The Nuts and Bolts of Global Emergency Medicine

Ch 13. Not Interested in Fellowship? Other International Options

Introduction

Fellowship is only one of many ways to become involved in global EM. While fellowship provides a core skillset for global EM, there are many other ways to develop similar skillsets and dive into international work. The opportunities below are all open to EM graduates.

Epidemic Intelligence Service

The Epidemic Intelligence Service (EIS) is a 2-year fellowship-level field epidemiology training program of the Centers for Disease Control and Prevention. Approximately 80 officers are recruited to the program each year, which is primarily a civilian service but also has a branch in the Public Health Commissioned Corps.¹ While EIS has historically recruited a wide variety of health professionals, it is increasingly popular among EM graduates. The program recruits people at varying stages in their career from those immediately after residency, to those after fellowship, to those wanting a mid-career change.

EIS officers have a bewildering array of possible opportunities to select. About half are assigned to a state-level position in which they are responsible for investigating and controlling all disease outbreaks within their state including tracking cases, shutting down restaurants, advising hospitals, and more. The other half are assigned to disease-level positions primarily based in Atlanta, GA in which they work on various aspects of disease research and control in a given discipline (for instance, tuberculosis, vector-borne diseases or influenza). EIS officers played a key role in the 2014-2015 Ebola response in West Africa.

The main disadvantage of EIS for the EM graduate is its lack of clinical exposure. EIS officers are prohibited from any paid clinical work or moonlighting during the 2-year period. While many EIS alumni return to part-time or full-time clinical practice, a substantial number opt to work only in public health. Some EIS alumni who entered straight from residency feel that their clinical skills had languished during their EIS training. They will often pursue a 6-9 month transitional period working in double-coverage Atlanta area EDs and attend residency conferences before starting full-time independent practice.

Non-governmental Organizations (NGOs)

There are many NGOs that recruit and hire EM physicians. In general, NGOs tend to focus on either humanitarian work or development work, although many bridge the line. Positions are of variable length and involvement, with some requiring on-the-ground commitment in one country while others are consultancies that require travel to multiple sites over the course of a year.

International NGOs

Doctors Without Borders / Médécins sans Frontières (MSF): The Nobel Prize-winning humanitarian organization recruits residency-trained physicians. For EM physicians, MSF typically requires a minimum 6-month commitment.

A field assignment with MSF is widely considered a quintessential global health experience, and many physicians work for an extended period of time with other organizations before working with MSF. After a multi-tiered application process, recruits are placed in a pool and offered field assignments.2 Physicians do not have much say in the types of assignments they are offered, but they are also not obligated to accept any individual assignment if they deem it unacceptable. While EM is a great preparation for an MSF assignment, physicians are usually called upon to provide a variety of types of general medical care.

The drawbacks to MSF are similar to those of other international NGOs. MSF is known to work in acute crisis situations, often in difficult, war-torn regions. Therefore, the assignments are usually focused on acute relief rather than long-term development and sustainability. Its policy of providing care for all patients without regard to religious, political or other factors has challenged its ability to maintain complete neutrality. MSF, like its sister organizations, has suffered from recent violence targeted at humanitarian workers requiring evacuations. Physicians are paid a per diem allowance and offered deferral letters for loans but compensation is minimal compared to a typical attending job. Physicians working in these extreme circumstances usually find their jobs to be exhilarating, exhausting, or a combination of both.

MSF recently partnered with Columbia University’s International EM (IEM) Fellowship to offer dedicated field placements to fellows.

International Medical Corps: This is another option for EM graduates. International Medical Corps works in similar areas to MSF but places a greater focus on development and capacity-building. Although International Medical Corps is not a primary care organization, physicians with the organization often provide more longitudinal or primary care. They typically advertise field positions directly rather than recruiting physicians into a general volunteer pool.³

International Medical Corps also recently partnered with Case Western Reserve University’s and Harbor/UCLA’s IEM Fellowships to offer dedicated field placements to fellows.

Partners in Health (PIH): This historically has been known for their development projects in Haiti, Rwanda, and other countries worldwide. PIH works in post-conflict and chronic low-resource settings in areas where MSF and IMC would have typically already completed the initial disaster relief work. PIH’s work in emergency medicine has focused on training and capacity-building. PIH has recently opened an emergency medicine residency program in Mirebalais, Haiti that has recruited faculty members on both a permanent and an interim rotating basis.

PIH recently partnered with UCSF to establish a new Health Equity fellowship open to emergency medicine.

The International Rescue Committee (IRC): It was founded to assist Europeans displaced during World War II and today focuses on care for refugees and displaced persons worldwide. IRC has worked with emergency physicians for refugee care.

Care International: This is primarily a European relief agency that works to end poverty in a multidisciplinary approach and is involved with a variety of sectors. Care International has recruited emergency physicians for its disaster and conflict response.

Mercy Ships: These are medical relief ships that travel from port to port to provide medical relief. Although Mercy Ships provides primarily surgical care, emergency physicians have also been recruited for medical care.

International Coordinating Organizations: While many international organizations do not employ emergency physicians in a clinical capacity, they still appreciate the emergency medicine perspective in disaster response. In a complex humanitarian emergency, the United Nations Cluster System is usually deployed.⁴ The cluster system organizes NGOs around their particular areas of expertise and prevents duplication of labor. The health cluster is typically led by the World Health Organization or its representative in conjunction with local Ministry of Health officials. In addition to physician groups being mobilized, the health cluster often includes representatives from NGOs such as the International Federation of the Red Cross, Save the Children, Oxfam, Partners in Health, and others. Any of these organizations may appreciate the expertise of an emergency physician on staff.

Human Resources for Health: This is a project of the Rwandan Ministry of Health with support from the U.S. Government. This multi-year training program aims to provide Rwanda with a fully trained specialist
workforce by 2019. Specialists, including emergency physicians, are recruited to be academic faculty in Rwanda typically for 1-2 year terms.

EM-specific NGOs

In addition to the international NGOs, there are a few organizations started by emergency medicine physicians that often have international postings focused on emergency care. Although smaller organizations, they tend to focus on development work in particular countries of interest.

Global Emergency Care Collaborative (GECC): It was founded with the goal of improving education for nurses in Uganda, but has now expanded to other countries as well. The organization uses the train-the-trainer approach to educate mid-level providers with EM faculty providing education, supervision, and research support.

Muhimbili National Hospital Emergency Medicine Residency: Is in Dar es Salaam, Tanzania, and was developed to train EM physicians. It relies on a consortium of five universities to provide academic attendings who rotate as visiting faculty for the program.

Systems Improvement at District Hospitals and Regional Training of Emergency Care (sidHARTe): It was established to improve care in sub-Saharan Africa, starting at the district level. Their programs, based mainly in Ghana and Rwanda, have utilized EM physicians in training physician assistants to perform emergency procedures.

Research Fellowships

Fogarty Global Health Fellowship Program: is an 11-month fellowship that trains medical students, residents and post-doctoral researchers in research techniques in an international setting. The Fogarty program partners with U.S. universities and designated countries for projects.

Marshall Sherfield Scholarship: is a program that pays for U.S. graduates to perform post-doctoral research through a British academic institution for 1-2 years.

The Road Less Traveled: Self-Initiated Projects

There’s no need to find a cookie-cutter international experience if you possess the drive to create your own. While individual physicians usually have difficulty starting a unilateral project in a disaster scenario, more
stable situations allow individuals to seek out or create the job they envision for themselves in global EM.

Directly Advertised Openings: Online job advertisement services such as ACEP’s EM Career Central occasionally list EM employment opportunities outside of the U.S. and Canada, with EM positions as close as the Caribbean and as far as Antarctica.⁵

International Academic Emergency Medicine: It is possible to apply for an academic position in another country of interest. The Accreditation Council on Graduate Medical Education (ACGME) recently launched an international accrediting body, ACGME International. Thus far, ACGME International has accredited residency programs in Singapore, Qatar and the United Arab Emirates with more program accreditations planned.⁶ Many countries have their own residency program accreditation programs and policies on licensure vary by country.

Direct Contact with Local Groups: It is possible to contact local hospitals and healthcare organizations directly. For instance, in the late 1990s, Dr. Haywood Hall, a young recent graduate of the University of New Mexico EM residency, piled his belongings into a car and drove to San Miguel de Allende, Mexico where he volunteered to teach life support classes. Over subsequent years and discussions with area governments and healthcare facilities, his center (PACEMD) has become one of the largest resuscitation training programs in the region.⁷

To facilitate contacts in other countries, the ACEP Ambassadors program through the ACEP International Section offers emergency physician contacts for most countries of the world.8 The AAEM International Committee also has frequent opportunities posted.⁹

The opportunities above are not intended to be a comprehensive list of fellowship alternatives, and many of them do not have a formal educational component. Regardless, they are sure to offer a unique window on global EM for those travelling off the beaten path.

References

1. Centers for Disease Control and Prevention. Epidemic Intelligence Service. Secondary Epidemic Intelligence Service 2015. http://www.cdc.gov/eis/.
2. Medecins Sans Frontieres. Who We Need: Physicians. 2015.
3. International Medical Corps. Careers. Secondary Careers 2015. https://careers.internationalmedicalcorps.org/careers.aspx.
4. U. N. Office for the Coordination of Humanitarian Affairs. Cluster Coordination. Secondary Cluster Coordination 2015. http://www.unocha.org/what-we-do/coordination-tools/cluster-coordination.
5. American College of Emergency Physicians. EM Career Central. Secondary EM Career Central 2015. http://www.healthecareers.com/acep/search-jobs/.
6. ACGME International. 2013-2014 ACGME-I Data Book. Secondary 2013-2014 ACGME-I Data Book 2014. http://www.acgme-i.org/Portals/0/Databook/2013-2014_ACGMEInternational_Databook.pdf.
7. Ashoka Fellowship. Haywood Hall. Secondary Haywood Hall 2015. https://www.ashoka.org/fellow/haywood-hall.
8. American College of Emergency Physicians. International Ambassador Program. Secondary International Ambassador Program 2015. http://www.acep.org/IntlAmbassador/.
9. American Academy of Emergency Medicine. International Medicine. Secondary International Medicine 2015. http://www.aaem.org.