Establishing an International Elective/Rotation

&Funding International Programs

Kumar Alagappan, MD, FACEP, FAAEM, FIFEM

Past Chair, ACEP International Section

Associate Chairman Emergency Medicine, Long Island Jewish Medical Center

Professor, Albert Einstein College of Medicine

Goals and Objectives

• Understand the agenda of the various partners• Know level of EM development in the country• Review the benefit(s) of an international rotation• Develop goals and objectives• Review RRC and GME requirements• Discuss Funding• Evaluate malpractice and liability needs

Emergency Medicine Today

• Urbanization and mobility of world’s population has led for an increased demand of EM

• Internet and communication (TV –Hollywood) has raised public awareness

• Popular field among young clinicians

• Specialty recognized by over 50 countries

Understand the agendasCultural Sensitivity !

• Program Director / Chairman

• Local Hosts

• Rotator

• Any other parties (Funding source, govt agencies etc)

What’s in it for the Program Director

• Great recruiting tool

• Excellent residents

• Improved medical care at home

• In the long run means less headaches for the PD’s

- (Hence the sudden interest by PD’s)

Program Directors

• Determine the type of Emergency Medicine system that exists in the country the resident will be going

• What is the level of maturity of EM

• Is the site conducive for training

Level of Development of EM

• Training standards & curricula setTraining standards & curricula set

• Residency programs organizedResidency programs organized

• National specialty journal publishedNational specialty journal published

• Specialty exam establishedSpecialty exam established

• Declared an officially recognized specialtyDeclared an officially recognized specialty

Classification System for Stages of Classification System for Stages of National EM DevelopmentNational EM Development

Classification system proposed by Dr. Jeff Arnold in 1999 (Ann. Classification system proposed by Dr. Jeff Arnold in 1999 (Ann. Emer. Med. 1999; 33: 97-103).Emer. Med. 1999; 33: 97-103).

Place countries into one of 3 categories related to their "stage" of Place countries into one of 3 categories related to their "stage" of national EM systems development :national EM systems development :

–Underdeveloped (most African countries)Underdeveloped (most African countries)–Developing (some European and Middle Eastern countries)Developing (some European and Middle Eastern countries)–Mature (U.S.A., U.K., Canada, Australia, Hong Kong, Singapore)Mature (U.S.A., U.K., Canada, Australia, Hong Kong, Singapore)

Categories of Dr. Arnold's Classification Categories of Dr. Arnold's Classification Scheme for National EM DevelopmentScheme for National EM Development

Specialty systemsSpecialty systemsAcademic EMAcademic EMPatient care systemsPatient care systemsManagement systemsManagement systems

Comparison of EM SpecialtyComparison of EM Specialty

SystemsSystems

Country Class :

Under- developed

Developing Mature

National EMOrganization

No Yes Yes

EM Residency Training

No Yes Yes

EM Board Examination

No Yes/No Yes

Official Specialty Status

No Yes Yes

What an International Elective means to you

• Rotation in a foreign country• Observe and/or practice in a new environment• Care for different types of patients• See a spectrum of disease and illness unique to the

country• Participate in educational programs in that country• Research

Kirsch TD, Holliman CJ, Hirshon JM, et al: The development of international emergency medicine: the role of United States emergency physicians and

organizations. Acad Emerg Med 1997;4(10):996-1001

Benefits- Observer/Rotator

• Exposure to other culture and health care system

• Exposure to medical problems not seen in US

• Opportunity for increased clinical responsibility and procedure performance

• Can have long term impact on health care system

• Appreciate US system

Arnold JL: International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med 1999;33:97-103.

Benefits

• Learn and interact with other cultures

• Learn novel approaches to common problems

• Appreciative patients and colleagues

• Influence on EM system structure for entire countries

• Promote specialty worldwide• Appreciate diversity• Understanding effect of epidemiology and socio-

behavioral aspects of patient care

Obstacles• Conflict with certain issues that are taken for granted in

home country (lack of guaranteed access to emergency or inpatient care in some countries).

• Language differences may inhibit patient or staff interactions.

• Personal safety or health risks

• Elective should meet the criteria of the home institution and the standards required of the visiting institution’s educational program.

RESIDENCY DIRECTORS!

• All 6 Core Competencies are Covered!!– Improve patient care– Increase medical knowledge– Enhance communications skills– Professionalism– Practice based learning– System based practice

Why are the Host countries Interested in EM? What is their

Agenda ?EM OFFERS-• Basic trauma care

• Training non physician pre-hospital care providers

• Management of multi casualty incidents

• Coordination of care for patients with multi- system problems

Why are the Host countries Interested in EM physicians?

• Act as system structure and training consultant

• Promote international collaborative research projects

• Participate in international conferences

Holliman, CJ, Cevik AA, How emergency physicians can use their everyday skills to manage a “near disaster” medical conference. Acad Emerg Med 2002;9(8):832-834Rodoplu U, Arnold J, Walsh DW:

Rotator-Pre-Elective contacts

• Contact persons in the US for leads

– Go to ACEP web site (International section members) look up rotations

• Identify interested parties who can host you

• Contact previous participants

How does one get Started?

• Identify Country

• Needs Assessment

• Research country

• Preferable to make pre-elective trip (or work with mentor)

Implementation

• Survey residents that have gone abroad

• Developing a validated survey that answers the above questions.

• Tally the different types of rotations available

• Describe an optimal educational experience

Formulate Goals and Objectives (some examples)

• Facilitate building of the infrastructure required to develop the specialty of emergency medicine in other countries

• Mentoring / leadership, provide clinical expertise, develop research and training programs.

• Understand and incorporate host country customs and culture and indigenous diseases when developing EM/EMS system

• Promote and exchange ideas between 2 countries

• Provide emergency medical care in a hospital setting to the urban residents of a developing nation.

• Study the pre-hospital care system in the urban setting.

• Perform population-based research on the medical needs

Who pays?

• Private• Hosting Institute• Grants/Scholarships

– J&J, NGO’s– Organizations

• Self-paid• Residency• Fellowship

Funding- Who pays?

• EM reimbursed in 1 month /4 week blocks

• Primary care in ½ day blocks

• No reimbursement for electives out of system– Therefore institution takes a loss

• Must have GME approval– No set standards as of yet – up to institution

Who pays

• Justification to institution for paying resident’s salary– Unable to get this experience at home

institution

• What is in it for the home institution ?

Which Residencies are Supportive?

• 40% of residencies do not support IEM electives

• Some 3 year residencies are supportive

• Financially feasible at any 4 year residency program

Time Requirements

• Where residents spend their time is subject to– RRC requirements– Reimbursement requirements

• EM 50% of time must be at home institution

• 50% must be spent in the ED

RRC Mandates for Away Rotations

• JCAHO approved site

• Supervising physician present at host site

• Elective /experience is unavailable at home institution

• Memoranda of Understanding (MOU)

JCAHO Approved Site (RRC mandate)

• Accrediting government body for institutions in host country

• Or other national body that maintains some form of accreditation for education– (Medical council approves residencies in country)

• JCAHO international

Supervising Physician (RRC mandates)

• One who is responsible for resident experience (didactic, clinical, administrative)

• Resident reports to this physician• Supervising physician will evaluate resident• Appropriate credentials for experience

– what happens when EM is not recognized in the country?

– what credentials do these people have?

Experience not available at homeCore Competency Guidelines (RRC mandates)

• Patient mix

• Cultural Diversity

• Language issues

• Disease patterns

• Resource availability

• Innovative ideas

MOU (RRC mandates)

• Document necessity for outside rotations• Will go over :

– Insurance– Liability– Responsibilities– Payments– Signed by institutional administrators

Malpractice

• Document necessity for outside rotations• Will go over :

– Insurance– Liability– Responsibilities– Payments– Signed by institutional administrators

Liability

• Sickness

• Injuries

• Evacuation

• ‘Unsafe conditions’

• What contracts must be signed– Are they legal?– Do they hold in court?

How can you convince an institution/program director?

• Progressive thinking / foresight

• Educational benefits

• Potential exchange of personnel / ideas

• Research and …………………….

Program Directors and Chairs:Program Directors and Chairs:

Powerful resident recruitment Powerful resident recruitment tooltool!!

Dey CC, Grabowski JG, Gebreyes K, Hsu E, VanRooyen MJ: Dey CC, Grabowski JG, Gebreyes K, Hsu E, VanRooyen MJ: Influence of International Emergency Medicine Opportunities on Influence of International Emergency Medicine Opportunities on Residency Program Selection. Residency Program Selection. Acad Emerg MedAcad Emerg Med. 2002;9(7)679-. 2002;9(7)679-6868

International programs

• 10 % of all US medical student graduates do some sort of international elective

• International fellowships now appearing in EM residencies

• International observer fellowships also popping up

VanRooyen MJ, Clem KJ, Holliman CJ, et al: Proposed fellowship training program in international emergency medicine. Acad Emerg Med 1999;6(2):145-149.

Future of International EM

• International electives are not going away– Similar to ultrasound– EMS etc

• Will be or is part of EM landscape• Currently the largest sections of ACEP and

SAEM are the international sections• AAEM has put on largest international

conferences

Collaboration

• As trend of international collaborations begin to increase in the world of emergency medicine, an approval mechanism may be beneficial for rotations

• Collaboration between countries is essential to the delivery of quality emergency care around the world.

• International clinical rotations are but one means to accomplish this, and

• Academic emergency physicians can assist in facilitating operation and expansion of international clinical electives.

International Fellowships• Specific unique educational opportunities include

international clinical and administrative experiences for emergency medicine residents, fellows and faculty

• Allow a more in depth study of the field– disaster relief– humanitarian relief – emergency medicine system development – public health

Society of Academic Emergency Medicine Webpage. International Emergency Medicine Fellowships http://saem.org/services/fellowsh.htm#inter

Smith DD, Gonzalez J: International Emergency Medicine Fellowship: The Basics. Ann Emerg Med 2003; 41: 144-147

Research

• International Emergency Medicine research is needed in order to support and develop the foundation of the specialty globally

• New Journal- IJEM

Summary

• IEM continues to grow in scope with many countries having recognized emergency medicine as a specialty

• Development of EM and faculty internationally leads to better mentorship in a host country.

• Fostering the exchange and international experience of medical students, residents, fellows and faculty also helps with the academic advancement of interest in international emergency medicine

• This exchange is a “two way street” and we have just as much to learn from our international colleagues on improving health care delivery and improving education.

• So if you want to do an IEM elective-

Questions

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Case study- Part 2