Establishing an International Elective/Rotation & Funding International Programs

1. 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

2. 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

3. 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

4. Understand the agendasCultural Sensitivity ! Program Director / Chairman Local Hosts Rotator Any other parties (Funding source, govt agencies etc)

5. 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)

6. 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

7. Level of Development of EM Training standards & curricula set Residency programs organized National specialty journal published Specialty exam established Declared an officially recognized specialty

8. 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)

9. Categories of Dr. Arnold's Classification Scheme for National EM Development • Specialty systems • Academic EM • Patient care systems • Management systems

10. Comparison of EM Specialty Systems Country Class : Under- developed Developing Mature National EM Organization No Yes Yes EM Residency Training No Yes Yes EM Board Examination No Yes/No Yes Official Specialty Status No Yes Yes

11. 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

12. 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.

13. 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

14. 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.

15. RESIDENCY DIRECTORS! All 6 Core Competencies are Covered!! Improve patient care Increase medical knowledge Enhance communications skills Professionalism Practice based learning System based practice

16. 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

17. 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 everydayskills to manage a “near disaster” medical conference. Acad Emerg Med 2002;9(8):832-834Rodoplu U, Arnold J, Walsh DW:

18. 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

19. How does one get Started? Identify Country Needs Assessment Research country Preferable to make pre-elective trip (or work with mentor)

20. 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

21. 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

22. Who pays? Private Hosting Institute Grants/Scholarships J&J, NGO’s Organizations Self-paid Residency Fellowship

23. 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

24. 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 ?

25. 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

26. 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

27. 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)

28. 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

29. 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?

30. Experience not available at homeCore Competency Guidelines (RRC mandates) Patient mix Cultural Diversity Language issues Disease patterns Resource availability Innovative ideas

31. MOU (RRC mandates) Document necessity for outside rotations Will go over : Insurance Liability Responsibilities Payments Signed by institutional administrators

32. Malpractice Document necessity for outside rotations Will go over : Insurance Liability Responsibilities Payments Signed by institutional administrators

33. Liability Sickness Injuries Evacuation ‘Unsafe conditions’ What contracts must be signed Are they legal? Do they hold in court?

34. How can you convince an institution/program director? Progressive thinking / foresight Educational benefits Potential exchange of personnel / ideas Research and …………………….

35. 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. AcadEmerg Med. 2002;9(7)679-68

36. 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.

37. 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

38. 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.

39. 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

40. Research International Emergency Medicine research is needed in order to support and develop the foundation of the specialty globally New Journal- IJEM

41. 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

42. 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-

43. Questions ?

44. Case study- Part 2