Transcript Establishing an International Elective/Rotation & Funding

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
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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 agendas
Cultural Sensitivity !
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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
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(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 set
• Residency programs organized
• National specialty journal published
• Specialty exam established
• Declared an officially recognized specialty
Classification System for Stages of
National EM Development
Classification system proposed by Dr. Jeff Arnold in 1999 (Ann.
Emer. Med. 1999; 33: 97-103).
Place countries into one of 3 categories related to their "stage" of
national EM systems development :
–Underdeveloped (most African countries)
–Developing (some European and Middle Eastern countries)
–Mature (U.S.A., U.K., Canada, Australia, Hong Kong, Singapore)
Categories of Dr. Arnold's Classification
Scheme for National EM Development
Specialty systems
Academic EM
Patient care systems
Management systems
Comparison of EM Specialty
Systems
Country
Class :
Underdeveloped
Developing
Mature
National EM
Organization
No
Yes
Yes
EM
Residency
Training
EM Board
Examination
No
Yes
Yes
No
Yes/No
Yes
Official
Specialty
Status
No
Yes
Yes
What an International Elective
means to you
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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- 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 sociobehavioral 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?
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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)
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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
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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.
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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 home
Core Competency Guidelines (RRC mandates)
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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
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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:
Powerful resident recruitment
tool!
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)67968
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
?
Case study- Part 2