Transcript International Emergency Medicine

Establishing an International
Elective/Rotation
&
Funding International Programs
Kumar Alagappan, MD, FACEP, FAAEM, FIFEM
Immediate Past Chair, ACEP International Section
Associate Chairman Emergency Medicine, Long Island Jewish Medical Center
Associate Professor, Albert Einstein College of Medicine
Goals and Objectives
 Review
the benefits of an international
rotation
 Formulation of goals and objectives
 Review RRC and GME requirements
 Discuss Funding
 Evaluate malpractice and liability needs
What is an International Elective?
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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 to Observer/Rotator

Exposure to other culture and health care system
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Exposure to medical problems not seen in US
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Opportunity for increased clinical responsibility and
procedure performance

Can have long term impact on health care system
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Appreciate US system
Arnold JL: International emergency medicine and the recent
development of emergency medicine worldwide. Ann Emerg Med
1999;33:97-103.
Benefits to Observer/Rotator

Learn and interact with other cultures
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Learn novel approaches to common problems
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Appreciative patients and colleagues
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Influence on EM system structure for entire countries
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Promote specialty worldwide
Appreciate diversity
Understanding effect of epidemiology and sociobehavioral aspects of patient care
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Why are the Host countries
Interested in EM?
 Improving
overall medical system
development
 Rapid
urbanization
 Increased
mobility of populations
 Increased
outpatient visits
 Success
in U.S.
Why are the Host countries
Interested in EM ?
EM OFFERS Basic
trauma care
 Training
non physician pre-hospital care
providers
 Management
 Coordination
of multi casualty incidents
of care for patients with multisystem 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:
RESIDENCY DIRECTORS!
 ACGME
Competencies and
International Electives
– Improve patient care
– Increase medical knowledge
– Enhance communications skills
– Professionalism
– Practice based learning
– System based practice
How does one get Started?
 Identify
Country
 Needs Assessment
 Research country
 Preferable to make pre-elective trip (or
work with mentor)
Make Pre-Elective Contacts
Contact persons in the US for leads
– Visit EMRA International EM Committee and
ACEP International Section websites to find list
of international rotations
– Contact ACEP to find the official ACEP
ambassador to your country of interest
 Identify interested parties who can host you
 Contact previous participants
 Network at national and international EM
conferences

Formulate Goals and Objectives
for your rotation

Facilitate building of the infrastructure required to
develop the specialty of emergency medicine in other
countries
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Mentoring / leadership, provide clinical expertise,
develop research and training programs.
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Understand and incorporate host country customs
and culture and indigenous diseases when
developing EM/EMS system
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Promote and exchange ideas between 2 countries
Goals and Objectives (Example)
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Provide emergency medical care in a hospital setting
to the urban residents of a developing nation.
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Study the pre-hospital care system in the urban
setting.

Become more familiar with and treat tropical and
warm weather illnesses.

Perform population-based research on the medical
needs

Teach emergency medicine to students and residents
Learning Objectives (Example)
 Learn
to manage multiple patients with
limited technical and physical
resources.
 Observe
and learn different medical
strategies as practiced in a developing
nation.
Who Pays for International
Rotations?
 Private
 Hosting
Institute
 Grants/Scholarships
– Johnson & Johnson, NGOs
– Organizations
 Self-paid
 Residency
Who Pays Resident Salaries?
 Hospitals
reimbursed in 1 month/4 week
blocks by Medicare
 No
reimbursement for outside electives
– Therefore institution takes a loss
 Justification
to institution for paying resident’s
salary during their away rotation
– Unable to get this experience at home institution
Which Residencies are
Supportive?
 60%
of EM residencies support IEM
electives
 Some
3 year residencies are supportive
 Should
be financially feasible at all 4
year residency programs
What’s in it for the institution?
 Great
residents
 Improved
 In
medical care at home
the long run means saved $$$$$$$$$$
 Can
the administration hold out, or is it the
bottom line each fiscal year ?
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
(MOU)
of Understanding established
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, admin)
 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?
Core Competencies
 The
ACGME/RRC
have established six
core competencies
that an Emergency
Medicine residency
program must meet
in order to be
accredited.
 These
–
–
–
–
–
are:
Patient Care
Medical Knowledge
Interpersonal Skills
Professionalism
System-based
practice
– Practice based
learning
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
MOU (RRC mandates)
 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 …………………….
Send them this article:
Dey CC, Grabowski JG, Gebreyes K, Hsu E, VanRooyen MJ: Influence of
International Emergency Medicine Opportunities on Residency Program
Selection. Acad Emerg Med. 2002;9(7)679-68
International rotations are a powerful
resident recruitment tool!
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
And Finally…Never Give Up!