International Emergency Medicine Faculty

Development

Jim Holliman, M.D., F.A.C.E.P.Professor of Military and Emergency MedicineUniformed Services University of the Health SciencesClinical Professor of Emergency MedicineGeorge Washington UniversityBethesda, Maryland, U.S.A.

International Emergency Medicine (EM) Faculty Development : Lecture Goals

ƒ Present background for the need for helping development of EM faculty in many countries

ƒ Present methods used successfully to assist in faculty development

ƒ Stimulate interest in participating in existing development programs and in starting new ones

Why is International EM Faculty Development Needed ?

ƒ Need for improved quality and quantity of EM recently recognized by many countries

ƒ EM as a defined specialty is a new idea in many countries

ƒ The physicians interested in starting the specialty may lack formal training in EM

ƒ The skills and knowledge of EM specialists are applicable and useful in any national health care system

Roles of the Initial "Core" Faculty to Start EM Training in Other Countries

ƒ Act as enthusiastic promoters of the specialty with :–Government–Other medical specialists–Public

ƒ Insist on quality of patient care, reliable access to emergency care, and quality of training programs as cornerstones of the new specialty

Additional Important Roles for the Initial EM "Core" Faculty

ƒ Establish model clinical Emergency Departments (E.D.'s)

ƒ Decide on length of training for new EM residency programs for physicians and content of "Core Curriclulum"

ƒ Develop support training programs for non-physician emergency health care workers

ƒ Start a national EM specialty societyƒ Develop standards for testing &

certification

Who Should Constitute the Initial "Core" Faculty for EM Development ?ƒ Must have strong interest in committing

career to EMƒ Must be willing to undergo further

medical training for themselves to augment their skills and knowledge in the aspects of EM practice which were not covered by their prior other specialty training

ƒ Ideally should have enough "political" power to effectively advocate for emergency patients and for the new EM residency programs

How Many "Core" EM Faculty Are Needed ?

ƒ 2 per hospital is minimum to supervise a training program

ƒ 5 or 6 is minimum if 24 hour per day E.D. coverage is to be provided

ƒ Ratio of minimum of 1 "core" faculty to 3 residents is current U.S. requirement

ƒ If > 5 faculty, assignment of specific program responsibility to each faculty could be done (one is Residency Director, one is Research Director, etc.)

Specific Program Responsibilities To Consider Assigning to Core Faculty

ƒ Overall Department Directorƒ EM Residency Program Directorƒ E.D. Clinical Operations Directorƒ Research Directorƒ Medical Student Programs Directorƒ Quality Improvement Programs Directorƒ E.M.S. (pre-hospital) Coordinator or

Directorƒ Coordinator for residents from other

specialtiesƒ Liasons with other departments (such as

Trauma, Pediatrics, etc.)

General Methods for Initial Training of the EM "Core" Faculty

ƒ Complete an EM residency in a country with well established EM training programs

ƒ Complete a non-residency EM fellowship training program

ƒ Obtain local clinical EM experience & supplement with :–On-site clinical training by experienced EM physicians from other countries–In-country or out-of-country short training courses

Difficulties for Physicians from Other Countries to Train in U.S. EM Residency Programs

ƒ U.S government attitude that too many physicians are already trained in the U.S.

ƒ High competition for EM residency positions by U.S. applicants (more applicants than positions)

ƒ Requirement (& expense) to pass a series of exams to qualify for U.S. medical license

ƒ Greater living and training costsƒ Need for English language fluency

U.S. Based International EM Fellowship Training Programs

ƒ Developed out of recognition of difficulties for other country physicians to train in U.S. residencies

ƒ Probably most useful for initial training of "Core" EM faculty

ƒ Can also supplement training for EM residents

ƒ No well established or uniform structural requirements or curriculum yet

The Two Types of Exisiting International EM Fellowships in the U.S.

ƒ "Observational" Fellowship–Operational at Penn State, George Washington, Stanford, & Harvard Universities–U.S. medical license not required, but fellows cannot do "hands-on" medical care

ƒ "Clinical Experience" Fellowship–Operational at Harvard Univ. & hospital consortium in Olympia & Tacoma, Washington–Fellow participates in E.D. patient care

Advantages of the "Observational" International EM Fellowships

ƒ U.S. medical license not required

ƒ Can utilize tourist visa for short (one to 2 month) fellowships (J1 visa required for longer programs)

ƒ Can focus on individual needs & interests for applicants

ƒ Facilitate two-way interactions for EM faculty & medical students & residents

Disadvantages of "Observational" International EM Fellowships

ƒ Fellow may not be able to augment his clinical skills (prolonged lack of clinical responsibility may even cause some felllows' clinical skills to deteriorate)

ƒ May be limited time or priority by EM faculty for teaching the fellow in the E.D.

ƒ Requires extra committment by the department over that for the other training programs

Recommended Structural Requirements for an "Observational" International EM Fellowship

ƒ Designated Fellowship Director–Responsible EM faculty when Director not available

ƒ Office or study space for the fellowƒ Agreed-upon individual goals for the

fellow prior to startingƒ Written schedule of required &

optional activities for the fellowƒ Access to facilities for making

teaching materials

Activties to Consider Including in an International EM Fellowship

ƒ Observation in the E.D.ƒ Attendance at all EM teaching

conferencesƒ Ambulance and / or helicopter ride-

alongsƒ Attendance at state & national EM

conferencesƒ Enrolling in modular couses (such as

ACLS)ƒ Observation in the I.C.U.'sƒ Attendance at administrative meetingsƒ Work in photography or research labs

Modular Courses To Consider As Part of "Core" EM Faculty Trainingƒ E.T.C. (Emergency Trauma Care)ƒ B.T.L.S. (Basic Trauma Life Support)ƒ A.T.L.S. (Advanced Trauma Life Support)ƒ A.C.L.S. (Advanced Cardiac Life Support)ƒ P.A.L.S. (Pediatric Advanced Life

Support)ƒ A.P.L.S. (Advanced Pediatric Life

Support)ƒ A.B.L.S. (Advanced Burn Life Support)ƒ E.M.T.-A (Emergency Medical Technician)ƒ First Responder

Advantages of Modular Courses for EM Faculty Training

ƒ Can provide intense focused trainingƒ Relatively inexpensive to conduct &

attendƒ Allow standardization of trainingƒ Coordinated teaching materials readily

availableƒ Can be inserted into longer already

established curriculaƒ Completion certificates & certifying as

instructor may boost the status of the person in their country

Disadvantages (Limitations) of Modular Courses for EM Faculty Training

ƒ Participants might feel they are "experts" in the subject after only a short course

ƒ May focus on clinical problems not of local occurence or relevance

ƒ May contain inappropriate recommendations (such as current ACLS)

ƒ Usually do not include supervised clinical experience to verify the course information is correctly applied in practice

Activities To Consider For International Fellows Who Already Are Well Skilled in Clinical EM

ƒ Need to individualize these according to the interests & goals for each fellow

ƒ Specific instruction on :–Lecture preparation & delivery–Preparation of teaching materials–Computer programs operation–Medical photography–Operation of clinical research projects–Quality Improvement programs–EM Residency operations (see next slide)

Aspects of EM Residency Operation To Teach International Fellows

ƒ Definition & coverage of Core Curriculum

ƒ Conference series organizationƒ Resident selection &

interviewingƒ Resident work schedulingƒ Interaction with other

departments & residenciesƒ Resident counselingƒ Testing

Specific Courses To Consider As Part of An International EM Fellowship

ƒ Spoken and / or written Englishƒ Medical statisticsƒ Animal surgical techniques for

researchƒ Medical photographyƒ Computer program operationƒ Humanities, ethics, or medical

historyƒ Library systems operationƒ Lab Medicine or Radiology

Technology

Other Courses to Consider for International EM Fellows Interested in E.M.S.

ƒ Hazardous Materialsƒ Emergency Medical Technician

Basic or Intermediate Level Courses

ƒ Emergency Vehicle Drivingƒ Rescue Techniquesƒ Personnel Managementƒ Post Incident Stress Counselingƒ Aeromedical Operations

Funding For International EM Fellowship Programs

ƒ Most require the fellow to have his own funding–Usually from the sending government, health ministry, or university–Minimum guaranteed funding requirement for a J1 visa currently is $ 800 per month–Agency for International Development & N.G.O.'s (such as Carelift International) have sponsored some fellows in the past

ƒ Extra funds must be budgeted for attendance at modular courses & state or national meetings

Lessons Learned by the Existing International EM Fellowship Programs

ƒ Newly arrived fellows may need a "cultural adjustment period" of a few days or even 2 weeks before being required to do intensive academic or clinical work

ƒ Fellows whose English skills are not good should be identified early and assisted with English instruction classes

ƒ Modular courses may need to be conducted over a longer than standard time frame

Lessons Learned by Existing International EM Fellowship Programs (cont.)

ƒ Work and activity schedules may need to be adjusted for cultural & religious beliefs

ƒ Fellows may need a lot of direct encouragement to participate actively in E.D. observation

ƒ Fellows not comfortable with their expressive English should not be forced to make formal verbal presentations

ƒ Having fellows obtain observation experience at more than just one medical center is useful

General Goals of the Existing International EM Fellowship Programs

ƒ Expose the fellows to U.S. E.D. and EM residency operations, so the fellows can assimilate aspects of these useful for them

ƒ Augment the fellows' knowledge and skills in non-clinical aspects important for E.D. and EM residency operations

ƒ Establish long term collaborative relationships for further development of EM worldwide

Further EM "Core" Faculty Development After Completion of Fellowship Training

ƒ Can translate & develop their own training books & materials

ƒ Can conduct their own modular courses

ƒ Can develop national level C.M.E. courses

ƒ Can start to train residents from other countries that do not yet have EM residencies

ƒ Can develop a national Residency Review Organization & national certifying exams

References on International EM Faculty Development

ƒ "Planning Recommendations for International Emergency Medicine and Out-of-hospital Care System Development", Holliman et al, Academic Emergency Medicine, August 2000, 7(8) : 911-917.

ƒ "Proposed Curriculum for an "Observational International Emergency Medicine Fellowship Program", Holliman et al, Academic Emergency Medicine, April 2000, 7(4) : 359-364.

International EM Faculty Development : Lecture Summaryƒ There is a great need at present to

help develop the "Core" faculty required to start EM training programs in many countries

ƒ A number of methods have been successfully employed, including use of International Fellowship programs

ƒ EM faculty development programs should adjust to the needs of each individual participant