Population Health and Social Emergency Medicine
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Population Health and Social Emergency Medicine

Authors

Sriram Venkatesan, FAWM
Medical Student
Sri Ramachandra Medical College, India
Vice Chair, EMRA Prehospital & Disaster Medicine Committee
EMRA Rep to the ACEP Tactical & Law Enforcement Medicine Section

Alexis Kimmel, MD
University of Cincinnati Emergency Medicine Chief Resident
Chair, EMRA Social EM Committee
EMRA Rep to the ACEP Social Emergency Medicine Section

Faculty Editor

John Purakal, MD
Assistant Professor
Department of Emergency Medicine
Duke University School of Medicine

Special thanks to our 2nd edition writing team

Edward Rippe, MSIII
Kandria Jumil Ledesma, MSIII

Special thanks to our 2nd edition faculty editor

Krystle Shafer, MD

INTRODUCTION

Description of the specialty
Population health has been defined by the American Journal of Public Health and Milbank Quarterly as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” The goal of this specialty is to reduce and potentially eliminate health disparities stemming from social determinants of health, such as housing, transportation, language, education, and access to healthy food. Social emergency medicine utilizes a population health lens to evaluate community-specific problems contributing to health outcomes seen in a given emergency department, which serves as the local population’s health and social “safety net.” By analyzing the interplay between the social elements of the local community and its interaction with the emergency system, this specialty strives to create lasting and meaningful impact at both the individual and community-levels through research, education, and advocacy.

History of the specialty/fellowship pathway
Population health and social EM are still relatively young specialties, although much work and research in these fields in the past few decades have helped them become more established. Population health did not become prominent in the United States until the early 2000s. Social emergency medicine did not become a recognized subspecialization until the late 2000s. Fellowship opportunities in these fields have grown rapidly since the first of its kind was formed in 2010.

Why residents choose to follow this career path
Residents choose this career path when they are interested in impacting population health and policy through community outreach, research, health policy, clinical services, and education.

How do I know if this path is right for me?
Are you interested in the social origins of health and disease? Do you find yourself dedicated to examining the interactions between emergency medicine and the social forces that affect population health and well-being of our communities? Are you interested in working on collaborative interventions where you design, implement, and evaluate these new strategies? If so, this fellowship may be for you.

Career options after fellowship
Career options after fellowship (beyond traditional roles as emergency medicine faculty) include, but are not limited to: government positions within federal or state health agencies; assisting in the formation of health policies; developing quality improvement initiatives; developing public health programs such as HIV testing or infant mortality prevention; employment with nonprofit agencies; working in academia with a focus on research; teaching students enrolled in a public health-related degree program; and consulting/assisting companies in the insurance and pharmaceutical sectors.

Splitting time between departments
Traditionally, EM physicians who complete this fellowship do not necessarily split time between departments. Rather, their primary appointment falls under emergency medicine, and their population health commitments fall under protected administrative time.

Academic vs. community positions
The decision between academic and community positions depends on the physician’s desire for research; academic programs traditionally have increased access to funding compared to community programs. Other factors to consider include geographical location and the hospital’s current — and/or willingness for future — involvement in programs that focus on improving population health. Regardless of setting, socially minded EM physicians are needed to improve ED operations related to social needs, challenge outdated policies, and advocate for the community.

IN-DEPTH FELLOWSHIP INFORMATION

Programs

*The Rush University Health Equity Fellowship is a newly minted fellowship. This 2-year opportunity combines clinical work, a master's of public health or similar degree, education in core health equity competencies, teaching and presentation opportunities, and a mentor-guided individualized area of academic focus. Interested applicants should contact timothy_gallagher@rush.edu.

Length of time required to complete fellowship
A typical social EM/population health (SEMPH) fellowship can take place over one or two years. Completion of a master's program (e.g., MPH or MSc) may take place during a two-year fellowship. Core components include research, education, and advocacy as they pertain to SEMPH. The fellow will identify a single component of major focus and develop competencies in additional areas.

Skills acquired during fellowship
During fellowship, you will obtain skills in scientific research, health policy formation, community health advocacy, team communication, program administration, academia, and mentorship. Focused research training on the design and conduction of clinical trials, biostatistics, epidemiology, population health interventions, grant writing, scientific manuscript writing, and practical experience implementing a public health intervention is included. A practical internship with regional and state public health leaders may also be incorporated to equip fellows to evolve as physician-leaders in SEMPH policy.

Typical rotations/curriculum
Curriculum usually includes research, involvement in curriculum development and health policy formation, involvement in community outreach programs/community health, and course work in public health.

Board certification afterwards?
Social EM/population health fellowships are not ACGME-accredited, and therefore there is no board certification after completion of the program.

Average salary during fellowship
Salary during fellowship is typically comparable to that of a PGY-4, with opportunities to moonlight generally available.

PREPARING TO APPLY

How competitive is the fellowship application process?
Competition varies among programs. Some may have difficulty filling slots due to proximity to other similar fellowships. As the number of fellowship programs increases, so does the number of candidates.

Requirements to apply
Candidates must have completed an ACGME-approved residency program in emergency medicine and be board-certified/board-eligible in EM. Prior to starting, the applicant must be licensed to practice medicine in the program’s state.

Application requirements often include a CV, a letter of interest, and three letters of reference.

Applicants with strong clinical backgrounds and demonstrated interests in teaching and research, population health or ED-based social determinant interventions will be given preference. It is recommended that applicants contact their programs of interest for program-specific application guidance.

Research requirements
Completing research — especially research with ties to population health — during residency is highly recommended for applicants considering this fellowship.

Suggested elective rotations to take during residency
Suggested elective rotations to consider include (but are not limited to) research, administrative, community health clinics, state or local public health offices, and substance abuse clinics.

Suggestions on how to excel during your elective rotations
On your elective rotations, strive to be the hardworking resident who is known to come in early and stay late. Be enthusiastic, helpful, and friendly. Be a team player. Continue to read every night and expand your knowledge base about population health topics.

Should I complete an away rotation?
If you are interested in any of the above programs, it may be worth considering an away rotation at their institution, if available. Be aware that this rotation will be a way not only for you to get to know the program, but also for the program to get to know you. As with any audition rotation, strive to be at your best during this rotation and treat every day as an interview day.

What can I do to stand out from the crowd?
The best way to stand out from the crowd is by building a strong CV with solid examples of leadership and educational/research activities that clearly demonstrate your interest in population health.

Should I join a hospital committee?
If there’s a hospital committee that interests you in which you could have a meaningful role, then you should definitely participate. Hospital programs with community outreach involvement would be ideal to help prepare for fellowship.

Publications other than research
Publications other than research, such as blog posts, magazine articles, podcasts, etc., are recommended and highly encouraged. These are great ways to educate yourself and the community especially about topics regarding population health. Do not forget to list such opportunities on your CV.

How many recommendations should I get? Who should write these recommendations?
Most programs require three letters of recommendation. Some programs may request that one of these letters be from either your program director or department chair. The other two letters should be from physicians and/or researchers who know you well and are willing to write a strong letter on your behalf. Having a letter writer within the field of public health would be very beneficial.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, you can still be competitive. Be prepared to answer questions during your interview about this gap in your application. Also, make sure you continue to build your CV during your time as an attending. For example, continue your involvement in research projects, community or hospital-based leadership roles, etc.

What if I’m a DO applicant?
There are no known barriers for DO applicants.

What if I am an international applicant?
We recommend international applicants contact each program individually to verify eligibility.

APPLICATION PROCESS

How many applications should I submit?
Apply to all programs where you would strongly consider accepting a fellowship position if offered.

How do I pick the right program for me?
Pick the program that strongly aligns with your career goals. Choose a program in an area where you will be comfortable living for one to two years.

Common mistakes during the application process

  • Missing application submission deadlines
  • Choosing authors for your letters of recommendation who do not know you well
  • Grammatical mistakes in your application
  • Failure to have activities on your CV that display leadership
  • Failure to have activities on your CV that display your interest in population health
  • Unfocused or inconsistent personal statement

Application deadlines
Fellowship schedules typically follow the academic year (July-June) so the best time to apply, particularly for senior residents, is the summer at the beginning of your final residency year. Interviews will typically take place October-November, and fellowship acceptance notifications will be sent out in November. Most programs accept applications on a rolling basis, but each program is different. Contact the programs you are interested in early to get application materials and guidance regarding deadlines.

Tips for writing your personal statement
Your personal statement is a place to let your personality shine through and to set yourself apart from the other applicants. Be careful not to simply repeat your CV, but rather explain why you are interested in population health and how this fellowship will help you achieve your career aspirations. The best personal statements are cohesive and immediately grab the reader from the beginning.

Is this a match process?
No.

What happens if I do not obtain a fellowship position?
If you do not secure a fellowship position, the best thing is to take a step back and analyze your application looking for areas of weakness. It may be worth gently asking programs where you applied if they have suggestions for improvement. It is also worth considering asking someone in a leadership position, such as your EM program director, to look over your application for weakness. Spend the next year addressing the deficiencies on your application and apply again. It is also possible to build a career in population medicine without completing a fellowship. Alternatives to a fellowship can include pursuing a master’s degree in public health, public administration, or public policy.

INTERVIEW PROCESS

How do I stand out from the crowd?
The best way to stand out from the crowd is by displaying a strong, clear interest in population health and articulating your plans for a career after fellowship. Be friendly and pleasant with everyone you meet. Practice your interview skills with someone in a leadership position at your current residency program prior to your fellowship interview.

What types of questions are typically asked?

  • Why are you interested in a population health fellowship?
  • Why are you interested in a population health fellowship at our program specifically?
  • Tell me more about “blank” that you list here on your CV.
  • What are your 5- and 10-year career goals?

How many interviews should I go on?
You should attend all interviews offered (assuming you applied only to programs you are serious about attending if offered a fellowship position).

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Alter HJ, Dalawari P, Doran KM, Raven MC. Social Emergency Medicine: Principles and Practice. 1st ed. Cham, Switzerland: Springer; 2021.
  • Nash DB, Skoufalos A, Fabius RJ, Oglesby WH. Population Health: Creating a Culture of Wellness. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2021.
  • Levy BS. Social Injustice and Public Health. 3rd ed. New York, NY: Oxford University Press; 2019.
  • Shi L, Stevens GD. Vulnerable Populations in the United States. 3rd ed. Hoboken, NJ: Jossey-Bass; 2021.

Important skills to practice while in residency to prepare for fellowship
It is important that you first and foremost strive to become a strong emergency physician during your residency. Other skills to focus on include developing your skills as a researcher, educator, and advocate for vulnerable patient populations.

Tips on how to succeed as a fellow
Take advantage of everything your fellowship has to offer. Fellowship is a unique time to develop your skills with the close guidance of mentors who have been in the field for years. Come in early for your required rotations and responsibilities, stay late, and make sure you continue to build your knowledge base by reading daily. Seek out feedback and strive to improve your skills daily. Existing fellowships offer opportunities to earn an advanced degree; strongly consider pursuing this opportunity. Finally, use this training to develop a community program or health policy initiative that improves local and/or global population health.

CONCLUSION

Additional training and resources
Some additional opportunities exist for emergency physicians interested in advanced training in population health and epidemiology outside of a traditional fellowship:

Journals and journal articles

Blogs/podcasts

National organizations

Conferences

How to find a mentor
There is no central website that links interested physicians with mentors within the field of population health. Consider reaching out to individual programs to find networking opportunities or mentors within that program or hospital system. You could also reach out to the EMRA Social EM Committee or sign up as a mentee in the EMRA Mentorship Program.

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