International Emergency
Medicine Faculty Development
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, 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 nonphysician emergency health care workers
ƒ Start a national EM specialty society
ƒ Develop standards for testing & certification
Who Should Constitute the Initial
"Core" Faculty for EM Development ?
ƒ Must have strong interest in committing career to
EM
ƒ 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
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Overall Department Director
EM Residency Program Director
E.D. Clinical Operations Director
Research Director
Medical Student Programs Director
Quality Improvement Programs Director
E.M.S. (pre-hospital) Coordinator or Director
Coordinator for residents from other specialties
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 costs
ƒ 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 fellow
ƒ Agreed-upon individual goals for the fellow
prior to starting
ƒ Written schedule of required & optional
activities for the fellow
ƒ Access to facilities for making teaching
materials
Activties to Consider
Including in an International
EM Fellowship
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Observation in the E.D.
Attendance at all EM teaching conferences
Ambulance and / or helicopter ride-alongs
Attendance at state & national EM
conferences
Enrolling in modular couses (such as ACLS)
Observation in the I.C.U.'s
Attendance at administrative meetings
Work in photography or research labs
Modular Courses To Consider
As Part of "Core" EM Faculty
Training
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E.T.C. (Emergency Trauma Care)
B.T.L.S. (Basic Trauma Life Support)
A.T.L.S. (Advanced Trauma Life Support)
A.C.L.S. (Advanced Cardiac Life Support)
P.A.L.S. (Pediatric Advanced Life Support)
A.P.L.S. (Advanced Pediatric Life Support)
A.B.L.S. (Advanced Burn Life Support)
E.M.T.-A (Emergency Medical Technician)
First Responder
Advantages of Modular
Courses for EM Faculty
Training
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Can provide intense focused training
Relatively inexpensive to conduct & attend
Allow standardization of training
Coordinated teaching materials readily
available
ƒ Can be inserted into longer already
established curricula
ƒ 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 organization
ƒ Resident selection & interviewing
ƒ Resident work scheduling
ƒ Interaction with other departments &
residencies
ƒ Resident counseling
ƒ Testing
Specific Courses To Consider As
Part of An International EM
Fellowship
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Spoken and / or written English
Medical statistics
Animal surgical techniques for research
Medical photography
Computer program operation
Humanities, ethics, or medical history
Library systems operation
Lab Medicine or Radiology Technology
Other Courses to Consider for
International EM Fellows Interested in
E.M.S.
ƒ Hazardous Materials
ƒ Emergency Medical Technician Basic
or Intermediate Level Courses
ƒ Emergency Vehicle Driving
ƒ Rescue Techniques
ƒ Personnel Management
ƒ Post Incident Stress Counseling
ƒ 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 Outof-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) : 359364.
International EM Faculty
Development : Lecture Summary
ƒ 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