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Wilderness Medicine

Author

Carrie Jurkiewicz, MD
Wilderness Medicine Fellow, Stanford University
Department of Emergency Medicine

Faculty Editor

Grant S. Lipman, MD, FACEP, FAWM
Clinical Associate Professor of Emergency Medicine
Director, Stanford Wilderness Medicine Section & Fellowship
Department of Emergency Medicine

Special thanks to our 1st edition writing team

Carrie Jurkiewicz, MD
Mark Christensen, DO 
Grant S. Lipman, MD, FACEP, FAWM

INTRODUCTION

Description of the specialty
Wilderness medicine (WM) is the practice of medicine with limited resources in austere environments, or health care provided anywhere in which environmental conditions have physiologic insult to a patient. This simple definition belies the complexity of this specialty, as well as the extensive and varied opportunities it provides. Training in wilderness medicine can prepare physicians to treat mountaineers and sherpas on Everest, serve as directors of national parks, provide medical training and oversight for search and rescue organizations, work in hyperbarics or dive medicine, and provide medical care on expeditions or at remote scientific base camps. A wilderness medicine physician must not only have knowledge of medical problems that arise in the elements (i.e. acute mountain sickness, hypothermia, lightning strikes, dysbarisms, and envenomations, to name a few), but also how to acutely manage these problems outside of the hospital and often with minimal support.

Wilderness medicine includes, but is not limited to:

  • Trauma and Emergency Medicine
  • Sports Medicine
  • Rescue and Evacuation
  • Diving and Hyperbaric Medicine
  • Disaster Medicine
  • Tropical and Travel Medicine
  • Expedition Medicine
  • High-Altitude/Mountaineering Medicine
  • Envenomations
  • Survival Medicine
  • Tactical Medicine
  • Space Medicine

History of the specialty/fellowship pathway
If defining wilderness medicine as health care performed beyond the boundaries of existing civilized medical infrastructure, one may argue that surgeons from early Greece and Rome were the true founders of the field.1 The evolution of wilderness medicine has been closely tied to military operations, a statement that remains true today. The current field of wilderness medicine gained momentum starting in the early 1970s, when experienced Himalayan mountaineers gathered in London to share stories and discuss tips on high altitude survival. A few years later in Wales, scientists joined the discussion and gave lectures on high altitude physiology. In 1975, the Yosemite Mountain Medicine Symposium expanded discussions beyond altitude medicine, to include topics such as search and rescue, trauma, and backcountry first aid. The first textbook on wilderness medicine, Management of Wilderness and Environmental Emergencies, was written by Dr. Paul Auerbach and Dr. Edward Geehr in 1983. The Wilderness Medical Society (WMS) was established in 1982, and this was the first national society for wilderness medicine.The first fellowship in wilderness medicine was established in 2003, and today 15 fellowships are offered throughout the United States.

Why residents choose to follow this career path
While residents may choose to pursue wilderness medicine with different specific goals in mind, the overarching commonality is a desire to combine one's passions for both medicine and the outdoors. Now more than ever the emergency medicine community is recognizing wilderness medicine as an important academic subspecialty. Residents are drawn by the plethora of opportunities to contribute meaningful research to a rapidly growing field, and the opportunity to further expand the role of wilderness medicine physicians.

How do I know if this path is right for me?
Residents and medical students who come down with serious cases of wanderlust the week before an exam or after a weekend of working 12-hour shifts will be well-suited for wilderness medicine. Those who daydream about a life outside of the hospital, revel in their sense of wonder in the world, have a propensity for adventure, and gravitate towards adrenaline-spiking experiences should consider this subspecialty.

Furthermore, wilderness medicine can fulfill one’s desire for involvement at the academic, community, national, and even international level. While all physicians serve their community by providing medical care, those trained in wilderness medicine are able to extend their skills to ski clinics, marathons and ultramarathons, and search and rescue efforts. At the national and international levels, wilderness medicine physicians are well prepared to provide care after natural disasters. Still others support scientific discovery by providing care to researchers collecting data in austere environments, like the Amazon or Antarctica. If you are looking for “something bigger” in your life, consider wilderness medicine.

Career options after fellowship
There are many paths to take after fellowship. Some physicians become involved with EMS, serving as medical directors for search and rescue teams, or training medics in the National Park Service program. Others volunteer as medical officers for disaster relief efforts on the local, national, and international scale. Wilderness medicine trained physicians provide medical care at races and ultramarathons, and on expeditions. There are many opportunities to become involved in education, including serving as a fellowship director, establishing and/or directing wilderness medicine student electives, and teaching training courses such as Advanced Wilderness Life Support (AWLS). Others contribute to the field through research on a variety of topics, including high altitude medicine, hypothermia, ultramarathon physiology, and effects of climate change on human health. Some physicians are able to devote the entirety of their careers to wilderness medicine, while others work full time in the emergency room and participate in wilderness medicine activities in their free time.

Splitting time between departments
Negotiations are not traditionally between separate departments but rather within the department regarding how you will utilize your wilderness medicine training. For example, you may have aspirations to create a medical student rotation in wilderness medicine, or to become a fellowship director within this specialty. Some physicians find part time employment with national parks, ski lodges etc. in addition to their emergency department responsibilities.

Academic vs. community positions
Academia affords many opportunities for education in comparison to community positions, and provides significant support in terms of both finances and protected time for research. In a community setting, it will likely be up to the individual to network and find opportunities for involvement. In many cases, geographic location is a key determinant in how easy or difficult it will be to find such opportunities. In some rural community emergency departments (EDs), you will likely be incorporating wilderness medicine into all of your shifts!

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are currently 15 available fellowships, 1 of which is only open to active military personnel: 

For ongoing updates, please refer to the ACEP Wilderness Medicine Section and EMRA Match.

The Wilderness Medical Society (WMS) also offers a unique certification pathway: Fellowship in the Academy of Wilderness Medicine, or FAWM. This is a great option for anyone who does not want to complete a formal year of fellowship, or for those who want flexibility in completing fellowship training. Fellows must complete lessons from a pre-established WM curriculum of twelve categories, similar to those covered in formal fellowships. In addition, they must gain experiential knowledge in 6 categories: publishing and research, volunteer teaching, public service, practice, service to WMS, and board certification and conference attendance. On average it takes Fellows 3-5 years to complete all requirements for their FAWM. You can start working towards your FAWM in residency and as early as medical school. In addition, the FAWM is open to any WMS member, regardless of medical specialty.

Differences between programs
All fellowship programs follow a standardized curriculum and core content. Clinical opportunities will differ between programs, depending on geographic location and which organizations (outdoor, rescue, international relief) faculty are involved. Likewise, research focuses and specific teaching opportunities will vary by program. Some fellowships have a heavier emphasis on incorporating EMS, international, disaster, or expedition medicine. We recommend spending time reviewing each fellowship’s website, noting opportunities that are particularly interesting to you.

Length of time required to complete fellowship 
Most fellowships are one year. Several fellowships have the option to extend a second year to pursue a Master of Public Health (MPH) degree.

Skills acquired during fellowship 
In general, a fellow can expect to develop a high level of proficiency in treatment of high altitude illnesses, wilderness trauma, envenomations, dysbarisms, and tropical diseases. They will receive search and rescue and/or EMS training and become proficient in medical evacuation. Fellows also develop leadership and educational skills and experience.

Typical rotations/curriculum
Emergency medicine-based wilderness medicine fellowships follow a standardized minimum core curriculum over one year. This core content was agreed upon by the Fellowship Subcommittee and Taskforce of the American College of Emergency Physicians Wilderness Medicine Section, and published in Academic Emergency Medicine in 2014. The curriculum provides an outline of topics that an expert in wilderness medicine is expected to master. Fellowship programs vary in presenting this material through educational and clinical experiences, as well as some self-learning. Most curriculums also include a scholarly project that can range from a simple case report to extensive vigorous research projects. Often fellows have the opportunity to give presentations at local, national, and international conferences.

Most fellowships provide 1-3 months of protected time for the fellow to dedicate to specific wilderness activities, off-site clinical experience, or site-specific research. Fellows have used this time staffing the Himalayan Rescue Association clinics in Nepal, working as expedition doctors, or other similar activities.

Because wilderness medicine fellowships are not ACGME accredited at this time, most fellows are hired as junior faculty and are expected to do a certain amount of shift work in the ED (specific amount of time required in ED varies by program).

Board certification afterwards?
No. 

Average salary during fellowship 
Anticipate a salary consistent with that of a PGY-4 or 5. However, because most fellows are hired as junior faculty, some programs provide salaries from $75,000-$110,000. Moonlighting is allowed in most cases.

PREPARING TO APPLY

How competitive is the fellowship application process?
Competitiveness will vary year to year. As the number of fellowship options continues to expand, the chance of finding a fellowship that suits your specific needs gets better and better. However, if you are focused on only 1-2 programs and they have 1 spot each, it can be quite competitive. 

Requirements to apply
Currently, almost all fellowships require American Board of Emergency Medicine (ABEM) eligible or ABEM certified physicians. However, an increasing number of fellowships are now open to both EM and non-EM applicants. Madigan is only open to military personnel. 

Most fellowships will require a letter of intent or personal statement, updated curriculum vitae (CV), and 2-3 letters of recommendation.

Research requirements 
There are no standard research requirements for the application process. Specific wilderness medicine research will definitely help you stand out as an applicant. However, Fellowship Directors understand that it may be difficult for residents to complete wilderness medicine research if they are training at a program without a robust WM interest. Any quality research will speak to your proficiency in the process, so take your residency research requirement seriously and be able to speak eloquently about your project during fellowship interviews. 

Suggested elective rotations to take during residency 
If your program offers international experience, EMS rotations, or flight medicine opportunities, they can provide a good base for branching into wilderness medicine. See below for more elective ideas. 

Suggestions on how to excel during these elective rotations 
Show your enthusiasm for the projects at hand whether they be specific to medicine or simply a new outdoor skill. Do not worry if you are not already a wilderness expert; after all, what would be the point of training if you already knew everything? Take advantage of every opportunity to learn skills and tips from your instructors as well as other more experienced members of your elective. Get to know the directors/staff of any wilderness related rotations as they can be valuable resources for future opportunities as well as solid letters of recommendation. 

Should I complete an away rotation? 
In wilderness medicine nothing is as valuable as hands-on experience. Using your elective time to pursue medical experience in a wilderness setting is a smart option. Elective time can be spent in an official wilderness medical course, an international medical mission, or something you come up with on your own. The EMRA Wilderness CommitteeACEP Wilderness Medicine Section, and Wilderness Medical Society list elective opportunities for residents and students. Other groups, such as the Wilderness Medicine Institute (WMI) of the National Outdoor Leadership School (NOLS), offer courses and medical expeditions. Set up your elective time early as some of them are popular and spots fill fast.

What can I do to stand out from the crowd?  
Try to complete wilderness medicine-specific research or projects. Even if you are not in a region known for WM, you can come up with creative ways to incorporate aspects of WM into your scholarly project. For example, you could research the incidence of hypothermia in the homeless urban patient population during winter months. Write up the patient you took care of in Chicago who had just landed from her vacation in Mexico with a jellyfish sting. Organize a Medical Wilderness Adventure Race (MedWAR) for your residency program, or design a WM track for your residency program if one does not already exist. 

Apply to serve on wilderness medicine committees through EMRA, ACEP, SAEM, or the WMS. If selected to serve on a committee, take an active role in the organization and have a tangible end result to show for your invested time.

Seek opportunities for valuable hands-on wilderness experience. Volunteer as medical support for ultramarathons, ask local hiking groups if you can host a workshop on packing survival kits, or sign up for a MedWAR. Consider using your residency elective to take a course through the WMS or NOLS.

Spend time reading about each area of WM and find an area that interests you. Reach out to fellowship directors early on in your residency training; ask about the program, let them know your area of interest, and stay in contact. Being known as a motivated candidate with sincere interest in WM will not only open the door to more opportunities for involvement, but will also make you more of a known candidate when it comes time to apply for fellowship. You don’t want a fellowship director hearing your name for the very first time when he or she reads your application!

Should I join a hospital committee? 
There are few hospital committees that directly relate to wilderness medicine. Focusing your energy elsewhere will likely prove more advantageous.

Publications other than research
There are ample opportunities to publish editorial, educational, and experience reports through various publications. EM Resident (EMRA publication), Wilderness and Environmental Journal, Wilderness Medicine Magazine (WMS publication), and ACEP’s wilderness medicine committee newsletter all accept manuscripts other than strict research. Any publication in the field of wilderness medicine shows your interest and level of commitment to the field and can help you get into a fellowship program.

How many recommendations should I get? Who should write these recommendations? 
Most programs require 2-3 letters of recommendation. One should come from your residency program director. If you have done a wilderness medicine related elective, the director of that rotation could provide valuable insight into your skills and commitment to the field of wilderness medicine.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes. Working prior to fellowship should not make you less competitive. 

What if I’m a DO applicant?
DO vs MD is unlikely to be an issue if you have a strong CV. 

What if I am an international applicant?
Again, the strength of your CV is the strongest predictor of being accepted into a fellowship program. However, visa issues may in some cases affect the consideration of an application. 

APPLICATION PROCESS

How many applications should I submit?
Clearly, applying to more programs will increase your chance of being accepted. However, every program is different, so do your research on what each program offers. Often finding 3-5 programs that will best fit your goals is sufficient. 

How do I pick the right program for me?
Every program offers a unique experience beyond the standardized core content. Some fellowships are more academic and research driven, while others focus more on experiential training. Some fellowships have a strong EMS component while others have little or no EMS focus. There are several programs that allow the fellow to extend a year and add a Master’s of Public Health (MPH) into their program curriculum. Each program will offer unique travel and expedition opportunities. An applicant that is interested in pursuing dive medicine will likely be drawn to certain fellowships while an applicant interested in pursuing altitude medicine will be drawn to other programs. Geography also plays a role, not only because of personal preference, but also because certain locations will provide more access to certain wilderness experiences. Again, the best way to determine the best programs for your interests is to spend time reviewing each program’s website and reaching out to fellowship directors. 

Common mistakes during the application process 
Get involved as early as you can. Massachusetts General Hospital’s fellowship website offers this sage advice: “It is never too early to be in contact with us about your future plans. We tend to take a long view of relationships. Over the years, we have discussed wilderness medicine fellowship training with EMT’s, college and medical students, residents and practicing physicians. While we have hired applicants who first approached us less than a year before starting their fellowship, we maintain an active roster of prospective fellows --some over more than 5 years – many of whom we have then hired as fellows. We are friendly people who like to talk about wilderness medicine. We ask you to begin a conversation with us early.”3 

In addition to starting too late, not having a clear goal is a common mistake. Most fellowships allow you to tailor your experience and research according to your specific area of interest. During the interview process be able to clearly define what you want to accomplish during your fellowship.

Application deadlines 
In the past each fellowship program accepted applications, interviewed, and extended offers throughout the fall. More recently fellowships have agreed to follow more specific deadlines to help prospective fellows who are considering multiple fellowship options. Most now follow a verbal agreement to have an application submission deadline of October 1 and final decisions and offers extended on November 1. Submit your applications as early as possible, as scheduling travel during residency can be challenging. Check each fellowship program’s website for dates.

Tips for writing your personal statement
Clearly highlight your past experiences and exposure to wilderness medicine. Describe your reasons for wanting to pursue a fellowship and what you hope to accomplish. In most cases you will be acting as both fellow and junior faculty, working several shifts each month in the emergency department. In addition to specific wilderness accomplishments, also describe why you would be a good fit in their emergency medicine department. 

Is this a match process?
No. 

What happens if I don’t obtain a fellowship position? 
There are many opportunities to pursue wilderness medicine with or without a fellowship. You can still get involved in many different areas of wilderness medicine. One option is to work toward becoming a Fellow in the Academy of Wilderness Medicine.

INTERVIEW PROCESS

How do I stand out from the crowd? 
Use your question responses to highlight your interests, research, projects, and accomplishments that demonstrate your commitment to the academic field of wilderness medicine. This is not the time to be timid about why you are the perfect candidate for that fellowship spot! Take pride in your CV and let your excitement about your future career plans shine through. In addition to knowing your own research projects inside and out, have a few ideas about where your past and current projects may lead you in the future. Anticipate questions about lessons learned from your field experiences. Importantly, articulate clear and attainable goals for your year of fellowship. If you want to start your own WM fellowship after training, have an answer prepared for how you developed that goal. It is OK not to know exactly where you want to end up within WM, but have a plan for how you want to explore one or two specific interests. Since each fellowship program offers unique field experiences, do your research ahead of time and tell fellowship directors why you have chosen to apply to his or her program as opposed to somewhere else. Additionally, the value of being amiable and friendly can never be overstated. In many cases you will be traveling and working under stressful environments with your fellowship staff, so they will want someone who is flexible and enjoyable to work with.

What types of questions are typically asked? 
As with most interviews, fellowship directors will likely review pertinent aspects of your CV with you. You will be asked what you learned from your specific wilderness experiences. You will be asked what you hope to accomplish during your fellowship and about your long-term wilderness medicine goals. 

How many interviews should I go on?
Most applicants end up going on 3-5 interviews. It is uncommon for applicants to do more than 5 interviews.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Auerbach, Paul S. Wilderness Medicine. Philadelphia, PA: Elsevier/Mosby, 2012.
  • Auerbach, Paul S. Field guide to wilderness medicine. Elsevier Health Sciences, 2013.

Important skills to practice while in residency to prepare for fellowship
Consider doing a skills course and getting a wilderness related certification. One of the most common is the Advanced Wilderness Life Support (AWLS). This is a multiday course with lectures and hands on experience and is taught in locations across the country throughout the year. Organizations such as the Wilderness Medicine Institute (WMI), National Ski Patrol (NSP), and Aerie also offer a variety of courses including Wilderness First Responder (WFR), Wilderness First Aid (WFA), Wilderness Medicine Essentials (WME), Wilderness Advanced First Aid (WAFA), Wilderness EMT (W-EMT), and Outdoor Emergency Care Course (OEC). These courses vary in length and amount of information covered. A more extensive course is the Diploma in Mountain Medicine (DiMM). It is quite expensive and requires a significant time commitment. For these reasons, a DiMM is more commonly completed either during a fellowship or after. Also consider sport-specific certifications such as American Institute for Avalanche Research and Education (AIARE) courses, ski patrol, swiftwater rescue, or SCUBA.

Tips on how to succeed as a fellow
Get started early. A year goes faster than you would expect. As soon as you are accepted to a fellowship, start to identify what you hope to accomplish. You often can start research projects early so you can hit the ground running. Most fellowships will have several optional experience opportunities. To a certain extent your fellowship will be what you make of it. Take as many opportunities as possible and be self-motivated. The more experiences you have the more successful your fellowship will be. At the same time, do not be afraid to say no to opportunities that will not suit your goals. It is very easy to overbook yourself as a fellow and struggle to finish all of your projects by the end of one year.

CONCLUSION

Additional resources

Journals

  • Wilderness and Environmental Medicine
  • High Altitude Medicine and Biology Journal
  • Wilderness Medicine Magazine

National organizations

Conferences

Local conferences are available and often sponsored by individual residency programs, such as UCSF Fresno, University of Michigan, WellSpan York Hospital, and Virginia Tech - Carilion School of Medicine.

How to find a mentor
Sign up for a mentor through the EMRA Wilderness Committee Virtual Mentorship. Reach out to program directors or past fellows with similar interests. Go to conferences and network, and join a national organization or committee.

References

  1. Rodway GA. The foundations of wilderness medicine: some historical features. Wilderness Environ Med. 2012;23:165-1969.
  2. Bowman WD. Wilderness medical society: the first dozen years. J Wilderness Med. 1994; 5(3):237-247.
  3. http://www.massgeneral.org/education/fellowship.aspx?id=94&display=apply