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Population Health and Social Emergency Medicine

Authors

Edward Rippe, MSIII
Touro University California

Kandria Jumil Ledesma, MSIII
American University of Antigua College of Medicine
Antigua and Barbuda, West Indies

Editor

Krystle Shafer, MD
Director of ED Critical Care
Co-Clerkship Director EM Medical Student Rotation
Critical Care Intensivist, MSICU and OHICU
Clinical Faculty, Department of Emergency Medicine
Wellspan York Hospital

Special thanks to our 1st edition writing team

Krystle Shafer, MD
Danish S. Malik, 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 cultural, economic, environmental, etc.) Social emergency medicine narrows the field of population health by focusing on the emergency department acting as the local population’s health and social “safety net.” By analyzing the interplay between the social forces of the local community and its interaction with the emergency system, this specialty strives to impact these social forces with the goal of improving the individual and thus community health and well-being.

History of the specialty/fellowship pathway
Population health as a specialty did not become prominent in the United States until the late 1990s and early 2000s. It is still a young specialty, with only a few fellowships available. 

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 the 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 the traditional appointment as an emergency medicine faculty include (but are not limited to) the following: government positions for the Department of Health Services, assisting in the formation of health policies, developing quality improvement initiatives, developing local programs such as HIV testing or infant mortality prevention, employment with nonprofit agencies, working in academia with a focus on research or teaching students enrolled in a public health-related degree program, or consulting and assisting in private companies such as insurance and pharmaceutical agencies. 

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 as compared to community programs. Other factors to help make this decision include desired location for employment and the hospital’s current and/or willingness for future involvement in programs that focus on improving population health.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
Some are combined population health and social emergency medicine fellowships whereas others are either population health or social emergency medicine fellowships. 

Combined Population and Social EM:

EM Population Health (Research based):

Population Health (Research and Advanced Degree Opportunities):

Non-Fellowship Opportunities (Resident Research Opportunities):

Differences between programs
UCLA has a heavy clinical focus in their program, which is different from the other opportunities, all of which are all primarily research based. The University of Wisconsin requires a master’s or doctoral degree in public health or an allied discipline at the time of appointment. This program does not specifically target emergency medicine physicians. UCI, NYU, and SBH however all target emergency medicine physicians for their respective programs. UC Irvine in particular offers a Research Fellowship in Population Health that prepares Emergency Physicians for a role in Research Directorship. Because of such, this program allows dedicated time for the participant to pursue an MPH or MS degree in research methodology. Stanford offers an additional year for advanced degree obtainment and also offers opportunities for curriculum development for undergraduate students. The Levitt Center is a research institute dedicated to advance the knowledge base regarding the interplay of social forces that influence emergency medicine.

Length of time required to complete fellowship 
Stanford is 1-2 years, depending on whether the fellow chooses to complete a master’s degree and/or research project. The University of Wisconsin is a two-year service and training fellowship. St. Barnabas offers a program that is one year in length. The Population Health fellowship at UC Irvine, NYU, and UCLA are all two-year programs.

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.

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? 
There is no board certification after fellowship. The Stanford fellowship offers a master’s degree in public health or health services research. At NYU, a Master of Science Degree in Clinical Investigation (MSCI) is given to fellows who have completed the program requirements. 

Average salary during fellowship
Salary during fellowship is typically comparable to that of a part-time ED attending.

PREPARING TO APPLY

How competitive is the fellowship application process?
Although there are typically a low number of applicants to these fellowships, because there are limited fellowships with limited spots, this is considered a reasonably competitive fellowship. 

Requirements to apply
Stanford requires candidates to be either in their last year of residency or have completed an ACGME-approved residency program in emergency medicine to apply. They must also be licensed to practice in California prior to applying to this program. University of Wisconsin requires a master’s or doctoral degree in public health or an allied discipline. St. Barnabas requires a CV, a letter of interest, and three letters of reference. Applicants must have completed an ACGME-approved program in Emergency Medicine. Applicants to the Population Health Fellowship at UC Irvine must have a California Medical License and must be board-certified or board-eligible emergency physicians. Applicants must also have three letters of recommendation, a CV, and a letter of intent. Candidacy for the NYU Healthcare Leadership and Operations Program requires a candidate to submit a CV, letters of recommendation, clinical references, cover letter from school of medicine, transcript, two essays, and completed Wagner application. The ideal candidate will have demonstrated a dedication to public service, passion for leadership, and interest in ED operations. NYU requires their candidates to be board certified and have an active license to practice in New York.  

UCLA’s IDHEAL program requires applicants to have completed an ACGME-accredited residency and be board-certified or board-eligible in emergency medicine. Applicants of a four-year residency programs can apply directly whereas applicants of three-year programs must have one year of post-residency experience or one year or more of fellowship experience. In addition, applicants must be eligible to practice in the state of California.

Research requirements
Completing research during residency is highly recommended for applicants considering this fellowship, especially research with ties to population health. It is better to have one completed research project than to have three incomplete projects at the end of your residency. 

Suggested elective rotations to take during residency
Suggested elective rotations to consider (but not limited to) include research, administrative, community health clinics, state or local public health office, 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. 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. Be on your best behavior 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 solid CV that displays leadership, educational, and research activities that clearly display your interest in population health. 

Should I join a hospital committee?
If there is a hospital committee in which you are interested and 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. Stanford specifically requests 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 you a strong letter. 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 to DO applicants. 

What if I am an international applicant?
We recommend for international applicants to contact each program individually. University of Wisconsin requires foreign nationals to have U.S. permanent citizen status. 

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 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
Stanford has an application due date of mid-November (with a July 1 start date in the following year). University of Wisconsin lists a deadline of mid-December. St. Barnabas has a rolling admission deadline. For UC Irvine’s Population Health fellowship admission deadline, call 714-456-5239. NYU has a rolling admission date starting in July.  Two-year cycle is from July-June. The application deadline for UCLA’s IDHEAL fellowship is October 15th.

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 achieve 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 the 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 as well. Spend the next year addressing the deficiencies on your application and apply again. It is also possible to find 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

  • Nash D, et al. Population Health. Burlington, MA: Jones & Bartlett Publishers; 2016.
  • Lueddeke G. Global Population Health and Well-Being in the 21st Century. New York, NY: Springer Publishing Company; 2015.
  • Levy B, Sidel V. Social Injustice and Public Health. 2nd ed. Oxford University Press; 2013.
  • Shi L, Stevens G. Vulnerable Populations in the United States. Hoboken, NJ: John Wiley & Sons; 2004.

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. The existing fellowships offer opportunities to earn an advanced degree; strongly consider pursing 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 resources

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.