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This chapter aims to guide emergency medicine residents to organize and find funding for an international elective. Our hope is for this guide to remain helpful for EM residents for years to come. Therefore, similar to resources for medical students, this chapter will be more of a framework rather than a list of resources. It is broken down into two sections – general information and funding.


Away Rotations

Before You Go

Figuring out your goals: Before planning an international elective there are several things to take into account. It is important to consider future career goals, whether it is in international emergency medicine and/or another area of global health. Remember that the term international emergency medicine (IEM) applies to the development of international emergency medical systems, emergency medicine residencies and training in certain global health areas such as humanitarian aid and disaster relief1,2. Global health, by contrast, refers to a multidisciplinary approach to the development of public health and healthcare systems worldwide3,4.
While many IEM careers are combined with global health, they are different and determining career interests will assist you in ascertaining the type of elective experience you wish to have.

Figuring out where to go: After identifying your own immediate and future goals for undertaking an international elective, the next step is to figure out where to go. There are a plethora of resources online to help plan and search for an international elective. While this chapter will not be exhaustive, Table 20.1 provides a good list of international emergency medicine electives to start from. Sifting through the myriad of international experiences can be a daunting task.


What To Look For When Choosing an Away Elective

. Safety – many residencies will not allow their residents to rotate in a country with travel alerts and or warnings. Visit the State Department Website http://www.state.gov/travel/http://www.state.gov/travel/ for current country specific safety information

. Is the elective affiliated with a U.S. residency or fellowship program?

. Have other residents gone there before?

. Can develop a lasting relationship between the elective and your residency?

. Is there someone that could act as your in-country mentor?

. What are your residency requirements for away electives?

 



Resources For Finding and Planning an Away Elective

EMRA International Division
http://www.emra.org/committees-divisions/International-Division/

ACEP International Section
http://www.acep.org/InternationalSection/

International Emergency Medicine Fellowship Consortium
http://www.iemfellowships.com/index.php

International Federation of Emergency Medicine
http://www.ifem.cc/

International Medical Volunteers Association
http://www.imva.org/



Other Early planning: Other things to consider in the early planning stages include establishing how much time you can commit to an international experience, what your motivations are for an abroad rotation, your ability to adapt to changing environments, and possible challenges to overcome when working and living in a different culture.

Gaining approval from your residency program: After you have decided to go abroad and found a suitable elective, the next step is getting approval from your residency program. If your residency has an established IEM or GEM track, ensure that your chosen site conforms to your residency’s requirements. Oftentimes your predecessors will have left
their experience in writing. Read them carefully and possibly contact the person to explore the details. Discuss your desire to travel abroad with your program director (PD) early on. In doing so, you assure that you have complied with all institutional administrative and legal procedures and have allowed them to plan ahead for staffing needs.
If your residency does not have international connections, what do you do? Understanding the challenges that residencies face when a resident rotates off site is vital to planning your elective and gaining approval from your PD. Two main challenges faced by programs are funding and time. Medicare reimburses residencies for resident salaries. When a resident rotates abroad, funding may no longer exist to pay that resident while away. Therefore programs have to provide justification to their home institution for salary reimbursement. The next section of this chapter will discuss funding options that can assist with this problem. The RRC and ACGME require that at least 50% of a resident’s time must be spent at their home institution. Determining how much time you have in residency to devote to an international experience will aid in not only planning but getting approval.
Another challenge that needs consideration is insurance coverage, which entails not only your own health insurance but indemnification/malpractice insurance and evacuation insurance as well. This can total almost 1/3rd of your salary on top of what you actually get paid! Ensure your overall benefits package is addressed before your final decision has been made to pursue any time abroad. After understanding and coming up with possible solutions to obstacles, you are well situated to sell the benefits of going abroad to your PD. Here are the steps:

Step 1 – Contact GME office for policies and procedures
Usually the Graduate Medical Education Office (GME) has specific policies with which you need to be familiar. The policies will delineate clearly which procedures need to be followed for approval. Some institutions will have organized Global Health Departments whose function is to facilitate and coordinate post-graduate travel abroad. Find the contact person in your institution, as there may be institution-specific requirements in addition to the national GME requirements.


GME Considerations

. Any institution specific GME office requirements?

. Who covers malpractice and liability insurance & workers compensation? The individual? Training program? Training institution? Host institution?

. Salary and fringe benefits

. Trip-related expenses

. Financial responsibilities of trainee vs. institution

 



Step 2– Identify Country and Elective Site
See the section and Table above.

Step 3 – Meet with your Program Director
Meet early with your Program Director to determine any specific requirements that your individual department or training program has in addition to those from the GME office. Your Program Director will likely need to fill and signs forms required by the GME office. And keep in mind, the more things that you have considered and already taken care of, the less work it will be on the PD and the more likely he/she will be to approve it!


Program Director Considerations

. Goals and objectives of your trip

. Structure of the elective

. Verification of supervision abroad

. Structure of evaluations

. Educational or research output after rotation

. Your salary / expenses / reimbursement after you return

 



Remember that different residency and fellowship training programs may have specific requirements for their electives especially in relation to GH or “away” electives. Please verify that your trip objectives, time away, and evaluations are in compliance. Check with your Residency Review Committee (RRC) for details.


Program-Specific Considerations

. RRC and ACGME requirements for your specialty training

. Competency or milestone-based goals of the rotation

. Competency or milestone-based evaluations of the rotation

. Verification that travel will not modify the length of your training

. Verification that your rotation will earn credit towards graduation

 






While You Are There

Now that your elective has been approved, here are a few tips for a successful experience. First of all, enjoy! This is a unique opportunity and hopefully the start of a long career in global medicine. Brush up on your history taking and physical examination skills. Read up on the cultural customs and practices in your elective county, and their traditional healthcare practices. If you are pursuing a career in GEM, use this opportunity as a starting point to develop and implement a project, or continue an existing one.

When You Return

When returning from your elective many residency programs will require a written summary of your experience. Consider turning your experience into a research paper, abstract or poster presentation. Leverage what you have done and explore your future job options. Most IEM fellowships and jobs prefer to see candidates with least 1-2 months of international experience during residency.


Funding

General Information

Obtaining funding for an international elective can be a daunting task, and for many it is a barrier to going abroad. Here are a few suggestions that will hopefully make this task easier. Participating in a sustainable project that targets one of the United Nations (UN) Millennium Development Goals (MDGs) increases your chances of getting funding for your elective, as these have been agreed upon by many countries and development organizations as the most important current world health issues. MDGs applicable to emergency medicine practitioners include improving maternal health, reducing child mortality and combating HIV/AIDS, malaria5. Other topics of high importance in the international setting include the development of EMS and trauma management systems, ultrasound training, and the management of cardiovascular disease. There are a myriad of organizations that provide money to practitioners working abroad, either in the form of grants or scholarships. Table 20.2 provides examples of current funding opportunities. Refer to Chapter 10 of this book for details on how to obtain grant funding for your project.


Funding Organizations

Multilateral Lending Agencies (Funding comes from multiple governments)
. WHO: http://www.who.int/tdr/grants/en/

. UN: http://www.unfoundation.org/faq.html

. World Bank: http://www.worldbank.org/projects/P123653/adkf-small-grants-program?lang=en



Bilateral Lending Agencies (Single government agency that provides aid to low-income countries)
. USAID: https://www.usaid.gov

. CDC: http://www.cdc.gov/grants/




NGO (Non- governmental organizations)
. Oxfam: http://www.oxfamamerica.org/donate/make-grant/

. Bill and Melinda Gates Foundation: http://gcgh.grandchallenges.org

. NGO aid: http://ngoaidmap.org/

. Global Medicine Network: http://www.massmed.org/Charitable_Foundation/Applying_for_Grants/International_Health_Studies_Program/#.Vy_0KWOPe-J



Emergency Medicine Organizations
. ACEP International Section: http://www.acep.org/_InternationalSection/International-Section/

. EMRA: http://www.emra.org/committees-divisions/International-Division/

. Emergency Medicine Foundation: https://www.emfoundation.org



Global Health Programs that provide funding
. Yale Global Health Scholars: http://medicine.yale.edu/intmed/globalhealthscholars/

. Mayo International health Scholarship: http://www.mayo.edu/msgme/mayo-international-health-program/

. Systems Improvement at District Hospitals and Regional Training of Emergency Care: http://www.sidharte.org/http://www.sidharte.org/

. American Society of Tropical Medicine: http://www.astmh.org/



OTHER
. Self-funding

. Fundraising through local organization, i.e. religious organizations, rotary clubs

 




References

1. Arnold, J.L., International emergency medicine and the recent development of emergency medicine worldwide. Annals of emergency medicine, 1999. 33(1): p. 97-103.

2. Kirsch, T.D., et al., The development of international emergency medicine: a role for U.S. emergency physicians and organizations. SAEM International Interest Group. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine, 1997. 4(10): p. 996-1001.

3. Macfarlane, S.B., M. Jacobs, and E.E. Kaaya, In the name of global health: trends in academic institutions. Journal of public health policy, 2008. 29(4): p. 383-401.

4. Koplan, J.P., et al., Towards a common definition of global health. Lancet, 2009. 373(9679): p. 1993-5.

5. News on Millennium Development Goals. United Nations. http://www.un.org/millenniumgoals/. Accessed on 5/29/2015.