EMRA Fellowship Guide, 2nd Edition

Health Policy

Authors

Summer Chavez, DO, MPH
Emergency Medicine Chief Resident
Virginia Tech-Carilion Clinic
Health Policy Fellow, Georgetown University

Yagnaram Ravichandran, MD, FAAP
Fellow, Pediatric Emergency Medicine
Children’s Hospital of Michigan
Detroit Medical Center, Wayne State University

Adriana Coleska, MD
Emergency Medicine Resident, PGY1
University of Chicago

Special thanks to our 1st edition writing team

Theresa Tassey, MD
Joshua Enyart, DO
Elizabeth Davlantes, MD
Krystle Shafer, MD
Kyle Fischer, MD, MPH
Natalie Kirilichin, MD

INTRODUCTION

Description of the specialty
The health policy fellowship is designed to educate/train future physician leaders who will work to effect change within the health care system and advocate for the practice of emergency medicine to ultimately shape the future health care landscape on both local and national levels. One way to accomplish this is through the development and refinement of academic, clinical, and professional skillsets. The firsthand experience of providing care to patients from all walks of life as well as the increasing role of primary care uniquely qualifies emergency medicine physicians to serve in this capacity.

History of the specialty/fellowship pathway
The history and current landscape of U.S. health care has been shaped by a complex relationship between the federal government and private industry. This large, expensive system has resulted in escalating medical bills for both the average individual American consumer as well as the government. Consequently, both struggle to cover extraordinary costs. It comes as no surprise that discussions of health care reforms have gained significant interest and attention within both local and federal government agencies. This led to the passage of the Patient Protection and Affordable Care Act, colloquially named “Obamacare” in 2010. In the time since, potential repeal of all or part of Obamacare and the role of Medicaid expansion dominates the conversation. Emergency physicians are distinctively suited as advocates in such debates due to the wide spectrum of patients that they provide care to. As a result, health policy fellowships designed specifically for the emergency physician have evolved over the course of time. 

Why residents choose to follow this career path
Residents may choose this path for a number of reasons, including but not limited to: (1) to advocate for patients and emergency medicine providers, (2) to promote health policies that improve emergency care in the United States, and (3) to develop leadership and administrative skills.

How do I know if this path is right for me?
This path tends to draw those who have a strong desire to be involved in the health care system beyond their clinical roles: those who desire to impact health care policy formulation and refinement, those who are passionate about public health, and those interested in health care based leadership roles for the benefit of both the specialty and the patients. Most people drawn to this path have a vision and an aim to make a significant impact on a larger scale.  

Career options after fellowship
The career options following a fellowship in health policy are broad and allow graduates to create a unique career path that best suits their policy interests. The level of involvement can vary ranging from health care policy or advocacy involvement at the community level to the national or international level (organizations like the WHO, UNICEF etc.). Many choose combined career paths that allow them to utilize their clinical skills and public policy expertise. After graduating from fellowship, one may choose to pursue work as an academic emergency physician focusing on health policy research or perhaps as a community physician representative on hospital or health care organization’s executive committees. Other opportunities include serving in an advocacy or government position (such as policy advisors for Congress, executive positions in ACEP or your state ACEP chapter), becoming a liaison to governmental organizations (such as HHS, CDC, or CMS). Graduates may assist as media or legislative representatives on health policy issues or consult for insurance or pharmaceutical companies.

Academic vs. community positions
While some health policy fellowships or grants for health policy career development allow one to pursue educational and experiential opportunities while working at any desired institution, the overwhelming majority of fellowships in health policy are located at academic institutions. Health policy fellowships are located widely across the United States, with most programs concentrated on the East Coast. Depending on the program, the clinical sites may vary in terms of number and length of shifts, patient types, and acuity. 

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are currently 9 active programs that offer health policy fellowships. There are further areas of specialization within health policy fellowships, such as social emergency medicine, administration, advocacy, safety and quality, research, or general health policy.

*A 1-year fellowship option is available for individuals who already possess an advanced degree in public health or public policy.

*Moonlighting or assigned shifts in ED

Other programs have positions available for emergency physicians, but may also extend invitation to applicants from all specialties. These include:

• The National Clinician Scholars Program
• The Commonwealth Fund  
• The Robert Wood Johnson Foundation Health Policy Fellowship
• The APHA Public Health Fellowship

Differences between programs
Fellowships offer a wide spectrum of options from those with a primary focus on advocacy, to translational or experiential training, to predominantly research in health policy. While almost all programs offer elements of each, fellowships vary in emphasis on these categories. The health policy fellowships that emphasize research aim to develop the necessary skills to conduct translational research in health policy. Those that have a more experiential emphasis tend to offer a larger variety of practicum placements, allowing fellows to rotate through different public policy experiences such as city, state, and national government organizations, advocacy groups, nonprofit organizations, or research centers. Most fellowships require the completion of a research, MPH, and/or capstone project. 

Length of time required to complete fellowships
Fellowships are usually 1-2 years in length but most are flexible depending on whether an applicant already has a master’s degree or graduate certificate in public health or a related field.  

Skills acquired during fellowship
Depending on the institution, a graduate certificate or a degree may be an option or a requirement. Particular knowledge and skills acquired during fellowship include, but certainly aren't limited to, basic understanding of American policy and procedures, understanding of how policy impacts health care, practice of medicine, public health, leadership development, and policy research. Furthermore, there is ample exposure to policy systems through involvement with advocacy groups, think tanks, city, and various levels of governmental organizations and legislative bodies. 

Typical rotations/curriculum
For fellowships specifically for emergency medicine physicians, clinical shifts are offered at one or more emergency departments. Most health policy fellows work part-time, approximately 5-8 clinical shifts per month, which varies from month to month depending on the fellowship demands.

Educational activities include:

• Graduate courses (degree/certificate) focusing on public health, health policy, research methods, statistics, and ethics
• City, state, or national government practicum to gain experience in public policy making, formulation and implementation
• Advocacy, nonprofit, or think tank practicum
• Research project focusing on health policy topic
• Leadership development and coaching

Board certification afterwards?
No. There is currently no certification agency for a health policy fellowship. Programs are variable in the nature of being accredited by the ACGME. The Master’s degree or certificate awarded as part of almost all fellowships and related coursework along with the examination requirements towards these are considered sufficient. 

Average salary during fellowship
Salary during fellowship varies depending on the structure of a particular program. Compensation may be based on the Graduate Medical Education pay scale, based on employment as a part time attending, or a combination of base salary and supplemental income from moonlighting opportunities. Not all health policy fellowships allow moonlighting, but those that do usually recommend not working more than at total of eight to ten clinical shifts per month so that you can fulfill the other requirements of the fellowship. Some programs may include tuition for advanced degrees as part of the fellowship, but this can vary among programs.

PREPARING TO APPLY

How competitive is the fellowship application process?
There are only a few programs (13 currently), each of which accept 1-2 fellows per year, which inherently makes it competitive. 

Requirements to apply
Completion of an accredited emergency medicine residency program is necessary to matriculate into a health policy fellowship. Other requirements, such as prior research, policy, or public health experience will vary amongst the programs. 

Research requirements
The amount of research required to apply for a health policy fellowship depends on the emphasis placed on research throughout the fellowship at an institution. However, research experience, particularly related to a health policy topic is likely to improve one’s application. Please note there are healthy policy grants available from the Emergency Medicine Foundation, ACEP, and other public and private institutions devoted to health policy research and advocacy that you may be able to utilize during both residency and fellowship. 

Suggested elective rotations to take during residency
EMRA offers a 4-week health policy elective for medical students and a 4-week mini-fellowship for residents. 

Suggestions on how to excel during these elective rotations
During your elective rotations, be enthusiastic, reliable, hardworking, and friendly to everyone. Arrive early and offer to stay late. Read every day and expand your knowledge base on topics such as lobbying, policy, legislation, regulation, etc. 

Should I complete an away rotation?
Away rotations are neither widely available nor required to apply for health policy fellowships. However, if an away rotation is available, it may be useful to preview a particular program of interest and further explore your interest in health policy. 

What can I do to stand out from the crowd?

Opportunities individuals can take to set themselves apart include:

• Active involvement in state EM organizations, EMRA, and/or ACEP, or AMA for advocacy and health policy education
• Special rotations or mini-fellowships in health policy
• Conducting health policy research
• Meaningful activities within hospital committees and administration
• Publishing reviews, articles, and book chapters relevant to policy

Should I join a hospital committee?
Hospital committees are excellent leadership opportunities as long as your involvement allows for meaningful contribution commensurate with your level of training. 

Publications other than research
Publications such as blog posts, magazine articles, book chapters, case reports, etc., can certainly strengthen your application.

How many recommendations should I get? Who should write these recommendations?
Typically 3 letters of recommendation are required, usually from your program director, department chair and someone who has worked with you clinically. Additionally, any eligible professional/mentor (attendings with health policy specialization, local chairperson of a city or state public policy committee) who can vouch for your involvement in health policy formulation and implementation and/or advocacy can also write a letter of recommendation. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Some programs do limit applications to those who have graduated from residency within the last 2 years. For the most part, aside side from personal logistics, there are no specific limitations to working as an attending prior to fellowship. Be mindful to remain involved in the health policy field and continue to build your CV after residency. Please note that some programs do limit applications to those who have been graduated from residency for less than 2 years. 

What if I’m a DO applicant?
No barriers currently exist for DO applicants. 

What if I am an international applicant?  
International applicants are encouraged to contact each program individually to inquire about whether or not they accept visa applicants. 

APPLICATION PROCESS

How many applications should I submit?
The answer to this question is dependent on the individual. Due to the small number of programs available, each with a varied focus, a lot of the determination will be on the basis of geographic location, offered graduate degree(s), and specific interest within the health policy realm. Apply to all programs that you have a strong interest in.  

How do I pick the right program for me?
Reaching out to current fellows and speaking with them is instrumental in the process. It is important to get an idea of their experiences, how they feel the training has helped them and maybe most importantly, what they would change about their program. Speaking with the current fellows of different programs offers invaluable insight into the programs structure, fellows’ quality of life and opportunities that are available. Communicating with fellowship directors is another way to obtain perspectives and goals for the fellowship. 

Common mistakes during the application process

• Missing application deadlines and applying late in the year.
• Choosing letter writers who provide weak letters of recommendations.
• Poorly written personal statements.
• Limited health policy knowledge.

Application deadlines
Application deadlines for each program are different. As with any application process, submitting materials earlier is always better. Spend the early part of your final year updating your CV, choosing which fellowship programs to apply to and picking your letter writers.  Most programs interview in the early fall of the year prior to matriculation and make acceptance offers by November. 

Tips for writing your personal statement
Personal statements are meant to demonstrate not only your interest, but also how you stand out, your commitment and qualifications for the program to which you are applying. All personal statements should reflect the author’s interest and intent for pursuing a health policy fellowship. It may be useful to include a story about what encouraged you to pursue health policy, your specific areas of interest and/or research, prior experience in health policy and ultimate career goals. Many programs will also ask you to include a paragraph specifically describing your reasons for applying to their program. 

Is this a match process?
No. 

What happens if I don’t obtain a fellowship position?
Options for future directions for those who apply and are not granted admission to a health policy program depend upon each applicant. An individual may choose to pursue a clinical emergency medicine career, work towards improving their fellowship application, reapply, or pursue health policy education through alternative experiences (mini-fellowships, graduate school, volunteer work, etc.). 

INTERVIEW PROCESS

How do I stand out from the crowd?
As with any interview, applicants should dress professionally in a business suit or professional skirt or dress. Be prepared by having additional copies of your CV and writing samples. Let your personality and enthusiasm for the field shine during your interview. 

What types of questions are typically asked?
Interview questions, as with most academic and professional interviews, focus on the applicant’s interest in health policy, research, their interest in the specific program at which they are interviewing, long term career goals, and occasionally personal opinions on well-known health policy subjects. Spend time familiarizing yourself with the latest developments in health policy before your interview. Considering asking a friend to help with a mock interview so that your answers are polished.  

How many interviews should I go on?
It is recommended that you attend all interviews offered by programs that you would strongly consider attending if offered a fellowship position. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

• Bohenheimer T, Grumbach K. Understanding Health Policy: A Clinical Approach. 6^th ed. New York, NY: McGraw-Hill Professional Publishing; 2012.
• Schlicher NR, Alison Haddock A. Emergency Medicine Advocacy Handbook. 4^th ed. Dallas, TX: EMRA; 2016.

Important skills to practice while in residency to prepare for fellowship
Since health policy is often focused on addressing important current public health issues and events, it is important to follow current events. That said, the best advice for moving towards a fellowship, is to simply stay informed, active, and maintain the passion for policy issues that drive you toward making this a prospective career choice. Active involvement in organizations, governmental affairs, or policy research can be important in honing the essential skills such as public speaking, leadership, and gaining the important policy knowledge that will serve the potential fellow well throughout their career.  

Tips on how to succeed as a fellow
Fellowship is a unique time to expand your knowledge and skills under the guidance of a mentor. Take advantage of all opportunities such as research, course work and advanced degrees, international opportunities etc. Strive to develop your professional network and  contacts in health policy. Work hard to become an exceptional leader, clinician, educator, and advocate.

CONCLUSION

Additional Resources

Blogs

• PolicyRx
• ACEP 911 Network
• http://www.govtrack.org/

Social media apps such as Twitter can be helpful in organizing the healthy policy information flow.

National organizations

• ACEP/EMRA Healthy Policy sections
• SAEM
• AAMC
• AMA
• State EM organizations (state or local chapters)

Conferences
ACEP hosts a yearly leadership and advocacy conference, usually in May, which is an excellent opportunity for all EM providers to learn, network, hone leadership skills, and discuss topics directly with legislators. There are also tracks for residents to help expand their knowledge and launch their involvement in health policy. AMA also hosts an annual conference usually in October-November which one should consider attending should they have specific interest in health policy fellowships.

How to find a mentor
Reaching out to program directors and other faculty at your home institution can be very helpful. Also, speak with current and past fellows, and attend conferences, as these can be a fantastic opportunity to network with others who have interests in health policy. Active involvement in ACEP/EMRA can help you find a mentor based on your specific requirements and career interests through the mentorship matching program. 

Finally………never give up. Good luck!