SPECIAL CONTRIBUTIONS
International Emergency Medicine and the Role for Academic Emergency Medicine Kumar Alagappan, MD, Robert Schafermeyer, MD, C. James Holliman, MD, Ken Iserson, MD, Indrani A. Sheridan, MD, G. Bobby Kapur, MD, Tamara Thomas, MD, Jeffrey Smith, MD, Jamil Bayram, MD
Abstract International emergency medicine continues to grow and expand. There are now more than 30 countries that recognize emergency medicine as a specialty. As the field continues to develop, many physicians are reaching across borders and working with their colleagues to improve patient care, education, and research. The future growth and success of the specialty are based on several key components. These include faculty development (because this is the key driver of education), research, and curriculum development. Each country knows what resources it has and how best to utilize them. Countries that are developing the specialty can seek consultation from successful countries and develop their academic and community practice of emergency medicine. There are many resources available to these countries, including distance learning and access to medical journals via the Internet; international exchanges by faculty, residents, and medical students; and physicians who are in fellowship training programs. International research efforts require more support and effort to be successful. This report discusses some of the advantages and hurdles to such research efforts. Physicians have a responsibility to help one another succeed. It is the hope of the authors that many more emergency physicians will lend their skills to further global development of the specialty. ACADEMIC EMERGENCY MEDICINE 2007; 14:451–456 ª 2007 by the Society for Academic Emergency Medicine Keywords: international emergency medicine, development of emergency medicine
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nternational emergency medicine (EM) continues to grow in scope and activity and serves an essential role as the safety net for patients in many countries. In recent years, urbanization, aging, economic changes, and worsening health care problems have led to an increased awareness and need for emergency care throughout the world. EM has become more important due to its ability to meet not only the day-to-day treatment needs, but also to provide planning and leadership From the Department of Emergency Medicine, Long Island Jewish Medical Center (KA), New Hyde Park, NY; Department of Emergency Medicine, Carolinas Medical Center (RS), Charlotte, NC; Department of Emergency Medicine, Hershey Medical Center (CJH), Hershey, PA; Department of Emergency Medicine, University of Arizona—Tucson (KI), Tucson, AZ; Department of Emergency Medicine, University of Florida—Gainesville (IAS), Gainesville, FL; Department of Emergency Medicine, George Washington University (GBK), Washington, DC; Department of Emergency Medicine, Loma Linda University (TT), Loma Linda, CA; Department of Emergency Medicine, George Washington University (JS), Washington, DC; and Department of Emergency Medicine, Rush University Medical Center (JB), Chicago, IL. Received January 2, 2007; accepted January 4, 2007. Contact for correspondence and reprints: Kumar Alagappan, MD; e-mail:
[email protected].
ª 2007 by the Society for Academic Emergency Medicine doi: 10.1197/j.aem.2007.01.003
for disaster preparedness. There are now more than 30 countries that have recognized EM as a specialty and, of those countries where it is not yet recognized, many are pursuing such specialty recognition and developing residency training programs.1,2 Many of the countries that are in the early stages of developing the specialty and their residency programs are reaching out for guidance from those countries that have been successful. The physicians from successful countries who are most active in organizations representing EM can provide guidance for the development of emergency health care systems, curriculum development, faculty training, residency education, and research. There are many prominent academic emergency physicians (EPs) in the United States who are in a position to assist and support academic EM development in the international setting.3 As noted in the report by Kirsch et al., it is important to provide assistance rather than impose our system on the host country because their resources and problems may require a unique approach. Many academic physicians receive multiple requests for assistance, and these requests include organizing rotations for medical students, residents, and faculty members from other countries to spend time in the United States and Canada, as well as for U.S. and Canadian physicians and students to rotate to other countries. The areas of support that academic physicians can provide
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include the development and mentoring of faculty, promotion of international distance learning, designing curricula for education of medical students and residents, establishing clinical rotations, developing guidelines for the establishment of international EM fellowships for those who are interested in long-term academic activities, and, finally, coordinating and conducting international research projects. As EM matures globally, support of training of faculty and residents is essential, as is the development of a research agenda. This report outlines the potential roles for academic EPs and could guide professional associations in the international arena. FACULTY DEVELOPMENT AND MENTORING Faculty development and mentoring are essential steps in promoting the development and maturation of EM in countries in which the specialty is nascent. In some instances, EM is such a new concept that only a small core group of dedicated physicians is committed to developing the specialty. Many of them come from other specialties, such as internal medicine, anesthesiology, or surgery, so they may have had limited exposure to mature EM systems and the full spectrum of clinical practice of the specialty. These physicians face the multiple daunting challenges of establishing clinical departments, developing effective curricula, implementing residency training programs, and eventually advancing the knowledge of the specialty through research. Faculty development may involve assistance from other academic physicians to provide knowledge of clinical and administrative emergency services, curriculum and program development, and implementation of these programs, as well as to develop careers in research and teaching and a road map for professional advancement. Mentorship must be a part of this program, because it has been shown to have a very positive influence on academic faculty members’ teaching, research, administrative activities, and overall greater career satisfaction.4,5 Academic EPs can play a vital role in promoting the academic advancement of EM in these new environments and can use resources available from their peers, such as from the Society for Academic Emergency Medicine (SAEM) and from other professional associations at minimal financial cost. For example, Web-based resources such as the Faculty Development Handbook, codeveloped by SAEM and the Association of Academic Chairs of Emergency Medicine, and the Academic Career Guide, codeveloped by SAEM and the Emergency Medicine Residents’ Association, are very valuable resources for international EM faculty (http://www.saem.org/facdev/ index.htm). Additionally, SAEM offers a consultative service (i.e., in areas of residency development, faculty development, and research) to the U.S. residency programs. There are videotape series on the fundamentals of research and advanced research and other short courses that may be available for international faculty. Academic EPs potentially can attempt to influence ministries of education, ministries of health, professional EM societies, and prestigious academic institutions to help advance EM in the host country. Collaborating with key international institutions could allow academic
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EPs an opportunity to further advance EM initiatives in curriculum development, educational methodologies, expanded research agendas, informatics, administration, vital emergency health policy issues, and clinical care delivery. International academic activities can have many benefits for academic EPs. Potential short-term faculty and resident exchanges can enhance the academic stature of a program. Other exchanges, such as visiting fellowships, are facilitated by these professional relationships. U.S. faculty members participating in international activities can have many interesting professional opportunities, including participating in international conferences and training initiatives and possibly functioning as initial external examiners for various international training programs and certification boards. The main disadvantage of embarking on international EM initiatives is the significant amount of time and effort that can be required for certain activities, time and effort that could be focused on domestic initiatives. However, as noted previously, the flow of information is in both directions, and all collaborating partners should benefit in some aspect of professional development. CURRICULUM IMPLEMENTATION One of the essential components of an effective academic training program is a solid curriculum plan that provides the faculty and the residents with the specific criteria for theoretical and clinical education. At the international level, The 2003 Model of the Clinical Practice of Emergency Medicine (the model)6 and The Model of the Clinical Practice of Emergency Medicine: A 2-Year Update7 can serve as a valuable resource for many countries that are implementing EM training programs, and it has already been used to help structure residency programs in multiple countries such as Turkey, Korea, Singapore, Jordan, Saudi Arabia, Poland, and Iran. The model has also been translated into Spanish, and academic institutions in Latin America have been able to use the translated model to integrate EM training programs alongside traditional training programs such as surgery and internal medicine by sharing the translated document with colleagues from other specialties.8 The model, based on the core content, represents a broad consensus from EM leaders about the breadth of education required to graduate well-trained EPs. With minor modifications based on local medical necessity and practice, it is an excellent basis for developing and implementing EM curricula throughout the world. Although each country has unique clinical settings for the practice of EM, establishing and implementing a specific training curriculum within a country has numerous benefits. Most importantly, a standardized curriculum will meet public and governmental expectations that graduates of EM residency training programs should have similar high levels of knowledge and skills encompassing the entire breadth of EM. In addition, a uniform curriculum will facilitate and improve communication among medical educators and among residents in training in different countries. In the arena of international research, a mutually agreed upon curriculum will foster greater opportunity for collaboration and research
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projects related to medical education. Having a similar curriculum will also assist in establishing exchange programs for residents and faculty among various countries, will enable a greater use of standardized teaching materials, and will encourage sharing of educational programs, particularly for distance education modalities.9 One of the primary long-term goals of curriculum implementation is the development of EM certification and licensing processes within countries. Those implementing a standardized curriculum among multiple countries will confront certain obstacles. One major issue will be the potential perception by educators in some countries that a standardized curriculum might be imposed and predecided rather than reflecting local input and needs. Although a standardized curriculum may be available, each country should modify the contents to address local practice settings. However, within a country, academic institutions and government authorities should make efforts to unify training programs within a single curriculum. In addition, certain countries place restrictions on the scope of clinical practice, and particular elements of the curriculum may need to be modified based on interactions with other medical specialties in that country. Also, use of a standardized curriculum may have the potential to limit or stifle innovations in curricular design in medical education within countries exploring the development of EM. The implementation of a standardized curriculum based on the model within countries developing EM residency training programs provides many opportunities and challenges for academic EM. Having a uniform framework for educating residents and for communicating among academic institutions will enhance the development and education of physicians within EM in countries where the specialty is in the early stages of development or transition. However, any efforts to establish an EM curriculum within a country should address the specific nuances of clinical practice in that setting. DISTANCE LEARNING Distance (or distributed) education uses electronic means to deliver course content directly to the learners. It is one of the fastest growing areas in medical education.10–12 Recent advances in terrestrial-wireless and satellite technologies can now extend distance medical education into many nonindustrialized countries without adequate hard-wired networks, including to deployed military medical personnel.13,14 Distance-based technologies have been cited as ‘‘cost-effective and sustainable ways of continuing to improve emergency medical services and education worldwide.an ideal opportunity to improve international medical education’’ that can complement existing physician exchanges.10 Electronic, primarily Internet-based, systems can quickly deliver static (slide presentations, written materials) and dynamic (videos) materials throughout the world. Other modalities have been used for international interactive presentations, with varying success and a high cost.15 However, the rapid improvement in satellite and broadband technologies should soon make all these methods easily affordable and of higher quality than in past years. Distance education provides users with
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‘‘just-for-you’’ learning (learning customized to the individual physician’s or group’s needs) and ‘‘just-in-time’’ learning (educational resources available exactly when needed).16 Interactivity can be solely between the learner and the computer program; off-line interactions with instructors, who may be in geographically disparate locations; or with instructors available to provide immediate feedback in ‘‘real time.’’ These distance learning modalities have been adopted by, among others, ‘‘virtual medical schools’’ in various parts of the world that provide students with a much wider array of resources than can normally be offered in traditional medical schools, at least in the preclinical years.12,17,18 The potential benefits of distance education include the ability to teach a large number of students at one time; reduced costs for travel, classrooms, and instructors; an extensive geographic distribution; time shifting for students and instructors; self-directed learning; and the potential for improved quality control. Distance education greatly improves upon the CRISIS criteria for effective continuing medical education: Convenience, Relevance, Individualization, Self-assessment, Independent learning, and a Systematic approach.16 Specialty societies such as the American College of Emergency Physicians, American Academy of Emergency Medicine, and SAEM could support EM-oriented distance learning projects, which would be consistent with and enhance their missions (education, research, writing, publication, EM academics). Simultaneously, it could place them in the enviable position of being a leader in this rapidly developing educational area. However, when following a vision such as this, EPs and professional societies must recognize that several obstacles could hinder success: interest, costs, and conflicts with commercial entities. Before any such significant undertaking can occur, sufficient interest must exist to provide the manpower needed to organize and direct it. Then, the principal obstacle is start-up expenses for support of existing projects or development of new projects, which may become costly. This is particularly true if existing materials need to be translated into what are currently the world’s major medical languages (English, French, Spanish, and Chinese). It is much less expensive if EM colleagues who are native speakers can produce such educational materials directly in the target languages. Another difficulty, more theoretical than real at this point, is that such projects would compete with existing commercial groups providing quality distance EM education. The support of academic EM for distance learning could include a number of projects, including demonstrations of the efficacy of different systems, fellowships in distance learning informatics,19 and a home for links to existing EM-oriented distance learning sites. One example is the REEME Project (Recursos Educacionales en Espan˜ol para la Medicina de Emergencia [Educational Resources in Spanish for Emergency Medicine]), which freely distributes Spanish-language EM teaching programs.8 Other distance education models include the University of Pittsburgh’s ‘‘Supercourse’’ on epidemiology and global health20 and medical journals that are electronically available through many medical libraries. Support for international distance learning is perhaps
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the most effective method for professional organizations to advance their research and educational goals, expand membership, and become truly universal EM organizations.
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rotations are but one means to accomplish this, and academic EPs can assist in facilitating operation and expansion of international clinical electives. INTERNATIONAL EM FELLOWSHIPS
INTERNATIONAL ROTATIONS FOR U.S. MEDICAL STUDENTS AND RESIDENTS An international rotation can refer to a clinical experience in a country different from the individual’s country of origin with an opportunity to observe or practice in a new environment and an opportunity to see a spectrum of disease and illness unique to a particular region or country.3 More than 10% of U.S. medical students participate in some form of international elective before graduating from medical school. The interest that has been generated in international medicine has carried into residency for many of these students.21 Due to the nature of EM work, it is highly conducive for international clinical electives. An international elective can also easily fulfill all six defined core competencies that are now so important in the U.S. educational forum. Some of the advantages of international clinical rotations include exposure to and interaction with other cultures. This permits the clinician to learn more about the historical background of other cultures and may lead to a better understanding of emergency department patients from other cultures in one’s home country.22 This would reinforce the greater awareness of cultural diversity and sensitivity. Physicians can better understand how culture influences compliance with medical care. Clinicians can also learn novel approaches to common clinical problems, because most urban emergency departments in other countries see a similar case distribution as in the United States or Canada. Finally, there may be discovery of novel ways to deal with common problems with emergency departments throughout the globe, such as overcrowding, efficient and safe triage, and so on. Some of the problems that can be encountered with rotations abroad can create a conflict with certain issues that are taken for granted in the United States, such as the lack of guaranteed access to emergency or inpatient care in some countries (unless the patient or family can pay for care). Language differences may inhibit patient or staff interactions. There are also personal safety or health risks (e.g., malaria) that must be taken into account. The elective should meet the criteria of the Accreditation Council on Graduate Medical Education and the standards required of the visiting institution’s educational program. Other logistical problems encountered with rotations abroad include the lack of federal funding. U.S. residency programs do not receive federal reimbursement for the time that residents spend outside the United States. Travel and housing expenses must often be borne fully by the resident or student. With the increasing trend of international collaborations taking place in the world of EM, an approval mechanism may be beneficial for rotations both within the United States and abroad. Collaboration between different countries is essential to the delivery of quality emergency care around the world. International clinical
Fellowship programs in EM allow EPs to learn a special aspect of the field in more depth or to qualify for a certificate of added qualification (subspecialty certificate). The SAEM Web site lists 31 different EM fellowships that are offered for EM residents after graduation. International EM fellowships are one example of such EM programs. After two fellowships were initiated, the essential components for international EM fellowship training were published in 1999.23,24 Since that time, additional international EM fellowships have been established in the United States with varying goals, durations, and structures. International EM fellowships may emphasize a specific focus, such as disaster relief, humanitarian relief, EM system development, or public health. Most international EM fellowships are two-year programs and offer a master’s degree in public health as part of the fellowship; a few are one-year programs. Currently, there are 18 international EM fellowship programs listed by SAEM and are offered exclusively to graduates of U.S. or Canadian residency programs in EM.25 There can be some confusion with semantics, because there are a few ‘‘observational’’ programs offered to international medical graduates to provide them with an EM experience, referred to as a ‘‘fellowship.’’ International EM fellowships can offer unique opportunities in both education and research. Specific educational opportunities include international clinical and administrative experiences for EM residents, fellows, and faculty. There is some evidence that international clinical opportunities favorably influence EM residency site selection.3 There currently are many residents interested in participating in an international experience.25,26 The directors of these fellowship programs or specialty societies could offer additional, more rigorous guidelines for minimum educational standards for these experiences. In addition, the fellowship directors can provide leadership and assist in linking interest groups in the Emergency Medicine Residents’ Association and other professional EM societies with international EM fellowships through provision of a speaker panel to discuss different international EM fellowship programs, curricula, objectives, and foci to attract more candidates. Fellowship directors should take the lead in standardizing the international EM fellowship curricula.23 It would be beneficial to distinguish international EM fellowships from other subspecialties in EM (e.g., disaster medicine/emergency medical services) and also from other international health fellowships that focus on primary care. The American College of Emergency Physicians, American Academy of Emergency Medicine, and SAEM potentially could collaborate with the Council of Emergency Medicine Residency Directors, international EM fellowship programs, and other stakeholders to develop standards for international EM fellowship curricula, in addition to tools and methods for both fellows’ and fellowships’ program evaluation. This is a crucial step toward establishing official recognition of the
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subspecialty, as well as toward Accreditation Council for Graduate Medical Education accreditation of fellowship programs leading to American Board of Medical Specialties subspecialty certification. Finally, many fellowships have a research requirement, and research in the international EM arena has great potential. Although clinical trials may be difficult to implement internationally, international research opportunities are both diverse and plentiful. The international setting offers numerous opportunities to study system evaluation, program development, implementation and quality management, emergency services policy and administration, and emergency health services theory and application on many different levels. INTERNATIONAL RESEARCH International EM research is needed to support and develop the foundation of the specialty globally. Unfortunately, the level of support for research in EM is somewhat lacking for a number of reasons. The lack of dedicated nonclinical time and funds are the most common reasons cited for the lack of research. Most EPs lack research funding to support them. EPs usually generate their revenue from clinical work, and this is even more so in the international setting. The sophistication of the research being conducted varies greatly throughout the globe. Some countries do not have institutional review boards, research consent forms, or systems for patient protection in research. In order for international research in EM to flourish, these issues need to be addressed. There may also be few local mentors and leaders in the specialty of EM who can advise and help develop a research agenda for a particular institution or country. What has become clear is that no EM organization has fully developed a research agenda for international EM. Due to the limited research conducted in EM, there are relatively few internationally established peer-reviewed journals for EM. Significant EM research is often reported in other specialty journals. The United States continues to have the most peer-reviewed EM journals and therefore should continue to play a role in the development of EM research globally.27 As more countries recognize the specialty of EM, this will hopefully add more EM journals to the field. The advantages of collaboration on international research are numerous. With more physicians from different backgrounds attempting to ask the same question, a wider perspective on approaching the problem can lead to a better-quality study.28 Collaboration can lead to improved study design, developing institutional review boards and informed consent in countries where it does not exist, and increasing the self-confidence of EPs in both the United States and abroad29; collaboration can lead to new and large ‘‘untapped’’ populations for study. This can also lead to completing a study in less time.30 New sources for funding may also be identified with international collaboration. As international EM studies are published, it will demonstrate the maturity of the specialty globally. U.S. EPs may also learn to adapt new ideas and practices into their clinical practice from these studies.
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Some ways academic EPs may assist with the development of international research (either on-site or distance) can include assisting in reviews of the study design for individual projects. Academic EPs can serve as advisors or coinvestigators and assist international colleagues as they develop projects or serve as consultants to the projects. There can also be assistance with statistical analysis for individual projects or as courses in other languages. In addition, there can be assistance with writing and publishing for individual projects or as courses. New sources of funding may need to be tapped, and this can be done with the help of individuals with experience, both in the United States and abroad. Within the annual meetings of the professional societies, there could be a separate track for international EM research presentations. Devoting a part of the meeting to this could lead to a significant boon for international EM research. By increasing the participation of physicians from other countries at the annual meetings and encouraging international abstract submissions, international EM research could flourish. There are several drawbacks that can occur with collaboration in international EM research. Many EPs are not trained in research methodology and have few mentors in their country, and their expertise is often unknown. Many countries do not have an institutional review board process, and this can prevent publication in U.S. EM journals. The long-distance relationships can be difficult with only e-mail and fax communications and even more of a problem related to language differences and translation errors. Numerous miscommunications can occur. There is also the possibility that local or national politics may interfere and derail the project. Despite the drawbacks, the recent rise in the number of international meetings has led to improved networking and collaboration among EPs around the globe. More countries are recognizing the specialty, leading to a rise in the number of papers and projects in EM across the globe. CONCLUSIONS International EM continues to grow in scope and activity, with many countries having recognized EM as a specialty. There are still significant academic and infrastructure needs in many countries that are trying to establish the specialty. Development of faculty and mentorship are essential to developing the specialty, as well as the establishment of residency training and subsequent board certification or its equivalent. Countries with an established specialty of EM should provide help to those countries trying to gain specialty recognition and acceptance. Mentorship, sharing developed curricula, and providing distance learning should reduce costs and improve the odds of success. Fostering the exchange and international experience of medical students, residents, and fellows also helps with the academic advancement in international EM. 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 as they have from us. Finally, international EM research can solidify the specialty and can improve health care for our patients. Academic EPs
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have the opportunity to work with their international colleagues to obtain worldwide recognition for the specialty of EM. References 1. Holliman CJ, VanRooyen MJ, Green GB, et al. Planning recommendations for international emergency medicine and out of hospital care system development. Acad Emerg Med. 2000; 7:911–7. 2. Alagappan K, Holliman CJ. History of the development of international emergency medicine. Emerg Med Clin North Am. 2005; 23:1–10. 3. 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; 4:996–1001. 4. Palepu A, Friedman RH, Barnett RC, et al. Junior faculty members’ mentoring relationships and their professional development in U.S. medical schools. Acad Med. 1998; 73:318–23. 5. Coates WC, Cherri D, Hobgood MD, et al. Faculty development: academic opportunities for emergency medicine faculty on education career tracks. Acad Emerg Med. 2003; 10:1113–7. 6. Thomas HA, Binder LS, Chapman DM, et al. The 2003 model of the clinical practice of emergency medicine: the 2005 update. Acad Emerg Med. 2006; 13:1070–3. 7. Hockberger RS, Binder LS, Chisholm CD, et al. The model of the clinical practice of emergency medicine: a 2-year update. Ann Emerg Med. 2005; 45:659–74. 8. University of Arizona. Educational resources in Spanish for emergency medicine. Available at: http://www. reeme.arizona.edu. Accessed Jan 5, 2007. 9. Bandiera G, Lee S, Tiberius R. Creating effective learning in today’s emergency departments: how accomplished teachers get it done. Ann Emerg Med. 2005; 45:253–61. 10. Haile-Mariam T, Koffenberger W, McConnell HW, Widamayer S. Using distance-based technologies for emergency medicine training and education. Emerg Med Clin North Am. 2005; 23:217–29. 11. Hovenga EJ. Globalization of health and medical informatics education—what are the issues? Int J Med Inform. 2004; 73:101–9. 12. Shyu FM, Liang YF, Hsu WT, Luh JJ, Chen HS. A problem-based e-Learning prototype system for clinical medical education. Medinfo. 2004; 11:983–7. 13. De Lorenzo RA. How shall we train? Mil Med. 2005; 170:824–30. 14. Azzi A. Scientific publishing in non industrialized countries: a pilot wireless Internet project for Africa. IUBMB Life. 2005; 57:259–61.
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