1. Establishing an International Elective/Rotation & Funding International Programs Kumar Alagappan, MD, FACEP, FAAEM, FIFEM Immediate Past Chair, ACEP International Section Associate Chairman Emergency Medicine, Long Island Jewish Medical Center Associate Professor, Albert Einstein College of Medicine Associate Professor, Albert Einstein College of Medicine

2. Goals and Objectives u Review the benefits of an international rotation u Formulation of goals and objectives u Review RRC and GME requirements u Discuss Funding u Evaluate malpractice and liability needs

3. What is an International Elective? u Rotation in a foreign country u Observe and/or practice in a new environment u Care for different types of patients u See a spectrum of disease and illness unique to the country u Participate in educational programs in that country u Research Kirsch TD, Holliman CJ, Hirshon JM, et al: The development of international emergency medicine: the role of United States emergency physicians and organizations. Acad Emerg Med 1997;4(10):996-1001

4. Benefits to Observer/Rotator u Exposure to other culture and health care system u Exposure to medical problems not seen in US u Opportunity for increased clinical responsibility and procedure performance u Can have long term impact on health care system u Appreciate US system Arnold JL: International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med 1999;33:97-103.

5. Benefits to Observer/Rotator u Learn and interact with other cultures u Learn novel approaches to common problems u Appreciative patients and colleagues u Influence on EM system structure for entire countries u Promote specialty worldwide u Appreciate diversity u Understanding effect of epidemiology and socio- behavioral aspects of patient care

6. Why are the Host countries Interested in EM? u Improving overall medical system development u Rapid urbanization u Increased mobility of populations u Increased outpatient visits u Success in U.S.

7. Why are the Host countries Interested in EM ? EM OFFERS- u Basic trauma care u Training non physician pre-hospital care providers u Management of multi casualty incidents u Coordination of care for patients with multi- system problems

8. Why are the Host countries Interested in EM physicians? u Act as system structure and training consultant u Promote international collaborative research projects u Participate in international conferences Holliman, CJ, Cevik AA, How emergency physicians can use their everyday skills to manage a “near disaster” medical conference. Acad Emerg Med 2002;9(8):832-834Rodoplu U, Arnold J, Walsh DW:

9. RESIDENCY DIRECTORS! u ACGME Competencies and International Electives –Improve patient care –Increase medical knowledge –Enhance communications skills –Professionalism –Practice based learning –System based practice

10. How does one get Started? u Identify Country u Needs Assessment u Research country u Preferable to make pre-elective trip (or work with mentor)

11. Make Pre-Elective Contacts u Contact persons in the US for leads –Visit EMRA International EM Committee and ACEP International Section websites to find list of international rotations –Contact ACEP to find the official ACEP ambassador to your country of interest u Identify interested parties who can host you u Contact previous participants u Network at national and international EM conferences

12. Formulate Goals and Objectives for your rotation u Facilitate building of the infrastructure required to develop the specialty of emergency medicine in other countries u Mentoring / leadership, provide clinical expertise, develop research and training programs. u Understand and incorporate host country customs and culture and indigenous diseases when developing EM/EMS system u Promote and exchange ideas between 2 countries

13. Goals and Objectives (Example) u Provide emergency medical care in a hospital setting to the urban residents of a developing nation. u Study the pre-hospital care system in the urban setting. u Become more familiar with and treat tropical and warm weather illnesses. u Perform population-based research on the medical needs u Teach emergency medicine to students and residents

14. Learning Objectives (Example) u Learn to manage multiple patients with limited technical and physical resources. u Observe and learn different medical strategies as practiced in a developing nation.

15. Who Pays for International Rotations? u Private u Hosting Institute u Grants/Scholarships –Johnson & Johnson, NGOs –Organizations u Self-paid u Residency

16. Who Pays Resident Salaries? u Hospitals reimbursed in 1 month/4 week blocks by Medicare u No reimbursement for outside electives –Therefore institution takes a loss u Justification to institution for paying resident’s salary during their away rotation –Unable to get this experience at home institution

17. Which Residencies are Supportive? u 60% of EM residencies support IEM electives u Some 3 year residencies are supportive u Should be financially feasible at all 4 year residency programs

18. What’s in it for the institution? u Great residents u Improved medical care at home u In the long run means saved $$$$$$$$$$ u Can the administration hold out, or is it the bottom line each fiscal year ?

19. Time Requirements u Where residents spend their time is subject to –RRC requirements –Reimbursement requirements u EM 50% of time must be at home institution u 50% must be spent in the ED

20. RRC Mandates for Away Rotations u JCAHO approved site u Supervising physician present at host site u Elective /experience is unavailable at home institution u Memoranda of Understanding established (MOU)

21. JCAHO Approved Site (RRC mandate) u Accrediting government body for institutions in host country u Or other national body that maintains some form of accreditation for education – (Medical council approves residencies in country) u JCAHO international

22. Supervising Physician (RRC mandates) u One who is responsible for resident experience (didactic, clinical, admin) u Resident reports to this physician u Supervising physician will evaluate resident u Appropriate credentials for experience –What happens when EM is not recognized in the country? –What credentials do these people have?

23. Core Competencies u The ACGME/RRC have established six core competencies that an Emergency Medicine residency program must meet in order to be accredited. u These are: –Patient Care –Medical Knowledge –Interpersonal Skills –Professionalism –System-based practice –Practice based learning

24. Implementation u Survey residents that have gone abroad u Developing a validated survey that answers the above questions. u Tally the different types of rotations available u Describe an optimal educational experience

25. MOU (RRC mandates) u Document necessity for outside rotations u Will go over : –Insurance –Liability –Responsibilities –Payments –Signed by institutional administrators

26. Liability u Sickness u Injuries u Evacuation u ‘Unsafe conditions’ u What contracts must be signed –Are they legal? –Do they hold in court?

27. How can you convince an institution / program director? u Progressive thinking / foresight u Educational benefits u Potential exchange of personnel / ideas u Research and …………………….

28. Send them this article: Dey CC, Grabowski JG, Gebreyes K, Hsu E, VanRooyen MJ: Influence of International Emergency Medicine Opportunities on Residency Program Selection. Acad Emerg Med. 2002;9(7)679-68 International rotations are a powerful resident recruitment tool !

29. International programs u 10 % of all US medical student graduates do some sort of international elective u International fellowships now appearing in EM residencies u International observer fellowships also popping up VanRooyen MJ, Clem KJ, Holliman CJ, et al: Proposed fellowship training program in international emergency medicine. Acad Emerg Med 1999;6(2):145-149.

30. Future of International EM u International electives are not going away –Similar to ultrasound –EMS etc u Will be or is part of EM landscape u Currently the largest sections of ACEP and SAEM are the international sections u AAEM has put on largest international conferences

31. And Finally…Never Give Up!