requirements of any faculty within the Department of Emergency Medicine.
Additionally, fellows will ..... Oxford Handbook of Tropical Medicine, 3 rd. Edition.
UNC-CHAPEL HILL EMERGENCY MEDICINE GLOBAL HEALTH AND LEADERSHIP PROGRAM GlobalEmergency Medicine Curriculum Purpose and Overview The aim of the University ofNorth Carolina (UNC)-Chapel HillEmergency Medicine Global Health and Leadership Program(GLHP) is to train future leaders in Global Emergency Medicine. This is accomplished by: 1) arranging a course of study leading to a Masters of Public Health (with a concentration in Global Health) at the Gillings School of Global Public Health at UNC-Chapel Hill; 2) facilitating relevant research projects and site-specific educational programs aimed at improving emergency care globally; and 3) arranging unique overseas sites for clinical care.
The program will equip GHLP fellows with the knowledge necessary to effectively address key issues in Global health, with particular emphasis on the delivery of emergency care in resource-limited settings. The program will also equip with extensive knowledge of communicable diseases, public health, and health systems management. Within the overall UNC-Chapel HillEmergency Medicine Global Health and Leadership Program curriculum, particular attention is given to issues of cultural sensitivity as well as medical and research ethics. The Emergency Medicine Global Health and Leadership Program curriculum expands this by drawing particular attention to the determinants and consequences of health disparities and to the key causes of morbidity and mortality in the emergency setting globally. Tables 1 and 2 highlight unique curricular goals and objectives for the fellowsduring their course of study and overseas experience.
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Summary of Program Global Health and Leadership fellows will begin this 24-month program upon completion of a three- or four-year ACGME-accredited Emergency Medicine Residency Program. During this time, the fellows will work to achieve specific curricular goals and objectives as well as to meet Global Health-specific core competencies. In addition, the fellows will earn a Masters of Public Health (with a concentration in Global Health) from the Gillings School of Global Public Health at UNC-Chapel Hill during their tenure.
Global Health and Leadership fellows will be classified initially as PGY-4 or -5 depending on whether the fellow has completed a three- or four-year ACGME-accredited Emergency Medicine Residency Program. Once selected, fellows will have the opportunity to attend special events and lectures sponsored by the UNC-Chapel HillGillings School of Global Public Health and the UNC Institute for Global Health and Infectious Diseases.
Fellows will serve as junior level teaching-attendings in the Emergency Department at UNC Hospitals. In this capacity, fellows will meet the clinical and educational requirements of any faculty within the Department of Emergency Medicine. Additionally, fellows will function as attending physicians at the global site, working closely with participating local health care providers who can provide mentorship. Importantly, fellows will benefit from close guidance from the UNC-Chapel Hill Emergency Medicine Global Health and Leadership Program Director as well as from key Emergency Medicine faculty throughout their tenure. Key Emergency Medicine faculty includes the Department Chair, the Program Director for the Emergency Medicine Residency, and the Emergency Medicine Research Director, among others.
In that fellows will have completed an ACGME-accredited residency in Emergency Medicine, they will be board-prepared in Emergency Medicine. Currently, there is no certification process for Global Emergency Medicine as a subspecialty of Emergency 2
Medicine. However, at the end of the UNC-Chapel HillEmergency Medicine Global Health and Leadership Program, fellows will receive a certificate of completion from UNC-Chapel Hill’s Department of Emergency Medicine. Finally, fellowsmust also be credentialed by UNC Hospitals.
Table 1.Ways in which Global Health-specific corecompetencies will be metduringthe UNC-Chapel HillEmergency Medicine Global Health and Leadership Program overseas clinical time. Patient care
Fellows will provide direct care to a variety of patients in the Emergency Department (“Casualty Ward”). Fellows will be trained to and then expected to provide care commensurate with need and available resources. Medical Fellowsparticipating in the UNC-Chapel HillEmergency Medicine Global Health and knowledge Leadership Programwill acquire expanded knowledge of key biomedical and social issues relevant to the treatment of both communicable and non-communicable diseases, public health, and health systemsmanagement in resource-poor settings.Fellows will acquire this knowledge through didactic activities (e.g., independent study,journal clubs, research conferences, clinical conferences, etc.) at UNC-Chapel Hill and while overseas as well as through course work during the master’s program. Practice-based Practice-based learning is a key focal point of the overall UNC-Chapel HillEmergency learning and Medicine Global Health and Leadership Program. In the context of the patient care improvement experience, fellows will have ample opportunity to appraise and assimilate relevant scientific literature. Interpersonal and As in any area of medicine, interpersonal and communication skills are critically communication important to establishing effective therapeutic relationships. Work rounds, skills communications among health professionals, and charts are kept in English. Professionalism Fellows will have added opportunity to demonstrate professionalism by demonstrating sensitivity to patients from diverse tribal backgrounds while abroad. Systems-based Sites selected for overseas training include teaching,tertiary referral hospitalsthat have practice access to many subspecialists, including full-time staffsin ophthalmology, dermatology, obstetrics/gynecology, neurology, urology, often trained in the U.S., Europe, and Australia.Fellowsworking in the Casualty Department will have ample opportunity to call effectively on specialists in other fields in the context of this resource-constrained, but expertise-rich environment.
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Table 2.Unique curricular goals and objectives. Health disparities
Communicable Diseases and Tropical Medicine
Emergency care in resource-poor settings
Public health
Management of emergency health systems
Goals Describe the knowledge, skills, and attitudes necessary for culturally competent care in low resource settings. Discuss the knowledge and skills necessary to treat a number of high prevalence tropical diseases, including, but not limited to, tuberculosis, malaria, diarrheal diseases, and HIV/AIDS. Describe and demonstrate resource-appropriate delivery of emergency care.
Objectives Fellows will maintain a log of instructive patient cases in which social determinants (e.g., education, access to clean water, food, security, housing, etc.) have played a major role in their health and health care access. Through direct patient care, fellows will gain an acute appreciation for the impact of communicable and tropical diseases on the lives of people throughout regions of the developing world.
Fellows will provide care to a variety of patients, both pediatric and adult, with a myriad of urgent and emergent complaints, including major trauma, medical, and surgical issues. Fellows will also assess emergency medical system designs in a resource-poor setting. Identify the knowledge, skills, Fellows will receive intensive didactic and attitudes needed to practice training in public health through completion the basic principles of of a master’s degree program. They will prevention. demonstrate the practical implementation of this knowledge at the overseas clinical site. Explain the needed knowledge Fellows will gain exposure to various and skills sets to design emergency care systems in resource-limited resource-appropriate emergency settings. These limitations will force care systems. fellowsto think in innovative ways about culturally-appropriate models for the delivery of emergency care Globally.
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Specific Educational Objectives Upon completion of the UNC-Chapel HillEmergency Medicine Global Health and Leadership Program, fellowsshould demonstrate proficiency in the following areas: I.
Communicable Diseases and Tropical Medicine
Outcome To diagnose and treat various infectious and tropical diseases. Plan: To expose fellowsto the following topics through didactic lectures, study, field experiences, and Masters of Public Health coursework:
Global epidemiology Gastrointestinal infections o General approach and treatment o Campylobacter and Yersinia o Clostridium difficile colitis o Entamoebahistolytica o Escherichia coli o Food poisonings o Giardia o Non-typhoidal salmonella o Shigellosis o Travelers’ diarrhea o Typhoid o Vibrio cholera o Viral gastroenteritis Parasitic infections o Entamoebahistolytica o Giardia o Helminthic infections Cestodes Nematodes Trematodes o Leishmania o Plasmodium and malaria o Toxoplasmosis o Trypanosoma Mycobacterial infections o Tuberculosis Global epidemiology Clinical features o Non-tuberculous infections 5
independent
Human Immunodeficiency Virus o Global epidemiology o Clinical features o Antiretroviral therapy o Opportunistic infections Candidal infections Cryptococcal infections Histoplasmosis Mycobacterial infections Pneumocystis jeroveci Toxoplasmosis Others Hemorrhagic fevers o Dengue o Ebola o Hanta viruses o Lassa fever o Yellow fever o Others Liver and bile tract infections o Hepatitis A, B, C, D, E o Liver abscess Amebic Pyogenic Genitourinary and sexually transmitted infections o Chancroid o Chlamydia o Gonorrhea o Granuloma inguinale o Herpes simplex o Lymphogranulomavenereum o Trachoma o Trichomonas Soft tissue and skin infections Central nervous system infections o Epidemiology of meningitis o Meningitis Bacterial Viral o Slow virus infections o Viral encephalitis Childhood infections o Diphtheria o Measles o Mumps o Pertussis 6
o Polio o Rubella o Small pox o Tetanus o Varicella Spirochete infections o Leptospirosis o Syphilis Zoonoses o General approach to animal bites o Anthrax o Brucellosis o Cat-scratch disease o Erhlichiosis o Plague o Rabies o Rickettsia o Toxoplasmosis o Trichinosis o Tularemia o Typhus Marine envenomations and infections o Ciguatera o Jelly fishes o Scombroid o Sting rays, sea urchins, scorpion fish o Vibrio parahemolyticus Evaluation Direct observation/written evaluation from GHLP Director, key Emergency Medicine faculty, and/or on-site mentor(s) Tools used for Masters of Public Health coursework
II.
Community Health in the Developing World
Outcome To apply key public health principles to the needs of developing countries. Plan
To expose fellowsto the following topics through Masters of Public Health coursework, independent study, and field experiences;
To implement these concepts during Global field experiences:
Diseases and the community 7
Disease prevention Clean water and sanitization systems Immunization programs Community health provider education Patient education Family planning Development of sustainable programs
Evaluation Direct observation/written evaluation from GHLP Director, key Emergency Medicine faculty, and/or on-site mentor(s) Tools used for Masters of Public Health coursework
III.
Delivery of Health Care Globally
Outcome To diagnose and treat a variety of patients with urgent/emergent health issues in developing countries with limited resources. Plan
To expose the fellowsto the following concepts through extensive Global field experiences and Masters of Public Health coursework:
Organizational structure of Global health care systems Organization of relief efforts Personnel management of health care team Project management Outcomes research in public health Legal and political challenges in public health
Evaluation Direct observation/written evaluation from GHLP Director, key Emergency Medicine faculty, and/or on-site mentor(s) Tools used for Masters of Public Health coursework
IV.
Development of Emergency Medical Systems (EMS) Globally
Outcome To appraise local resources in a developing country in the establishment of appropriate EMS systems.
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Plan
To equip fellowsto serve as consultants in the development of appropriate EMS systems Globally through exposure to the following concepts during field experiences (such as “ride-alongs”), independent study, and dedicated didactics with Orange County EMS Director and UNC-Chapel HillEMS faculty:
EMS basics Local political and administrative climate for EMS development Assessment of appropriate level of pre-hospital care given local health care resources Development of training sessions for pre-hospital personnel o Approach to the patient in cardiac arrest o Approach to the patient with major trauma o Approach to the pediatric patient in cardiac arrest o Pre-hospital provider protocols Funding for EMS systems Quality assurance for EMS systems
Caveat: This portion of the UNC-Chapel HillEmergency Medicine Global Health and Leadership Program curriculum is not intended to replace formal EMS fellowship training, but rather exposes the fellowsto basic elements of EMS design and implementation. Evaluation Direct observation/written evaluation from GHLP Director, key Emergency Medicine faculty (including the UNC-Chapel Hill EMS Fellowship Program Director), and/or on-site mentor(s)
V.
Development of Emergency Medicine Globally
Outcomes To compare the different approaches to the delivery of emergency care around the world. To design and implement a program promoting culturally and resourceappropriate aspects of Emergency Medicine at an overseas site. Plan
To expose the fellowsto the following concepts through extensive Global field experiences, independent study, and didactics with UNC-Chapel Hill Emergency Medicine faculty with expertise in administration and EMS; To implement some or all of these concepts in the development of Emergency Medicine abroad, taking into account cultural differences, resources, and needs: Emergency medicine system design 9
o EMS capabilities o Trauma capabilities o Emergency Center physical plant design o Hospital design o Databases Evaluation Direct observation/written evaluation by GHLP Director, key Emergency Medicine faculty, and/or on-site mentor(s)
VI.
Environmental Health
Outcomes To identify the central importance of water in maintaining health. To cite mechanisms for effective water sanitation. Plan
To introduce fellows to the following concepts through independent study, Masters of Public Health coursework, and domestic and Global field experiences:
Water supply Water-related diseases Water assessment Water treatment techniques Sanitation Vector control Personnel hygiene o Hand washing o Food supply and safety o Universal safety precautions
Evaluation Direct observation/written evaluation by GHLP Director, key Emergency Medicine faculty, and/or on-site mentor(s) Tools used for Masters of Public Health coursework
VII.
Global Relief and Development Organizations
Outcomes To identify governmental and non-governmental organizations (NGOs) involved in Global relief and development. To assemble partnerships between fellowsand local relief agencies. Plan 10
To expose fellows to the following organizational infrastructure through independent study, public health coursework, and field experiences with relief agencies in the host country:
United States Government organizations o United States Agency for Global Development (USAID) o United States Office of Foreign Disaster Assistance o Center for Disease Control and Prevention Non-governmental organizations o Relief organizations o Development organizations European Governmental organizations o European economic community United Nations organizations o General structure o United Nations Children’s Emergency Fund (UNCEF) o United National High Commission for Refugees (UNHCR) o World Food Program o Others
Evaluation Direct observation/written evaluation by GHLP Director, key Emergency Medicine faculty and/or on-site mentor(s) Tools used for Masters of Public Health coursework
VIII. Programmatic Resources and Funding Outcomes To identify the various sources of funding for Global relief and development organizations. To compose a successful grant proposal. Plan
To expose residents/fellows, through the following topics/experiences, to relief and development organizational funding as well as to the essentials of funding proposals using independent study, Masters of Public Health coursework, and mentorship from UNC-Chapel Hill faculty (including the Emergency Medicine Research Director):
Sources of funding o USAID o Department for Global Development of the United Kingdom (DFID) o European Agency for Reconstruction (EAR) o Various NGOs and private foundations Basics of grant writing
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o Statement of need o Delineation of goals o Proposal format o Budget design Identifying and responding to research funding announcements (RFAs) Writing unsolicited grant proposals
Evaluation Written evaluation by GHLP Director and key Emergency Medicine faculty (including the Emergency Medicine Research Director) Tools used for Masters of Public Health coursework
IX.
Public Health Curriculum
Outcomes To identify critical public health concepts, ranging from health care administration to statistical analysis and epidemiology. To earn a Masters of Public Health (MPH) degree with a concentration in Global Health. Plan
To expose fellows to key concepts/topics in public health, as laid out by the Masters of Public Health curriculum at UNC-Chapel HillGillings School of Global Public Health.
Evaluation Tools used for Masters of Public Health coursework
X.
Scholarship in Global Emergency Medicine
Outcomes To cite sources for state-of-the-art information on Global Emergency Medicine and Global Health. To contribute to the general body of Global Emergency Medicine and Global health literature. Plan
To expose the fellows to this concept in Global Emergency Medicine through:
Lectures/Grand Rounds on Global topics o Fellows to give at least two per year as part of the UNC-Chapel Hill Emergency Medicine weekly conference series o Fellows to attend (when their clinical and coursework schedules permit) weekly Emergency Medicine resident conference 12
o Fellows to design and implement educational programs for the physicians and health care providers at the overseas site o Teaching mentorship from GHLP Director/UNC-Chapel Hill Emergency Medicine faculty Literature review/journal club Research project o Design o Coordination and implementation o Presentation and publication o Research mentorship from GHLP Director, Emergency Medicine Research Director, Emergency Medicine Research Committee, and other UNCChapel Hill faculty National organization involvement o Society for Academic Emergency Medicine o American College of Emergency Physicians o Others
Evaluation Written evaluation (“teaching evaluations”) by UNC-Chapel Hill Emergency Medicine residents and faculty Written evaluation by GHLP Director, key Emergency Medicine faculty, and/or on-site mentor(s) Tools used for Masters of Public Health coursework
XI.
Travel Health and Medicine
Outcome To define proper disease prevention for Global travelers. Plan
To expose fellows to the following topics through independent study, personal preparation for various field experiences (e.g., different climates, hemispheres, urban vs. rural, etc.), and didactic lectures:
General principles of travel health and medicine Preparation for travel Vaccinations Global health regulations Epidemiology of communicable diseases o Africa o The Americas o Asia and the Middle East o Europe o Oceania Health risks and disease prevention
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o Local disease epidemiology o Environmental hazards Food- and water-related illnesses o Sexually transmitted infections Medical care for the Global traveler o First aid kit o Local health care resources o Personal care plan/insurance o Medical evacuation strategy Injury Prevention Special considerations o Pregnancy o Travelers with disabilities
Evaluation Direct observation/written evaluation by GHLP Director, key Emergency Medicine faculty, and/or on-site mentor(s)
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Schedule for UNC-Chapel HillEmergency Medicine Global Health and Leadership Program Global Health and Leadership fellows from the Department of Emergency Medicine (who have already completed a three- or four-year ACGME-approved Emergency Medicine Residency Program) will extend their training by an additional 24 months in orderto gain specific Global Health core competencies and an additional advanced degree.
Again, Global Health and Leadership fellows must complete an ACGME-accredited residency program in Emergency Medicine prior to starting the UNC-Chapel HillEmergency Medicine Global Health and Leadership Program. Each fellow will enter the program as either a PGY-4 or 5, depending on whether the fellow completed a three- of four-year Emergency Medicine Residency Program. Preference will be given to the recruitment of internal candidates from UNCChapel Hill’s Emergency Medicine Residency Program, which is comprised of ten residents per year. However, consideration will be given to outside candidates in an attempt to matriculate one fellow per year.
The UNC-Chapel HillEmergency Medicine Global Health and Leadership Program is a 24- month track, which includes approximately 12 months of didactic course work for a Masters of Public Health degree as well as approximately seven months overseas providing clinical care and working on a master’s project at a developing country partner site. In the event that candidates already have a comparable advanced degree upon entry into the program, they will have the option to either enroll in additional class work or spend an extended period of time overseas. An alternative curricular schedule must be approved by Program leadership. All Global Health and Leadership fellows will be expected to complete a project and produce a thesis/manuscript of publishable quality. In addition, fellows will have the opportunity to attend special events, journal clubs, and lectures sponsored by the UNC-Chapel HillDepartment of Emergency Medicine and Institute for Global Health and Infectious Diseases as well as at the UNC-Chapel Hill Gillings School of Global Public Health.
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Global Health and Leadership fellows will begin their program on July 1 of each academic year. After a brief orientation, the fellows willembark on coursework leading to an MPH advanced degree over the first 12 months of the GHLP. Also during this first 12-month period, fellows will work clinically (approximately 7 shifts/month) in the UNC Hospitals Emergency Department (ED) as junior faculty.Following this, fellows will work full time (about 17 shifts/month) in the UNC ED for the first three months of year two of the GHLP. During this time, fellows will have no coursework or travel obligations. Fellows will then implement and complete their scholarly projects while engaging in approximatelysevenmonths of mentored clinical and research activities at an overseas training site. For the last 2 months of the GHLP, fellows will work full time (about 17 shifts/month) in the UNC ED. During this final two-month period, fellows are expected to produce and submit a manuscript for publication.
Time Line PGY 4/5 PGY 5/6
12 months MPH Coursework + Junior Faculty (UNC HospitalsED) 3 months 7 months 2 months Junior Faculty Overseas site Junior (UNC Hospitals ED) Faculty (UNC Hospitals ED)
Suggested Resources Tropical Infectious Diseases: Principles, Pathogens, and Practice, 2nd Edition. R.L. Guerrant, D.H. Walker, and P.F. Weller (Eds.), Churchill Livingstone, 2006. Oxford Handbook of Tropical Medicine, 3rd Edition. M. Eddleston, R. Davidson, and A. Brent (Eds.), Oxford University Press, 2008. Schull CR. Common Medical problems in the Tropics; 2nd Edition. Macmillan, 1999.
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