EMRA Fellowship Guide, 3rd Edition

Emergency Medical Services (EMS)

Author

Luke Wohlford, MD, MPH
University of Vermont Medical Center
Chair-elect, EMRA Prehospital and Disaster Medicine Committee, 2023-24 

Faculty Editor

Yevgeniy Maksimenko, MD, MA, MPH, NRP, FAWM, DiMM
Maj., USAF, MC
Assistant Professor
Department of Military and Emergency Medicine
Uniformed Services University 

Special thanks to our 2^nd edition writing team

Jared Ross, DO, FF/EMT-T
Avram Flamm, DO

Special thanks to our 2^nd edition faculty editors

Joshua Bucher, MD
Matthew Chinn, MD

INTRODUCTION

Description of the specialty
The specialty of emergency medical services (EMS) is the medical practice involving the clinical oversight and delivery of medical care outside of a hospital or medical facility (also known as “prehospital care” or “out-of-hospital care”).

The specialty of EMS focuses on two domains: (1) clinical practice of EMS medicine, and (2) clinical and system oversight of EMS systems.

The main objective of an EMS fellowship is to teach fellows how to apply the best practices of emergent and community medicine to the prehospital setting, with the goal being improved patient outcomes. As part of the clinical practice of EMS, many fellowships include field response, where the fellow responds to emergency calls in an EMS vehicle or with an EMS supervisor, with some programs dedicating a vehicle for physician response. Many fellowships are attached to a flight program as well, which provides the fellow an opportunity to serve as a physician on an aircraft for interfacility transfers and emergency requests. The goal of “field time” is to familiarize the EMS fellow/future medical director with the challenges of delivering medical care in the prehospital setting, and to help develop best practices focused on patient-centered outcomes. In some systems, delivery of medical care can involve actual clinical medicine and performing advanced prehospital procedures, while in other systems, the role is limited to indirect clinical supervision.

In addition to clinical prehospital care, EMS fellowships train physicians in the medical oversight of EMS systems. Fellows are intimately involved in many aspects of EMS education, as well as continuous quality improvement activities. EMS policies are constantly in flux due to changing research and guidelines, and fellows learn how to create, implement, and evaluate policies and protocols. Fellowships also offer opportunities in scientific research, as well as disaster planning and response.

Ultimately, the variability of EMS systems across the country and internationally will lead to unique training experiences for EMS fellows, with the age-old adage “if you’ve seen one EMS system, you’ve seen one EMS system” still holding true.

History of the specialty/fellowship pathway
Emergency medicine and EMS share a common ancestry, as both evolved from the core purpose of taking care of patients with time-sensitive conditions at their moment of injury/illness. Although EMS has been practiced for hundreds of years, EMS medicine only recently became an ABMS subspecialty of emergency medicine in 2010 (2006 by the AOA).

EMS fellowships are uniquely positioned to give emergency physicians (and physicians from other specialties) the knowledge and experience to provide, oversee, and improve prehospital care.

Historically, EMS fellowships have varied widely in terms of the experiences for individual fellows. However, with the arrival of subspecialty certification and ACGME accreditation, there is now a standard core curriculum for EMS fellowships. As of today, the subspecialty of EMS is over 800 strong and is the largest subspecialty under the American Board of Emergency Medicine umbrella.

Why residents choose to follow this career path
This field attracts physicians interested in becoming involved in the EMS field in roles such as clinical providers, researchers, educators, and/or medical directors.

EMS board certification may translate into increased funding, whether directly through a monetary payment from a medical direction contract or via funds to offset clinical time in the emergency department for EMS-related activities. EMS agencies and municipalities are increasingly recognizing the value of EMS board-certified physicians and seeking out those with the training to fill their positions. Many physicians interested in EMS complete a fellowship to gain experience and engage in their field of interest. Board certification has the added benefit of allowing for more diversified work and may decrease burnout by providing other work activities outside of ED shifts. Additional training may also increase competitiveness for obtaining academic emergency medicine positions that prefer fellowship-trained faculty.

How do I know if this path is right for me?
A career path in EMS may not be right for all physicians. Being involved in EMS requires significant time dedicated to furthering the EMS field. This involves collaboration with multiple committees and working groups, which includes meeting with members of the community, public safety agencies, and governmental bodies. EMS work requires skills in interpersonal communication, outreach, diplomacy, and politics. Serving as an EMS medical director requires some knowledge of finance, administration, management, and policymaking.

Career options after fellowship
Local, state, federal, and private positions offer opportunities for physicians interested in EMS. Many states and larger EMS systems have dedicated full-time medical directors. Some larger organizations require multiple physicians. Tactical teams and local law enforcement, large event organizations, sporting arenas, and international medical groups may employ the services of an EMS medical director or physician. Medical director positions in larger EMS organizations are typically filled by physicians with backgrounds in emergency medicine and prior EMS experience or training. However, many EMS agencies do not have medical directors with EMS experience or training. Completing an EMS fellowship will greatly help your chances to obtain a job as an EMS physician or medical director. Some EMS physicians build upon their administrative and management experience in the prehospital setting and take on positions in the emergency department and hospital setting as well.

Splitting time between departments
Depending on where you’re employed and the specific requirements of that role, an EMS medical director position may include working clinically within an emergency department — or it may not include any clinical work. Some EMS positions require a full-time administrative commitment, which means the physician must make his/her own arrangements separately for clinical work. Smaller agencies may have funding to hire a medical director for only a few hours per week; thus, some physicians will combine contracts from several EMS agencies. Many departments may not compensate for time and instead may expect that the work is performed as a community service. Often, the largest challenge for a physician involved in EMS is balancing time spent between EMS and non-EMS work, as well as on clinical, educational, academic, and administrative duties within EMS.

Academic vs. community positions
There are both academic- and community-based positions in EMS. EMS agencies may be university-based, hospital-based, fire-department based, municipal, or private organizations. They may be associated with medical schools or academic departments, or they may have no affiliation. All these variables can affect the working environment and responsibilities requested of a medical director/physician.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are more than 80 ACGME-accredited fellowships, with more in the accreditation queue. Lists and links to current programs can be found on the ACGME website, the National Association of EMS Physicians website, and EMRA Match.

Differences between programs
With the implementation of ACGME accreditation of EMS fellowships in 2013, all fellowships are required to provide their fellows with a foundational level of knowledge regarding the basic tenets of EMS; however, programs differ significantly in their focus and flavor.

The joint ABEM and ACGME “EMS Milestone Project” provides a framework for the assessment of the development of the fellow in key dimensions of the elements of physician competency in EMS. They reside in the domains of patient care, medical knowledge, system-based practice, practice-based learning and improvement, professionalism, and communication skills. The Core Content of Emergency Medical Services Medicine, published by ABEM, lists the skills that should be acquired during an accredited fellowship. This is also the content upon which the board exam is based. The ACGME has established a specific set of program requirements for any EMS fellowship. Many of these requirements are similar to other specialty residency and fellowship programs. These requirements can be found in the ACGME Program Requirements for Graduate Medical Education in Emergency Medical Services.

The execution of these requirements is left to the individual program, with significant variability. Programs generally focus on one or more aspects of prehospital care including operations, administration, and research, and offer different and unique prehospital opportunities.

Operational experience may range from ride-alongs with various EMS units to a vehicle that allows the fellow more flexibility to respond to incidents as they occur. This may be a shared vehicle or a dedicated take-home vehicle. Similarly, aeromedical exposure may vary from occasional shifts as an observer to weekly scheduled shifts as part of a crew. Most programs have opportunities to be involved in the planning and execution of special-event and mass-gathering medicine. Fellowships also may have operational opportunities in disaster medicine, wilderness medicine, tactical medicine, and rural EMS.

Administrative duties may include appointment as an assistant or associate medical director for an EMS agency with scheduled continuous quality improvement activities, regular meetings, conducting investigations, rewriting clinical policies, and planning. Duties may require different levels of governmental involvement. Clinical oversight and supervision may range from on-scene medical direction to online medical command provided by phone or radio to EMS providers. Fellows likely will have an opportunity to review and revise written EMS protocols. Many programs offer opportunities to teach both clinical and didactic material to EMS providers.

All fellowships require the completion of a scholarly activity. However, this varies widely among programs, as it can range from a popular media publication or quality improvement project to retrospective or prospective trials and peer-reviewed publication.

With the ACGME accreditation of EMS fellowships, other prehospital fellowships in disaster medicine or tactical medicine fellowships have been merged into EMS fellowships. Generally, they all offer training in ground and air medical services in such areas as patient care, communications systems, system design, quality assurance, education/training, and disaster medicine, among other areas.

Length of time required to complete fellowship
ACGME-accredited fellowships are one year; however, some fellowships offer an additional year for an advanced degree (MPH, MHA, MBA) or other endeavors.

Skills acquired during fellowship
As mentioned, all accredited fellowships are required to provide their fellows with a foundational level of knowledge regarding the basic tenets of EMS. The Core Content of Emergency Medical Services Medicine and “EMS Milestone Project” describe the knowledge and skills graduates of accredited programs are expected to have mastered.

Typical rotations/curricula during fellowship
Fellowships differ on the specific structure/schedule used to deliver curriculum. Most intersperse various areas and topics throughout the year. Some fellowships have set rotation schedules with discrete blocks of time in each area. Additional areas that may be covered during fellowship are mass-gathering medicine, disaster medicine, tactical medicine, wilderness medicine, and medical education.

Board certification
EMS subspecialty board certification became available in 2013 through a written certification exam administered every two years by ABEM. Subspecialty certification is open to any primary specialty, provided it meets the requirements for EMS certification. Fellows who complete an ACGME-accredited fellowship may take the board exam at the next offering after completing their fellowship. Not every EMS-trained physician pursues board certification, but it generally opens up more opportunities in academic positions.

Average salary during fellowship
Most programs offer a salary equivalent to your PGY level of training, at minimum. For some programs, this is the sole source of salary. However, others offer a varying stipend for clinical shifts worked during fellowship (which may or may not be considered “moonlighting”). This stipend will vary in amount by institution and must follow ACGME work-hour restrictions. Some fellowships may come with clinical instructor or other academic appointments as well. In addition to salary, fellowships may offer CME (continuing medical education) budgets, retirement plans, or other compensation.

PREPARING TO APPLY

How competitive is the fellowship application process?
Although more positions are currently available than applicants, the fellowship application process may become more competitive over the next several years. The designation of EMS board certification has led to a surge in interest in fellowship training. EMS is also a field rapidly growing in physician involvement and research.

Requirements to apply
EMS fellowships are open to any board-eligible or board-certified physicians; however, virtually all applicants come from emergency medicine.

Suggested elective rotations to take during residency
Your EMS rotation during residency will be an important area of focus. Fellowship programs are looking to train people who will be committed to improving EMS care. Different programs have different requirements and opportunities, but any involvement in EMS is a good way to demonstrate dedication and obtain some experience in the topic. Getting involved with EMS provider education and training during residency is a great way to get involved. Completing ride-alongs, with ground or air-based EMS, especially if done outside of your mandatory rotation, will further solidify your commitment.

Suggestions on how to excel during these elective rotations
The best way to excel during these rotations is by displaying strong clinical skills, teamwork capabilities, and enthusiasm for prehospital medicine.

Should I complete an away rotation?
Away rotations for EMS are relatively rare, though may be a consideration if your residency program does not have a strong EMS component and you wish to bolster your experience. Away rotations may increase your competitiveness if you have a strong desire to match to a particular program.

What can I do to stand out from the crowd?
To stand out from the crowd, fill your CV with activities that display a strong interest in EMS and leadership skills. Participating in or creating an EMS track in your residency program is another way to gain EMS exposure and demonstrate commitment. Prior EMS experience also strengthens your CV.

Should I join a hospital committee?
Hospital review committees involving problems encountered in EMS, such as STEMIs, stroke care, and trauma care, provide administrative experiences that will help solidify your candidacy.

Research requirements
As with many subspecialties, prior research experience is helpful when applying to an EMS fellowship. There has been an increasing drive toward evidence-based medicine in EMS, and having research experience demonstrates commitment in this area of importance. Certain EMS fellowships are known for their research focus, in which case such experience is extremely important.

Publications other than research
Non-research publications are also helpful for your application. As a resident, there are many opportunities for publication, such as EM Resident, the magazine published by EMRA, or one of the many newsletters, such as ACEP Now. There are also EMS-specific publications including JEMS and EMS1.

How many recommendations should I get? Who should write these recommendations?
Most programs require three letters of recommendation, with one being from your department chair or residency program director. A recommendation from your local EMS director, or any EMS faculty in your department, is very helpful and recommended. Having a good recommendation from your department chair and/or residency program director is equally as important, as it demonstrates your overall ability as a physician as well as your personal character.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Almost all EMS fellowships will accept physicians who have been practicing as attendings before applying. The key is to ensure that you stay involved with EMS as part of your practice. Again, fellowship programs are looking to train people who will remain committed to EMS. However, it is important to note that many people find it hard to “switch back” to a trainee rank, salary, and lifestyle after being an attending. Most fellows come directly out of residency.

What if I am a DO applicant?
Most EMS fellowships do not differentiate between MD and DO applicants.

What if I am an international medical graduate (IMG)?
Most EMS fellowships are more concerned with where you completed residency than where you attended medical school.

What if I am an international residency applicant?
ACGME-accredited fellowship programs, by regulation, can only accept board-eligible or board-certified physicians. Plus, most EMS fellowships help to offset the costs of training a fellow by having a fellow cover clinical shifts in the emergency department. Both of these factors mean the individual has to be licensed to practice medicine and have completed an ACGME/AOA-accredited residency. However, some EMS fellowship programs have an international track designed for physicians who are not trained/licensed in the United States. These tracks would not be eligible for board certification. Also, usually, the individual would have to pay tuition to cover the costs of training.

APPLICATION PROCESS

How many applications should I submit?
This is highly subjective, depending on your qualifications, geographical restrictions, and family considerations, among others factors. Numerically, there are more EMS fellowship positions than applicants, so barring any personal preferences, there is likely to be a position available. Even if you have your mind set on a single program, it is a good idea to apply to or visit several programs to provide some perspective.

How do I pick the right program for me?
The right program is also a very subjective question. Most fellowships have a website you can visit for highlights about their program. Additionally, the EMS community remains a relatively tight-knit subspecialty, so EMS faculty in your department are often able to provide insight into other programs. The application and interview process also are very revealing, and the impression you get from meeting the fellowship director and core faculty can have a huge impact on picking the right program. In addition to program elements, many applicants have their own family, geographical, or other requirements that may shape their decision of picking the right program. In the end, as with choosing any job, do your research and trust your gut.

Common mistakes during the application process
It cannot be stated enough that the EMS community is small. Everyone knows each other and talks to each other!. Always be professional and honest throughout the application process.

Application deadlines
The EMS fellowship application process moved to an NRMP Match in 2018, and that continues to be the principal route for fellowship programs to recruit applicants. Applications are typically accepted by email, but be sure to check individual program requirements for applications on their respective websites. Interviews typically occur July through September, depending on program preferences. Rank lists are formed and submitted in October, with Match occurring in the second week of November.

Tips for writing your personal statement
Your personal statement can serve to emphasize points on your CV as well as delve into those intangible things that don’t fit on a CV. For instance, it is your opportunity to show the reader why you decided to go into EMS medicine. Be honest and concise. Writing individual letters to each program emphasizing why you would be a good match for them and demonstrating that you have done some research into their program is a good idea as well. Having a faculty member review your draft statement can often be valuable. The American Medical Association, EMRA, and many other organizations offer personal statement advice you can review as well.

What happens if I don’t obtain a fellowship position?
If you do not obtain a fellowship position, you have several options. As stated before, there are usually more positions than applicants, so if you have no restrictions, you have a good chance to place somewhere. Another option can include applying during the next cycle.

INTERVIEW PROCESS

How do I stand out from the crowd?
During any interview process, it is always of benefit to you and the program to be yourself. There is no advice specific for EMS fellowship interviews. Program directors, like any supervisor, are looking for energetic candidates with a commitment to learning about EMS and taking that knowledge to improve the field.

What types of questions are typically asked?
Questions may range from EMS-specific to the more typical general interview prompts. For example, questions regarding the aspects of EMS that you feel are important, the latest science of EMS, or opinions about specific issues are all valid. Be knowledgeable about the latest controversies, scientific breakthroughs, and news in the area of prehospital medicine. Most importantly, be prepared to explain why you want to complete an EMS fellowship and elaborate on your career goals.

How many interviews should I go on?
There is no “magic number” of interviews. You should interview at an adequate number of programs depending on your competitiveness. If you feel you are not a strong candidate, you should interview at more programs to increase the likelihood of obtaining a position. Remember there are still more positions than there are applicants, so the odds are with you. However, with the increasing interest in EMS fellowships, this may change over the next several years, so you may want to apply to more than you feel is necessary.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading
There are no required texts to read prior to fellowship. Some considerations include the seminal texts and papers in EMS that may offer some background on the specialty. One of those foundational papers is the EMS Agenda for the Future. The NHTSA website contains links to many others. The National Association of EMS Physicians (NAEMSP) publishes what is considered the core textbook for EMS medicine: Cone’s (2021) Emergency Medical Services: Clinical Practice and Systems Oversight, 3rd ed. NAEMSP also advocates for some additional reading materials that may be used as references. Certainly, you should be familiar with all these materials by the end of fellowship and before taking the board exam. Thus, it doesn’t hurt to start reading them before beginning your fellowship.

An additional recommendation is to read American Sirens by Kevin Hazard, which gives perspective to the early beginnings of paramedicine and the importance of a physician-paramedic relationship in delivery of high-quality prehospital medicine.

Important skills to practice while in residency to prepare for fellowship
Getting solid emergency medicine training should be your focus during residency. You have to know how to practice medicine in the hospital before you can adapt it outside the hospital. Showing EMS interest through research, involvement in medical direction, or other avenues is encouraged during residency.

Tips on how to succeed as a fellow
Fellowship should be a fun experience. Everyone entering this field has a desire to work in the prehospital setting. Work hard, enjoy your time there, soak up the mentorship from your peers, network with others, and never forget your roots in emergency medicine.

CONCLUSION

Additional resources
There are further resources for EMS for those who are interested. NAEMSP has a wealth of resources available on its website at www.naemsp.org, as well as a podcast that interviews authors of major articles. Prehospital Emergency Care (PEC), published by NAEMSP, is considered one of the most influential journals for EMS medicine.

National organizations
NAEMSP is one of the most important organizations for EMS physicians. NAEMSP provides resources for new and established EMS physicians, publishes position papers on important topics, and promotes opportunities for research and networking. NAEMSP also publishes the quarterly journal Prehospital Emergency Care. NAEMSP offers a medical director’s course annually, which is an excellent three-day course that helps prepare you to become an EMS director. NAEMSP welcomes medical student, resident, and fellow members.

Conferences
NAEMSP hosts an annual conference in January that is highly recommended for those interested in EMS.

How to find a mentor
Finding a mentor is an important part of the journey to become an EMS physician. EMRA offers a fellowship mentor program that can pair you with a mentor or let you be a mentor, if interested. Ideally, a mentor should be located at your site of practice/residency. Mentors can provide valuable guidance and assist with your EMS involvement, and they can help you decide if an EMS fellowship is right for you. SAEM and ACEP have EMS sections that can provide a forum to seek advice and make connections.