EMRA Fellowship Guide, 2nd Edition

International Emergency Medicine

Authors

N. Shakira Bandolin, MD
International EM and Global Health Fellow
University of Utah

Joseph M. Reardon, MD, DTM&H, FAAEM
International Emergency Medicine and Global Health Fellow
Vanderbilt University

Ryan Joseph, DO
Resident Physician
Texas A&M Corpus Christi

Faculty Editors

Matthew Fuller, MD
Assistant Professor
University of Utah

Ryan Ernst, MD
Adjunct Faculty
Division of Emergency Medicine
University of Utah

Special thanks to our First Edition Faculty Editor

Jennifer Bellows, MD, MPH

INTRODUCTION

Description of the specialty
International emergency medicine (IEM) is a subspecialty of emergency medicine (EM) that focuses on the development of EM capacity across national borders.¹ Some IEM practitioners prefer the term global health, which refers to the systematic quest for health equity around the world, and they have adopted the term global emergency medicine (GEM). In most countries of the world, emergency medicine is a young specialty or has not yet been established. There is a great need for EM physicians to build and equip emergency departments, establish training and research programs, mentor colleagues, and provide patient care across borders. There are currently more than 40 GEM fellowship programs, with more being added every year. GEM fellowships are widely variable in goals, work balance, training, and target population. Fellowship tracks are as varied as the programs that offer them, thus a fellowship in GEM can generally be tailored to your specialty interests and needs.

History of the specialty/fellowship pathway
Emergency medicine is a relatively young specialty that has become well-established in only a small number of countries. The United States was the first to recognize the specialty. The first EM practice was established in 1961 by Dr. James Mills Jr. and three other colleagues in Alexandria, Virginia, and it wasn’t until 1979 that the American Board of Emergency Medicine (ABEM) was established. 

Between 1980 and 1986, Canada, Australia, Hong Kong, Singapore, and the U.K. followed suit and formalized specialties in EM along the lines of the American model. Simultaneously, continental Europe developed a competing model, termed the Franco-German model. In this model, physicians in the field triaged patients to specialty inpatient units; therefore, there was little need for an ED with generalist physicians and undifferentiated patients. With time, the American model has been adopted in most countries that have incorporated EM into their health system design.

With the development of EM in these countries, a number of EM trained physicians in the early 1990s turned their attention to developing the specialty in other regions. Arnold et al. described 3 stages of EM development: underdeveloped, developing, and mature. In underdeveloped systems, EM is not recognized as its own field, and specialty systems for patient care do not exist. In developing systems, emergency medicine is recognized as a specialty, residency training is usually underway, and a national EM society often exists. In mature systems, academic EM, subspecialty fellowships, national databases, and peer reviewed journals are well established.

With increasing interest and demand for international assistance and a desire to develop mature EM systems globally, GEM was born. GEM was first composed of medical relief organizations. One of the first organizations, Doctors Without Borders, delivers emergency medical care when war, civil strife, epidemics, or natural disasters occur. It was founded in 1971 by 13 French doctors and was known as Médecins Sans Frontières (MSF). Their first mission was in Managua, the capital of Nicaragua, where an earthquake in 1972 had destroyed most of the city and killed between 10,000 and 30,000 people. MSF now has offices in 28 countries, employs more than 30,000 people, and has treated more than 100 million patients—with 8.25 million outpatient consultations being carried out in 2014 alone.

World Association for Disaster and Emergency Medicine (WADEM) was one of the first EM development organizations, founded in 1976 to “promote the worldwide development and improvement of emergency and disaster medicine.” WADEM focuses on the development of disaster management systems and sponsors the biennial World Congress for Disaster and Emergency Medicine. This organization also publishes the journal Prehospital and Disaster Medicine.

In 1989, ACEP was among 4 international organizations to found the International Federation for EM (IFEM), which is now the most broad-based international organization dealing with GEM development issues. In 1998, the ACEP International Section was founded, which quickly became one of the largest sections in ACEP, and currently has more than 1,000 members.

The Society for Academic Emergency Medicine (SAEM) had an international committee from 1991-1996, which then changed to the GEM Interest Group. SAEM’s international arm is now known as the Global EM Academy (GEMA), which provides an academic framework for GEM activities and provides guidance for individuals and organizations seeking to guide the development of EM in other countries.

The first GEM fellowship program was established in 1994 at Loma Linda University, and now there are more than 40 GEM fellowships in the United States alone. In more recent years, academic institutions have become more involved in GEM by sponsoring medical missions, physician-exchange programs, and long-term development projects. Currently, GEMA is working to establish curriculum standards for these fellowships. Funding continues to be a challenge in resource-limited settings, and fellowships rely on a combination of US-based clinical work, teaching, research grants, government programs and non-governmental organization (NGO) sponsorship to cover GEM fellow salaries.

In the past 50 years, the medical care in underdeveloped countries has continued to grow, making GEM a rapidly growing field in medicine. The future for GEM is a bright one as an increasing number of countries seek to improve their health care systems and young physicians continue to push the boundaries of medicine, especially in the developing world.

Why residents choose to follow this career path
Embarking on a 1- to 2-year post-residency fellowship is a big decision. Though GEM fellowships have varied goals, there are a few things that a fellowship can offer you: mentorship, skills development, networking opportunities, research opportunities, and opportunities for obtaining advanced training, such as a Diploma in Tropical Medicine and Hygiene (DTM&H) or a Master of Public Health (MPH) degree. International EM is a small community. The personal relationships and networking opportunities you develop while in fellowship can set the stage for your GEM career for the rest of your life. First-hand education from those who have experience is priceless. During fellowship you will be focused on developing international medicine skills, which usually translates into scheduling flexibility with reduced shift load to accommodate possible graduate work and international travel. 

How do I know if this path is right for me?
Some residents may choose a fellowship if they have a special interest in academics and may want to continue their global EM career in an academic setting. Many physicians in GEM pursue academic careers because of more available time for travel, international projects, and teaching. Participating in a GEM fellowship may be a great way to get your feet wet and discover your niche in GEM. 

Career options after fellowship
International EM is broad, so the career options afterwards are nearly unlimited. Before choosing to do a fellowship, it is important to undertake a personal inventory of your goals, career aspirations, and lifestyle. Some career paradigms include:

• Overseas work: Some graduates pursue full-time international positions. NGOs and other international organizations (such as Doctors without Borders, MSF) employ physicians and offers volunteer opportunities. Another strategy is to apply to a specific hospital or clinic and work as an international physician in a clinical setting.
• Research: Some graduates devote themselves solely to international research. Though most people balance this with a clinical career, governmental or non-governmental organizations (such as the World Health Organization (WHO) or the United Nations (UN)) offer positions for clinical researchers interested in global health.²
• Domestic Practice and Education: Graduates of international EM fellowships do not have to settle on a life abroad. Many graduates use the lessons they learned from their international work to inform their practice in the United States, becoming more versatile providers in rural and low-resource settings. Others use their experience to teach in residencies or to serve remotely as a mentor to international programs. Whether you decide to pursue a fellowship or not, one of the first career decisions you will make related to working in a community or academic site for your subsequent job. If you choose to work overseas for an NGO or other international organization this decision may not apply to you immediately, but if you choose to return to domestic work, you will have to figure out how to find a job that allows you to best pursue your career interests. One of the initial decisions most resident and fellows make is related to choosing an academic or community-based practice.

Academics: Working in an academic medical center with a specialty interest in global health is one strategy for those who are passionate about teaching or research. One advantage of pursuing an academic career is that some institutions may reduce clinical service and provide scheduling flexibility to allow you to divide time between international and domestic work. An academic affiliation may help open doors when collaborating with certain organizations who may be looking for an academic or institutionally-backed partner.

Community work: A strategy is to work in a community setting and negotiate time off to pursue international work. As many community jobs base pay on clinical productivity, it may be easier to reduce clinical service requirements, but your paycheck may reflect the time you spend doing other non-clinical activities. The advantage to this route is flexibility and the ability to have full control over what activities you participate in.

Academic vs. Community positions
Community jobs typically pay more than academics, and this can be used to fund time and work overseas, instead of relying on grants or departmental funding, although recognize that if you are working less shifts, your paycheck will reflect the decrease. It may be more difficult to negotiate longer periods of time off (greater than two weeks), but often community groups will be supportive if your intents and goals are clearly stated and discussed with leadership at the beginning of your employment.  In addition, much of the work of developing EM in low and middle-income countries is not necessarily done onsite, and much can be accomplished while in your home country.  The overall advantage to this route is flexibility and the ability to have full control over what activities you participate in.

It is important to realize that most substantive global EM opportunities will have the involvement of a university or academic center, and it is difficult, and likely problematic to pursue projects either individually or with a small group. Therefore, involvement with academic centers with global EM projects is likely essential, so maintain and develop relationships with centers you have worked with as a resident.  Global health conferences also provide opportunity to find collaborative partners.

While working internationally, it is imperative to have a thorough understanding of the guiding principles and common pitfalls of global medicine. If this route is pursued outside of a fellowship, it requires some level of additional formal or self-directed education.  The principle of “good intentions are not enough” definitely applies.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
The International Emergency Medicine Fellowships Consortium (IEMFC) is the primary administrative body for GEM Fellowships and lists many fellowships at iemfellowships.com/programs (43 programs in 2018). Additionally, there are many great fellowships that are available but not yet advertised or part of the IEMFC. If you are applying to a fellowship that is not a member of IEMFC, you may want to ask why their fellowship is not included. There are many reasons for non-affiliation, but it is worth a conversation to understand the program’s specific reasons and to ensure they would be a good fit for you. 

SAEM also maintains a directory of GEM fellowships and additionally accredits programs. As of 2018, 7 programs were SAEM-accredited.

Differences between programs
Most GEM fellowships encompass three components; clinical work, educational experiences, and operational functions.

• Clinical work: Most fellows work clinically in the ED with a reduced shift load. This varies by program. It is important to strike a balance between clinical work and GEM projects.
• Personal Education: Some time will be allocated for your personal educational goals, such as an advanced degree or continuing education. The most popular degrees are detailed below.

• Master of Public Health (MPH): The MPH was long considered the foundational credential of a global health practitioner due to its broad coverage of skills for building public health infrastructure for the development of emergency medicine. More recently, MPH programs have sought to distinguish themselves by offering specialized concentrations in disaster relief, tropical medicine, management, and other topics.
• Diploma in Tropical Medicine and Hygiene (DTM&H): The DTM&H is a two to three month clinical course in diagnosis and treatment of tropical disease. Most DTM&H students are infectious disease fellows, but a growing number of GEM fellows take the course. The most well-known DTM&H courses include the Gorgas Course, taught in Peru by the University of Alabama-Birmingham and Cayetano Heredia University; the London School of Hygiene and Tropical Medicine; and the Liverpool School of Tropical Medicine.
• Master of Science in Global Health (MSc-GH): This is a specialized research degree offered by a few universities.
• Master of Business Administration (MBA), Master of Education (MEd), Master of Science in Emergency Medicine (MSc-EM): Many of these degrees can be tailored to build skills relevant to GEM.
• Operational: Much of GEM fellowship is spent participating in field work. This component may vary based on goals of the fellowship, but it could include global health research, field work, clinical time abroad, etc. Most fellowships include projects focused in one of these four areas:
• Emergency medicine specialty development (Residency building, EM skills training)
• Public health/capacity building (EMS/Emergency services)
• Disaster Relief/Humanitarian Aid
• Academic research

Length of time required to complete fellowship
Most GEM fellowships last 1-2 years. Some programs will allow you to finish in 1 year if you already have an advanced degree, and there are a few programs that are 1 year but offer no advanced degree.

Skills acquired during fellowship
The skills required for GEM are extensive and can be different from what you learned during residency. Only you can determine what skills you want and what skills you think will benefit your career. Here are a few to consider:

• Public Health Skills/Epidemiology: An MPH degree teaches you about health on a large scale. This skill can be valuable in international medicine where it is often public health interventions rather than brilliant diagnostic skills that make the greatest impact.
• Research Skills: How do you set up a formal focused needs assessment? How do you ensure a quality homogenous chart review? How do you talk to the IRB in India? These are skills that will benefit you.
• Education Skills: How do you teach an internal medicine physician in Kenya about ATLS? How do you educate residents in Cambodia?
• Program development skills/Health systems: What does it take to set up an EMS system in Panama? Can you design a program for combating maternal mortality in Slovakia? What do you do to help out with the earthquake in Nepal?
• Clinical Skills: How do you treat typhoid? What do you do about sepsis when you have only limited antibiotics and no IV fluids?

Typical rotations/curriculum
One of the most important aspects of a fellowship is the type of curriculum it offers. Programs have either a structured or flexible program. Structured programs have a set curriculum that all fellows follow, because it is believed that there are core concepts that all fellows need to learn regardless of specific interests. More flexible programs allow the fellow to determine what they want to learn. Some applicants prefer the structure because it can help them develop their skills with more guidance from experts in their area of interest, but some prefer more flexibility to allow them to determine how much time they travel, what they learn, or how they’ll develop their skills further. Most programs have a mixture of both styles of learning, so be sure to match your program with your career goals and your style of learning. 

During fellowship you typically spend 2-7 months per year working on projects abroad. The rest of the time is spent working clinical shifts in the ED, preparing didactics, working on research, and fulfilling administrative responsibilities.

Board certification afterwards?
ACGME does not accredit GEM fellowships. There are multiple programs that offer the opportunity to get certifications from other schools or their own (such as the Certificate in Tropical Medicine (CTropMed) or advanced degrees). SAEM accredits GEM fellowships, and a few have achieved this accreditation. 

Average salary during fellowship
Many fellowships offer salaries between $60,000 and $100,000, although the most accurate information is available by contacting potential fellowship programs. Additional things to consider in your fellowship search could include fees that are paid for by the program (ie, do they pay for certifications or for a public health degree, travel stipends, benefits, and/or allow moonlighting).² One should consider the cost of living since this will varies widely.

Splitting time between departments
International emergency medicine work typically falls as part of your EM appointment within your home institution. However, the key points to a negotiation will be regarding how much international time you are given versus how much time you spend practicing medicine within your home institution, as well as how this time will be compensated. 

PREPARING TO APPLY

How competitive is the fellowship application process?
Several spots go unfilled most years. The IEMFC posts a list of unfilled positions after the application process each year (mid-November). As with many other fellowships, there are specific programs that are much more competitive. In general, competition for GEM spots at well-known institutions has grown in recent years and will likely continue to grow. 

Requirements to apply
Global emergency medicine fellowships are available to graduates of all accredited EM residency programs. 

Research requirements
Research requirements vary by program. Grant writing and research skills will likely be an advantage, but there are some programs that are more research-oriented and will favor candidates with research experience. 

Suggested elective rotations to take during residency
Consider completing an international away elective sometime prior to submitting your fellowship application. 

Suggestions on how to excel during these elective rotations
As with anything else in residency, you will excel at things you are passionate about. If you choose an experience that you are excited about and have clear goals for your time, you will likely excel and learn a great deal. 

Should I complete an international rotation?
Though an international rotation is not required, it would be helpful to increase your breadth of experience. Participating in an international rotation during residency is not always possible due to time and financial constraints, but most applicants have had experience abroad in the past. If you get the chance for an elective, try to use it to engage in something that you are passionate about. You will not have much time in residency, so use your time to do something that will reinvigorate you and serve as a reminder for why you went into emergency medicine. While many people will try to get clinical experience abroad, you may want to serve in an educational activity and teach abroad or take a course at the CDC to learn more about epidemiology. Whatever you choose, if you get something out of the experience it will add depth to your application and your ability to talk about why you want to be a GEM fellow. 

What can I do to stand out from the crowd?
The best thing you can do is to research the programs you are most interested in and start building the skill set that those programs expect. Does your dream program focus on a particular country? Visit and/or research that country in depth. Does your dream program require an MPH? Most distance learning MPH programs allow you to start taking classes for credit online before formally enrolling. Joining a hospital committee, teaching courses for medical students, going to international conferences, volunteering abroad, or contributing to an international research project may help you in your GEM career endeavors. Most importantly, the quality of involvement is much more important than the quantity – a CV filled with small one-day projects is less impressive than a CV with 1 or 2 longitudinal projects showing a sustained record of engagement and service. 

Should I join a hospital committee?
Hospital committees may help you build a targeted skill set but are not required for GEM fellowship application. 

Publications other than research
As mentioned earlier, it is more important to be involved with experiences that you are passionate about and that have in some way contributed to your education or career. Everyone understands that you have little free time in residency. As a general rule, program directors understand that you are busy and have a lot of clinical and educational time constraints. You have too little free time to be participating in activities that you do not enjoy, so choose your experiences wisely. Writing for EM related journals or magazines is a way to get more publications and experience writing without detracting from residency. These are not required but can be a helpful experience and accomplishment to have on your resume. 

The most important approach to residency activities for the GEM fellowship applicant is to limit the breadth of your work to 1 or 2 high-quality projects. Choose a project and do it very well and you will stand out from the crowd. Even if your interests change, your reputation for high-quality work will be valuable.

How many recommendations should I get? Who should write these recommendations?
Most fellowships require 3 letters of recommendation, with one being from your residency director or chair. We recommend that the other 2 letters be from someone who can speak to your versatility, attitude, and skill set. As with all letters of recommendations, it is important that they are heartfelt and are from someone who really knows you. Most programs are looking for fellows who can operate in very diverse and challenging situations, and for fellows who can maintain a positive attitude and work with a team. Additionally, the most successful applicants are people who are competent and passionate about their work, so make sure you choose mentors who can speak to this. Ideally, choose someone who has worked with you on specific projects or shared experiences with you that showcase how remarkable you are and why you would be a great GEM fellow.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Absolutely. Taking some time to work can help you solidify your clinical skills, allow you to really clarify your career goals, and give you time to gain more experience in educational and clinical roles. It may be more professionally and financially difficult to return to an academic environment if you have been working in the community, but many fellows have previously made this transition. 

Several residents interested in GEM are able to customize a GEM fellowship-like experience by taking a part-time attending job and connecting directly with a mentor and project in the field, bypassing the fellowship route altogether. If you have a specific project in mind, you may find this “build your own experience” approach to be much more rewarding than fellowship. Salaries are typically higher and the commitment is much more flexible. However, this strategy does make it harder to enter some academic roles. Additionally, a lot of flexibility requires an equal amount of self-discipline and the ability to network and find mentoring independently, which can be difficult.

What if I’m a DO applicant?
Programs do not have specific requirements for DO or MD candidates. However, some countries do not recognize the DO degree, and thus DO applicants may be excluded from fellowships that have projects in those countries.

What if I am an international applicant?
Applicants to most fellowships must be ABEM board-certified or eligible by the July 1 fellowship start date and be eligible to live and work in the US. 

APPLICATION PROCESS

How many applications should I submit?
Apply to all programs that you may want to attend. Choosing a fellowship is an intimate process since you are not only choosing a curriculum, but you are also choosing your colleagues and mentors. Most applicants apply to 5-10 programs. 

How does an applicant pick the right program for them?
The most important part in choosing a fellowship is first figuring out your own goals and priorities. You have 1-2 years in fellowship and want to make the most of your experience, in programs that are incredibly heterogeneous. Consider your particular interests, type of curriculum, degree of autonomy you are seeking, mentorship and personality of your program and colleagues, any advanced degrees or certificates you are looking for, proportion of time spent abroad, length of program, program affiliations, and benefits/salary. We have already touched on many of these previously but here is a brief rundown on each topic:

• Location of Interest: Most fellowships are based at a single sponsoring North American institution and have one or two international partner institutions. Your first consideration should be the site where you want to work or the type of project you want to be involved with, as your fellowship may have limited capacity to add additional sites.
• Particular Areas of Interest: Most programs focus on one of several areas of interest including EM development, public health/capacity building, research, or humanitarian disaster relief.
• Degree of Autonomy: Fellowships offer a variety of structured and flexible curricula. It is important to conduct an assessment of your personal learning style and goals to find a program that will best serve your needs.
• Mentorship: Your future fellowship program mentors are one of the strongest reasons to do a fellowship. Find a mentor with the same goals and objectives as you who can offer the degree of mentorship that you desire. This is particularly relevant in international EM, because mentors may spend a significant portion of each year out of the country. Choosing a mentor with similar interests may be helpful, but itt is most important to find someone who will be supportive of you and has a vested interest in your education.
• Advanced degrees: Pay close attention to the degree(s) offered by your fellowship program. In general, academic degrees are no substitute for field experience if you primarily seek clinical expertise. Commonly an MPH program is included, and many fellowship directors recommend fellows complete a diploma or certificate. If you are not sure about committing to a full degree, consider participating in certificate programs, which often are shorter and can still offer a valuable and tangible experience. Online degrees offer more flexibility and may allow you the time to become a stronger GEM practitioner. As this is not a board certified specialty, a degree or certificate give you something tangible to show for your time in fellowship.
• Length of program: Most programs are 1-2 years. Two year programs include an extended year to allow for you to complete an advanced degree.
• Program Affiliations: These can be incredibly helpful to provide networking and career opportunities after fellowship. Fellowships generally fall into 3 categories: those that serve in a global research or advisory role at several sites, those that affiliate with one or two partner academic institutions, and those that affiliate with an NGO such as MSF, IMC or Partners in Health. The first category is most useful for fellows seeking a specific academic area of expertise. Fellowships that partner with other institutions are useful ways to establish connections with a particular part of the world. NGO affiliations provide a stable long-term link to populations in greatest need. Consider your goals and be sure to ask about program relationships when you interview.
• Benefits/Salary: Assess the salary, as well as the cost of living, amount of clinical time you are expected to work, and other expenses covered by the program to get a real sense of your true benefits package.

Common mistakes during the application process

• Applying to only “the best” fellowships: Just because a fellowship is associated with a prestigious institution does not mean that it is the best for you. Most fellowships only focus on one or two regions of the world or topics within GEM.
• Over-emphasizing research or practice: When applying, don’t try to fit yourself into the mold that you think the fellowship wants out of you or you may be disappointed during your fellowship years. Be yourself and you will find the fellowship with the right blend of work experience.
• Not showing enough interest: When you find the right program, reach out to the faculty in that division. Start planning your fellowship projects as an applicant and you will stand out as the best match.
• Applying too late: Programs start accepting applications at various times. For most programs, this is from early April to early June. Submit your application early.
• Not applying to degree programs in time: Ask if you need to start your application to MPH or DTM&H programs simultaneously, or immediately after you matriculate at a fellowship program.
• Not having minimum credentialing requirements: This is more often an issue after you have accepted a position, so don’t sweat it too much up front. Make sure your ACLS, BLS, and PALS are up to date. Ask if the institution requires a Difficult Airway certification. Ask about the institution’s ultrasound credentialing requirements, as most institutions require documentation of at least 25 scans of each type (FAST, echo, bladder, etc.). Make sure you have copies of your immunization documents and citizenship documents, just like during residency credentialing.

Application deadlines
For applications submitted via the International Emergency Medicine Fellowships website, please review the site for specific details. Applicants are accepted April through October. Programs offer acceptances on the second Monday of November, and applicants are given 24 hours to make a decision regarding the fellowship. For non-IFEM fellowships, contact the institution directly, as their deadlines and requirements may vary. 

Tips for writing your personal statement
Fellowship personal statements may be more prosaic than residency personal statements. Show why GEM is important to you. Reflect on your experiences thus far. Most importantly, show a vision for your career plans 5-10 years down the road.

Is this a match process?
No. 

What happens if I don’t obtain a fellowship position?
If you are not offered a fellowship, you can call other programs you were interested in to see if they have an unfilled spot, or you can consider spending your time working with an international organization. There is not a backup application process for GEM, but with many programs unfilled each year, there should be positions available for you if you are well prepared. 

INTERVIEW PROCESS

How do I stand out from the crowd?
Show that you have an understanding of the breadth of GEM and your place within it. Show that you have thought out your long-term career plans personally, academically, and financially (are you really going to go volunteer with that NGO forever?). Show that you are passionate and you will stand out. 

What types of questions are typically asked?
Fellowship interviews are focused and typically not intimidating. You will typically interview with the fellowship director, the emergency medicine department chair, a teaching faculty member, and additional global health faculty. Example questions include:

• What skills have you focused on developing during residency inside and outside the ED?
• What motivates you to be involved in global health? Do you find special personal, philosophical, spiritual, cultural, or academic experience in the field?
• Do you mind living in austere conditions? Are you comfortable using an outhouse, taking cold showers, eating rice and beans every day? How do you take care of your personal safety? Programs should not ask directly about your relationship status or family situation, but they may touch on these topics indirectly as many field sites may be dangerous for families.
• What are your long-term career plans?
• What research have you performed? What research interests you? Why did you choose it? What challenges did you encounter?
• How well do you understand the state of GEM globally? International organizations? EM capacity in various countries?
• What is your clinical style as an academic EM attending?
• What is your approach to teaching residents?
• Why did you choose your particular residency program?
• What experience do you have working or visiting a region we focus on?

If you feel intimidated at a fellowship interview, then that institution is probably not the right place for you.

How many interviews should I go on?
In general, most applicants interview at fewer than 10 programs. GEM fellowships are vastly different from each other and fellowship applications are less competitive than residency applications. Applying to too many programs suggests you have not established your specific fellowship goals. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading
Focus on clinical excellence during the residency years. Work hard to do well on the national board exams. Your greatest asset in GEM is your clinical credentials. Do not worry about reading a GEM textbook during residency. If you need a guide while on rotation, consider the EMRA GEM guide. 

Important skills to practice while in residency to prepare for fellowship
Practice placing IVs without ultrasound guidance. Practice as much bedside ultrasound-based diagnosis as possible. Make sure to work on language skills if relevant to your region of interest. 

Tips on how to succeed as a fellow
Establish a good balance of clinical care and project involvement. 

CONCLUSION

Additional Resources

Literature

• The Global EM Literature Review summarizes the best GEM literature each year
• The Nuts and Bolts of Global Emergency Medicine John Roberts, Janet Lin, Scott Weiner

Podcasts

• The MSF YouTube channel summarizes the greatest under-reported humanitarian challenges weekly.
• EM:RAP offers editions tailored to several parts of the world in several languages.

National organizations

• EMRA International Division
• ACEP International Section
• SAEM Global Emergency Medicine Academy
• AMA
• Global Academy of Emergency Medicine

Conferences

• ACEP Scientific Assembly
• SAEM Annual Meeting
• ICEM – International Conference on Emergency Medicine
• CUGH – Consortium of Universities for Global Health
• There are many other International Medicine conferences abroad.

How to find a mentor
Check out www.globalem.net, a website run by GEMA that allows you to connect with a mentor in a social network-style format. If you have a specific institution or project in mind, reach out to someone who has similar interests in you.

Citations

• Arnold J. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med. 1999;33(1):97-103.
• Roberts J, Lin J, Weiner S. The Nuts & Bolts of Emergency Medicine. 1^st ed. 2016.