. Many global health opportunities at your medical school may not be in Emergency Medicine so branch out to other clinical departments to see what people are working on. Participate in any available activities such as a global health track or global health concentration if available.

• U se the summer break between MS1 and MS2 year on a project. This requires early planning, so reach out to mentors early in your MS1 year.

• L ook for global health funding opportunities through you home institution or fellowships such as the Benjamin H. Kean Travel Fellowship in Tropical Medicine through the ASTMH.

– Remember to publish or present your work at a conferences [See Resources]

• There are numerous national and international programs for those interested in global health.

– World Health Organization (WHO) Internship – https://www.amsa.org/advocacy/action-committees/global-health/international-health/ • G lobal is Local. Don’t forget that many skills learned in the public health arena at home can directly be applied to global health. Use your time during your first 2 years of medical school to work in local public health programming such as student run clinics.

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Year Off Planning: If you want to take a year off between MS3/MS4, start looking at opportunities now. This can be a hugely rewarding experience and establish a foundation for your a career in global health, however they often require preparation on developing a research project with a mentor within the program prior to the application deadline. Here are a few opportunities, not by any means a comprehensive list.

– NIH Fogarty Global Health Program for Fellows and Scholars – Global Health Corps – UCLA SAHIR Program

Medical School Years 3 and 4: Start to explore what niche in global health you may want to pursue and work to improve your foundation of knowledge in global health.

• L earn the fundamentals of global health: Check out The Practitioner’s Guide to Global Health • Y ear Off Options: See above.

• E lectives: Use your time during MS3 or MS4 year to explore the many facets of global/public health: – CDC Epidemiology Elective – Indian Health Service (IHS) Medical Student Clerkship • R esidency Interview Season: Consider residency programs with global health opportunities for residents. If you have a particular area of interest, find programs with mentors that match your interest. Strong mentorship can help jumpstart your global health career and guide global health training opportunities after residency. Some programs offer global health tracks, global health clinical and/or electives, and global health fellowships, so you will need to find the right program for you.

• M entorship: Remember - mentorship is key! Mentors will help you learn and grow, and also avoid pitfalls that may increase frustration and stumbles. Mentors are available at your institution, in your state or across the country in the SAEM GEMA / ACEP International Committee /EMRA international committee networks and beyond. Look for mentoring events like SAEM’s Speed Mentoring to give you access to national mentors!

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2 - JUNIOR RESIDENT PGY-1: Focus on developing your clinical skills and identifying mentors at your institution.

• During your intern year, focus on building your clinical skills. This will not only be important to your residency training, but it will make you competent in your future career as an emergency physician. This will translate into knowledge and skills that you can bring to your global EM career.

• If you are able to identify mentors and potential projects (specifics on mentors and projects in the senior resident section), ensure that they are feasible and will not take away from your clinical training. This may mean that you should not be initially traveling internationally for work due to the significant time investment, typically requiring at least several weeks.

• Instead, if there is are more local opportunities such as projects with data previously gathered internationally, then this may be an optimal use of your limited time.

• Typically, programs do not have elective time during intern year, and you may want to save your vacation time for non-work activities to allow work-life balance. Intern year will be challenging, so it’s important to remember that your career is a marathon, not a sprint.

• If you have time to participate in regional, national, or international meetings, consider that as a wonderful opportunity to network with others. This may be critical in identifying mentors, especially if you are planning for an away elective.

• If you are in a three-year program, you may decide to travel in your second year to allow for timing to complete your projects.

However, consider traveling in the latter half of the year so that you have maximized your clinical training. This is especially critical if you are going to be teaching or practicing emergency medicine internationally.

PGY-2: This depends if you are in a three or four-year program • Traditional four-year programs do not have significant elective time in the first two years as your focus is on your clinical training. Thus, focus on developing the relationships that you have established previously and working on smaller projects that do not require travel for weeks at a time.

• Because your annual schedules are often set in advance, it is important to start planning for your away electives and research time in advance.

3 - SENIOR RESIDENT PGY-3/4: As a senior resident, you should finally have elective time to accomplish your international goals. Two key aspects will be the away elective and planning for a post-residency career in international emergency medicine.

Away Elective • There are several paths of international emergency medicine to consider: emergency systems development, patient care, education, research, humanitarian aid and disaster response. These are not necessarily mutually exclusive, and these will be important concepts to consider when pursuing a potential project.

• You may either create your own project with the assistance of a mentor or partake in a mentor’s existing project. If you are fortunate to encounter a mentor that is doing the exact project you are interested in, then that’s amazing. There are benefits to working on your own project, such as the learning and flexibility. However, you will need to invest a significant amount of time and resources to accomplish this task. If you participate in a mentor’s project, the resources and infrastructure will be mostly set and you will be responsible for investing your time. Before you make this important decision, please consult your mentor regarding the best course of action for you.

• Funding may already be established if you participate in a mentor’s project. You may also seek out additional funding from your department, other departments, or within your institution. Additional funding outside the institution can be from emergency medicine associations, government and non-government organizations.

• List of funding opportunities?

– http://www.saem.org/saem-foundation/grants/funding-opportunities – https://saem.org/research/saem-grants-guide/what-grants-are-appropriate/i-am-a-resident – Many more…

• Four-year programs typically have three to four months of electives or more. Consider spending one to two months abroad to be able to accomplish necessary objectives that you can only achieve there. This will give you more elective time at home to complete your projects.

Post-Residency Planning: • Is fellowship the right path for you? If you already have an advanced degree such as a Master’s in Public Health, or if you have significant prior experience before residency and seek to continue that path, perhaps fellowship is not the best fit for your career needs. Please explore the next section to see if fellowship will make a significant impact to your future.

• If you are considering a fellowship, applications typically occur in the early months of your last year of training, there are numerous programs with different deadlines and interview dates. Applications will typically require several letters of recommendation including one from your program director. Check out the fellowship consortium website https://www.iemfellowships.com/ with more information on many of the available programs. Most, if not all programs, participate in the no-offer date agreement, which sets a unified time and date for fellowship offers in mid-November, in order to hopefully improve the process for applicants and programs alike.

4 - FELLOWSHIP Post-Residency and Beyond (1-5 years): Consider an International Emergency Medicine Fellowship (IEMF) to obtain exposure to the various areas within international EM as well as to obtain an advanced degree in tropical medicine, public health, research methods or medical education. IEMFs, ranging from 1 to 2 years in duration, are offered at over 35 institutions throughout the United States. Each fellowship offers a slightly different focus based on goals of the institution, faculty expertise, and existing country partnerships. Most importantly, fellowship offers you time - the most valuable commodity. Time to travel, time to learn, time to develop your projects and expertise, and if you are seriously considering this pathway as a career, fellowship should be something you seriously consider.

IEMF Focus Areas: Education: Providing direct education to individuals in the countries where there is interest in developing emergency medicine is a cornerstone of IEM. Education can be provided directly to interested healthcare professionals or through the establishment of a residency. Examples of education activities include serving as visiting faculty in country-specific EM programs, in-service trainings for general practitioners on fundamentals of emergency care or global ultrasound training.

Humanitarian/Disaster Health: This focus is about providing both direct patient care during humanitarian or disaster crisis and/or leading the medical community on research and implementation techniques in these humanitarian/disaster settings. Some fellowships provide advanced training in humanitarian response such as taking the Health Emergencies in Large Populations course offered by International Committee of the Red Cross. Additionally, many fellowships offer opportunities to be on the roster for humanitarian response organizations such as International Medical Corps, International Rescue Committee, Medicines Sans Frontiers (Doctors without Borders) and NYC Medics.

Health Systems Development: Health systems development is a new field of interest in-line with the WHO goal of creating a systems approach in improving health indicators. Fellowships focused on health systems development work closely with the WHO Initiative on Emergency care as well as partnering with the Ministry of Health and lead academic institutions within countries.

Research: Global health research fellowships help train a cadre of investigators to improve the health of vulnerable populations using evidence-based research. Important aspects of this training include overcoming challenges such as research design, data ownership, ethics and logistics when working in global settings. Fellowships focused on research will provide mentorship on all aspects of research including procuring funding, designing studies, obtaining ethics approval, storing and analyzing data, writing peer-reviewed publications, and disseminating research findings.

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Advanced Degree Options: The specific advanced degree, if offered, differs between fellowships. Many fellowships are flexible in the type of degrees or degree concentration you can choose during your fellowship. The advanced degree allows for development of skills in global health, epidemiology, tropical medicine and research methods. Below are common degrees pursued during the IEMF. Master in Public Health (MPH): The MPH provides fundamentals in global health, epidemiology, biostatistics and research methodology. The MPH is generally 1-2 years in length and often requires a thesis or capstone research project.

Diploma in Tropical Medicine and Hygiene (DMT&H): Provides training on tropical diseases as well as travel medicine. These courses are offered both in the US and abroad. After completion of the diploma course the fellow is eligible to sit for the cTropMED exam which is offered every two years.

Master of Science (MSc): Provides an opportunity to cater the coursework to the fellow’s interest such as specific research methodology, which can include implementation science, humanitarian research, or demography.

Master in Medical Education (MEd): Provides the tools and skills to become a leader in medical education provision and research.

Why Choose an IEMF? The fellowship offers protected time to explore various projects and directions within global EM and affords dedicated time and funding for IEM field work. The goal of the fellowship is to mentor the next generation of international EM physicians. The fellowship provides mentorship on cultural and ethical issues when working globally as well as instruction on how to build successful partnerships with governments, educational institutions and non-governmental organizations. These are necessary skills for a career in international EM.

Should I Choose a 1-year or 2-year Fellowship?

Most fellowship options are two years because this will give you adequate time to develop your own skills and your projects, in addition to adequate opportunities for field work. You may consider a one year fellowship program if you already have an advanced degree and very specific career goals.

Alternative Fellowship Opportunities: There are a few other fellowship opportunities to consider outside of the IEM fellowship list. For example, the Centers for Disease Control offers the Epidemic Intelligence Service fellowship program which is a two year, highly regarding opportunity. The Fogarty International Center at the NIH offers the Global Health Program for Fellows and Scholars. USAID offers the global health fellows program and the Fulbright scholarship program may offer alternative pathways for international work. All of these options may be worth looking into, especially if your career goal is to land more in the world of public health than clinical medicine.

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Post-Fellowship: Once you complete a fellowship you are equipped with the skills to work in international EM. Many options exist post fellowship including providing direct clinical care through response efforts, teaching residents in other countries, working with governments and academic institutions to advance emergency care or performing high quality, ethically sound research. Graduated fellows work both in academic institutions as fellowship directors and global health faculty but also at community hospitals with clinicians dedicating time to focus on international EM projects. Some fellows go on to different career pathways altogether, such as Médecins Sans Frontières or other international organizations.

Important tips for post-fellowship: • If you have not done so during residency, you should become involved in organized medicine during your fellowship. Join the SAEM Global Emergency Medicine Academy and/or the International Section of ACEP. Both organizations have ongoing projects to which one can contribute, while networking outside of your institution.

• Take every opportunity to polish your writing skills- contribute newsletter articles, case summaries, etc while working on larger manuscripts.

• Continue to develop your niche within Global Health • As you start the job search for your first post-fellowship position, consider what opportunities you will have as junior faculty. Is the institution committed to global health, and demonstrating that commitment with funding and protected time? Does your area of expertise have synergy with ongoing projects at the institution?

• Clarify your role within global health programming, and ensure teaching commitment and protected time are reflected in your contract.

5 - BACKGROUND Description and Background:

Imagine yourself working with international partners to change the system of Emergency care in a country or a region of the world.

Imagine yourself working in the field in a humanitarian response, coordinating efforts with various global health experts to provide coordinated care to people in need. Imagine yourself working to develop educational curricula to be delivered to emergency care providers in any country in the world, taking into account cultural context, local disease processes, and availability of advanced care facilities. The career pathway of Global Emergency Medicine can provide you with any of these opportunities and more. It is the intersection of Global Health and Emergency Care, and choosing this as a career pathway will open doors to endless opportunities.

Why an Global Health Path in Emergency Medicine?

Choosing to formally pursue the career pathway of Global Health and Emergency Care is an important step in recognizing the professionalization of this career choice. While opportunities to travel are many, the decision to take an academic pathway embraces the realization that this is not just a hobby, and it is not as simple as traveling to another location to work in a clinic. The growing field of knowledge and research in global health and emergency care is still in its early stages, but nonetheless should inform the next steps of development, and for the field to continue to grow, there is much more work to be done. This is really the most exciting part - the Global Health and Emergency Care Career Pathway offers so many opportunities to contribute to the developing field of science and inform the research and policy decisions of the next generation. While also having the opportunity to visit really great places, and meet amazingly awesome people!

What are the challenges?

The field of global emergency care is exciting, yet it can also be daunting and broad. There are numerous challenges associated with Global Emergency Care, including but not limited to identifying and defining your own niche within the broad field, gaining core competencies, finding time to travel, and funding. While many medical schools and EM departments have divisions of global health and have active projects in the field, many still lack this area of expertise. There can be obstacles to navigate at various steps along the way, from finding and funding a global health opportunity to working with your local GME office to approve an elective. Thankfully, there are many resources available to help guide you along the way.

Mentorship:

Finding mentorship will be an essential tool to help you navigate the different career options and pathways for Global Emergency Medicine. While some institutions have divisions of global health, others have very few or even zero faculty members. However, the good news is that in this relatively new field, finding a mentor outside of your own institution is very doable - and can lead to opportunities and advice that may well define your own career.

The charts of 11,000 sickle cell clinic patients at Mulago Hospital Sickle Cell Clinic, Kampala, Uganda� - Aubri Carman, MD, Maricopa Emergency Medicine Residency.

6 - RESOURCES Conferences For Abstract Submission and Meeting Global EM Leaders: • SAEM • ACEP (American College of Emergency Physicians) • IFEM (International Federation for Emergency Medicine) • CUGH (Consortium of Universities for Global Health) • ASTMH (American Society of Tropical Medicine & Hygiene) • CORD (Council of Residency Directors in EM) • EUSEM: https://eusem.org/ • Developing EM:

Information regarding fellowships: • International EM Fellowship Consortium Website • SAEM Fellowship Directory

Funding Opportunities: • Check out this AMSA resource which includes a long list of creative funding ideas for medical student rotations • Resident funding – check out EMRA: – International EM Rotation Scholarship

– International EM Conference Travel Scholarship • SAEMF •F unding global emergency medicine research: from seed grants to NIH support (Hansoti et al)

Articles, Books & More •C ore curricular Elements for Fellowship Training in International Emergency Medicine (Bayram et al.)

• Commentary: International Emergency Medicine (Burdick, Hauswald, Iserson) • Development of a Global Health Milestones Tool for Learners in Emergency Medicine: A Pilot Project (Douglass et al) •P lacing Emergency Care on the Global Agenda (Hsia, Razzak, Tsai, Hirshon) • I nternational Emergency Medicine and Global Health: Training and Career Paths for Emergency Medicine Residents. (Morton, Vu) •N uts and Bolts of Global Emergency Medicine, First Edition

7 - INSIDER ADVICE Final Thoughts from the Authors: “If you want a career in Global Emergency Medicine, then I would say develop a plan for a sustainable and feasible approach to maintaining a global health career early on. Most of us enter this field with a passion for making worldwide change, however as life gets more complicated and competing priorities add up it is difficult to self-fund travel and stack up shifts etc. Think about how you are going to maintain a global health career, identify mentors, partners and champions in other fields, and other institutions.”

— Dr. Bhaki Hansoti MD MPH, Johns Hopkins University “Medical students who are interested in global health often wonder whether to do a joint MD/MPH program. My advice is to wait and do the MPH as part of your fellowship. Too often I’ve seen MD/ MPH students waste a year of their lives—and $60,000—taking MPH courses that don’t actually build their global health skills. An MPH degree does not have a universal curriculum like an MD does; you have to know what tools you need in your toolbox in order to choose classes wisely. If you wait until you have had some field experience, you will be in a much better position to make the best use of your MPH time. Plus, most fellowships will pay for the degree!”

— Stephanie Kayden, MD, MPH, Chief of Global Emergency Medicine and former International Emergency Medicine Fellowship Director, Brigham and Women’s Hospital, Harvard Medical School