The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–6, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.11.101
International Emergency Medicine
GLOBAL HEALTH EDUCATION IN EMERGENCY MEDICINE RESIDENCY PROGRAMS Tatiana Havryliuk, MD,* Suzanne Bentley, MD,† and Sigrid Hahn, MD, MPH* *Icahn School of Medicine at Mount Sinai, New York, New York and †Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, New York, New York Reprint Address: Tatiana Havryliuk, MD, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029
, Keywords—international medicine education; global health education; emergency medicine residency programs; preparation
, Abstract—Background: Interest in global health and international electives is growing among Emergency Medicine (EM) residents in the United States (US). The majority of EM residency programs offer opportunities for international electives. The degree of participation among residents and type of support provided by the residency program, however, remains unclear. Study Objectives: To explore the current state of global health education among EM residents who participate in international electives. Methods: A 12question survey was e-mailed to the program directors of the 192 EM residency programs in the US. The survey included questions about the number of residents participating in international electives and the types of preparation, project requirements, supervision, and feedback participating residents receive. Results: The response rate was 53% with 102 responses. Seventy-five of 102 (74%) programs reported that at least one resident participated in an international elective in the 2010–2011 academic year. Forty-three programs (42%) report no available funding to support any resident on an international elective. Residents receive no preparation for international work in 41 programs (40%). Only 25 programs (26%) required their residents to conduct a project while abroad. Forty-nine programs (48%) reported no formal debriefing session, and no formal feedback was collected from returning residents in 57 of 102 (59%) programs. Conclusion: The majority of EM residencies have residents participating in international electives. However, the programs report variable preparation, requirements, and resident supervision. These results suggest a need for an expanded and more structured approach to international electives undertaken by EM residents. Ó 2014 Elsevier Inc.
INTRODUCTION In recent years, Emergency Medicine (EM) residents have expressed a growing interest in international electives. Only 62 of 113 EM programs (55%) reported participation in international projects in the 1999 study by Alagappan et al. (1). By 2002, Dey et al. found that 86% of EM residents were interested in international health and actually ranked residency programs that offered international experience higher (2). Likewise, major EM organizations, including the American College of Emergency Physicians and the Society for Academic Emergency Medicine, now include specific sections and interest groups dedicated to international EM (3). To accommodate the rising interest in global health, many EM residency programs are offering international electives. King et al. found that 91% (101 out of 111 programs that responded) offered international electives, and 80% of the 111 programs had graduating residents completing an international elective during their EM training at the time of survey (4). International experience during residency has numerous benefits, such as improved cultural competency and clinical skills, as well as resident physician exposure to cost-effective ways of practicing medicine (5).
RECEIVED: 13 June 2013; FINAL SUBMISSION RECEIVED: 21 September 2013; ACCEPTED: 17 November 2013 1
2
T. Havryliuk et al.
However, it remains uncertain what degree of formal global health education and supervision (e.g., didactics, mentoring, postelective feedback, and project completion requirements) are available to interested EM residents. One study found that preparation for international electives ranged from none to an organized international medicine curriculum among the 161 (65%) of 248 pediatric residency programs that were surveyed (6). Even the limited number of residency programs that offer residency specialty tracks or ‘‘mini-fellowships’’ in global health have variable requirements (7). Lack of preparation can lead to burdens on the host institution in a resource-limited setting, negative impact on patients and community, and concerns for best resource utilization and project sustainability (8,9). MATERIALS AND METHODS Study Design This project consisted of a short survey to explore the current state of global health education in the United States among EM residents who participate in international electives. One hundred ninety-two EM residency program directors (156 Accreditation Council for Graduate Medical Education [ACGME]-accredited and 36 non ACGME-accredited) were surveyed between June 2012 and January 2013. SurveyMonkey.com (SurveyMonkey, Palo Alto, CA) was used to create the 12-question survey and collect and collate responses. The survey was distributed twice using the Council of Emergency Medicine Residency Directors (CORD) listserv. The text in the e-mail provided a description of the survey, and an option to forward the survey to a qualified global health/international EM faculty contact to answer the survey if more appropriate than completion by the program director. The program directors or designated global health/international EM fellowship directors or faculty at the residency programs that did not initially fill out the survey were additionally contacted individually via e-mail. The last question of the survey asked for the name of the residency program solely for the purpose of tracking
programs. The Institutional Review Board deemed this study exempt. Methods of Measurement The survey contains 12 questions assessing the number of residents participating in international electives in the past academic year vs. 5 years ago, and the type of preparation, project requirements, and supervision of the participating residents. Also collected was information on the availability of or plan to develop an international EM/global health fellowship at the residency program. The complete survey is available in the Appendix. Data Analysis Data were collected via SurveyMonkey and exported into Excel (Microsoft Corporation, Redmond, WA) format. RESULTS Participation One hundred two of 192 (53%) EM residency programs completed the survey. Resident participation in international electives is high overall and increasing over the last 5 years. Forty-three (42%) programs report no funding for residents to participate in international electives. See Table 1 for full results. There was a trend showing correlation between the funding availability and resident participation in international electives. Preparation Residents receive variable preparation for international electives. Forty-one (40%) programs offer no preparation at all. Twenty-three (23%) programs provide safety training, and six (6%) conduct a preparation course for the residents. The remaining programs report a mix of lectures, conferences, checklists, travel health consultation, assigned readings, and mentoring to prepare their residents for international electives (Table 2).
Table 1. Resident Participation in International Electives and Funding Availability
Number of Residents 0 1–2 3–5 >5 Total answered IE = international electives.
Number (%) of Programs Reporting Resident Participation in IE in 2005–2006
Number (%) of Programs Reporting Resident Participation in IE in 2010–2011
Number (%) of Programs Reporting Available Funding for 2010–2011
32 (31) 41 (40) 20 (20) 9 (9) 102 (100)
27 (27) 29 (28) 27 (27) 19 (19) 102 (100)
43 (42) 25 (24) 15 (15) 19 (19) 102 (100)
Global Health Education in Emergency Medicine Residency Programs Table 2. Preparation Received by Residents Prior To an International EM Elective Answer Options
Number of Programs (%)
No preparation Lectures Courses Conferences Checklists Safety training Travel health consultation Required readings (books, handouts) US-based mentoring International mentoring Total answered
41 (40) 20 (20) 6 (6) 12 (12) 31 (30) 23 (23) 41 (40) 15 (15) 44 (43) 33 (32) 102 (100)
EM = emergency medicine; US = United States.
Feedback and Requirements Upon return from an international elective, 57 (52%) programs conduct formal debriefing sessions, most often with a mentor (68%) or program director (50%). Most programs (59%) collect no formal feedback from resident physicians after their elective. A minority, 25 of 97 (26%) programs, require their residents to complete an educational or research project while on elective, and 50 (47%) require formal presentation by the resident on the international experience. Fifty-nine of 95 (57%) programs reported that at least one resident had completed an international project in the 2010–2011 academic year, regardless of program requirements, equaling a rate roughly double the presentations that were required by the residency programs. International EM Fellowships As reflected in the growing number of international EM/ global health fellowships (IEM/GH), the number of EM residents seeking formal international health education is also on the rise. Thirty-two of 97 (33%) programs have an IEM/GH fellowship, the majority of which were initiated in the last 5 years. Furthermore, 11 residency programs reported plans to start new IEM/GH fellowships at their institutions. DISCUSSION It is clear that there is a growing interest and involvement of EM residents in global health. This survey shows that 74% of EM residency programs had at least one resident participate in an international elective in the last academic year. This is similar to the 2012 study by King et al. showing 80% participation (4). To our knowledge, there are no available data to date systematically assessing the type of preparation, debriefing,
3
requirements and feedback that EM residents involved in international work undergo. This study found that 40% of programs surveyed offer no preparation of any type and the remaining programs offer a variable combination of courses, lectures, and readings. Importantly, only 23% provide residents with safety training prior to travel. These results suggest a concerning lack of formal global health education provided to EM residents who engage in international electives. It is likely that a more structured curriculum would greatly benefit residents going on international electives, as well as the patients and medical colleagues with whom they interact while abroad. Structured preparation would provide residents with cultural context and realistic expectations for their international experience. Safety training can teach them core competencies in the case of political, environmental, or health crises as well as general measures required while working clinically abroad. Project requirements would not only provide residents with a focus, but could also encourage production of potentially valuable work that could be published or presented to share their experiences and expand the field of global health. Ensuring access to a mentor would also allow residents to obtain guidance prior to, during, and after their endeavors abroad. Furthermore, collecting feedback from returning residents could be utilized to improve and help facilitate more worthwhile experiences for their successors. Further study is needed to assess the actual benefits of the aforementioned suggested improvements. Drain et al. advocate that global health training can be better achieved by offering global health tracks or educational pathways with set educational and practical requirements (5). With the increased trend in resident interest and participation in international electives, it will likely become imperative for residency review committees to develop overreaching global health training competencies and policies in the future (5). The Working Group on Ethics Guidelines for Global Health Training has published a set of consensus guidelines to minimize the ethical pitfalls inherent to global heath work. The 33 recommendations for trainees, host and home institutions, and sponsors emphasize the importance of preparation (e.g., safety training and cultural competency), supervision/mentorship, and the development of clear objectives and expectations prior to embarking on international electives (10). Limitations Small number of respondents. Only 102 of the 192 (53%) EM program directors or global health faculty completed the survey despite multiple inquiries sent via the CORD listserv and direct individual e-mails to the programs.
4
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Our goal was to achieve at least a 50% completion rate, which was accomplished. It is possible that our data would be different if more programs participated. It seems reasonable to consider that residency program directors with more programmatic involvement in global health would be more likely to take our survey. Thus, it is feasible that some of our results are overinflated. To evaluate for the effect of selection bias, we compared responses for initial responders, those that took the survey after the first inquiry, and late responders, those that answered the survey after the second inquiry. It would be rational to assume that the late responders would be more similar to nonresponders and likely less interested in the topic surveyed. However, our analysis showed that late responders reported more resident participation, funding availability, and preparation for international work in comparison to the initial responders. This would suggest that nonresponders, being more similar to the late responders, likely did have comparable involvement in international work. It is less likely that their nonparticipation skewed our results.
4. King RA, Liu KY, Talley BE, et al. Availability and potential impact of international rotations in emergency medicine residency programs. J Emerg Med 2012;44:499–504. 5. Drain PK, Holmes KK, Skeff KM, et al. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med 2009;84:320–5. 6. Torjesen K, Mandalakas A, Kahn R, et al. International child health electives for pediatric residents. Arch Pediatr Adolesc Med 1999; 153:1297–302. 7. Anandaraja N, Hahn S, Hennig N, et al. The design and implementation of a multidisciplinary global health residency track at the Mount Sinai School of Medicine. Acad Med 2008;83:924–8. 8. Jesus JE. Ethical challenges and considerations of short- term international medical initiatives: an excursion to Ghana as a case study. Ann Emerg Med 2010;55:17–22. 9. Suchdev P, Ahrens K, Click E, et al. A model for sustainable shortterm international medical trips. Ambul Pediatr 2007;7:317–20. 10. Crump JA, Sugarman J, Working Group on Ethics Guidelines for Global Health Training (WEIGHT). Ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg 2010;83:1178–82.
Survey method. There is an inherent bias in utilizing the survey method, as it relies on self-reporting. The program directors might unintentionally inflate their programs’ achievements and opportunities or provide a nonevidence-based ‘‘best-guess’’ answer if unsure. Furthermore, many of the program directors might not have held their position 5 years ago and thus, gave unreliable answers pertaining to that time period. Some of the questions could have also been misunderstood, as anonymous surveys do not provide opportunities for questions or clarification.
Given increased resident involvement in the fields of Global Health and International Medicine, there is also a greater demand for structured GH education. This survey aims to explore the current state of GH education among Emergency Medicine residents who participate in international projects.
CONCLUSION EM resident involvement in international electives is continuing to rise. Formal preparation and education offered to such residents, however, is either lacking or very variable, as shown in this study. A more structured curriculum will likely provide great benefit to the resident physicians, their patients, and the overall residency programs in the future. REFERENCES 1. Alagappan K, Somoza C, Kahoun J, et al. Participation in international EM by U.S. EM residencies [abstract]. Acad Emerg Med 1999;6:411. 2. Dey CC, Grabowski JG, Gebreyes K, et al. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med 2002;9:679–83. 3. Kirsch TD, Holliman CJ, Hirshon JM, et al. The development of international emergency medicine: a role for U.S. emergency physicians and organizations. SAEM international interest group. Acad Emerg Med 1997;4:996–1001.
APPENDIX: GLOBAL HEALTH EDUCATION IN EMERGENCY MEDICINE RESIDENCY PROGRAMS SURVEY
1. Approximately how many residents in your program participated in an international elective in the last academic year (2010–11)? __0 __1–2 __3–5 __>5 2. Approximately how many residents in your program participated in an international elective 5 years ago? __0 __1–2 __3–5 __>5 3. For how many residents per year is your residency program able to provide any financial support to participate in an international elective? __0 __1–2 __3–5 __>5 4. What kind of preparation, if any, do your residents receive prior to going abroad? Check as many boxes as apply __lectures __courses __conferences __checklists __safety training __travel health consultation __required readings (books, handouts) (Continued )
Global Health Education in Emergency Medicine Residency Programs
5
Appendix. Continued
Appendix. Continued
__individual mentoring __United States-based mentor __international mentor 5. After returning from the field site, is there a formal debriefing session with returning resident? __Yes, face time with __mentor, __ program director, __ senior resident, __other: __Yes, written with __mentor, __ program director, __ senior resident, __other: __No 6. Are all of your residents required to complete a project (educational or research) during their international elective? __Yes __No 7. Are returning residents required to present their experience? __Yes, write-up __Yes, presentation __No 8. How many residents completed an international project during the last academic year? __0 __1–2 __3–5 __>5
9. How many had a publication or a presentation at a local/regional/national conference as a result of this project? __0 __1–2 __3–5 __>5 10. Do you formally collect resident feedback upon residents’ return? __Yes __No If so, how? 11. Is there an international emergency medicine fellowship at your site? __Yes __No If yes, in what year it was started? _____ If no, are there plans to start international emergency medicine fellowship at your site in the next 5 years? __Yes __No 12. Please provide the name of your residency program below. This information will only be used to track survey completion, and will not be published, used in data analysis, or for comparison among programs.
(Continued )
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ARTICLE SUMMARY 1. Why is this topic important? There is a growing interest in global health and international emergency medicine (EM) among EM residents. However, the degree of participation, among residents and type of support provided by the residency program is unclear. 2. What does this study attempt to show? This study explores the current state of global health education among EM residents who participate in international electives. 3. What are the key findings? The majority of EM residencies have residents participating in international electives, however, the programs report variable, and in many cases very limited, preparation, requirements, and resident supervision. 4. How is patient care impacted? We believe that a more structured curriculum for residents going on international electives will greatly benefit the residents and their patients.
http://dx.doi.org/10.1016/j.jemermed.2013.11.101
International Emergency Medicine
GLOBAL HEALTH EDUCATION IN EMERGENCY MEDICINE RESIDENCY PROGRAMS Tatiana Havryliuk, MD,* Suzanne Bentley, MD,† and Sigrid Hahn, MD, MPH* *Icahn School of Medicine at Mount Sinai, New York, New York and †Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, New York, New York Reprint Address: Tatiana Havryliuk, MD, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029
, Keywords—international medicine education; global health education; emergency medicine residency programs; preparation
, Abstract—Background: Interest in global health and international electives is growing among Emergency Medicine (EM) residents in the United States (US). The majority of EM residency programs offer opportunities for international electives. The degree of participation among residents and type of support provided by the residency program, however, remains unclear. Study Objectives: To explore the current state of global health education among EM residents who participate in international electives. Methods: A 12question survey was e-mailed to the program directors of the 192 EM residency programs in the US. The survey included questions about the number of residents participating in international electives and the types of preparation, project requirements, supervision, and feedback participating residents receive. Results: The response rate was 53% with 102 responses. Seventy-five of 102 (74%) programs reported that at least one resident participated in an international elective in the 2010–2011 academic year. Forty-three programs (42%) report no available funding to support any resident on an international elective. Residents receive no preparation for international work in 41 programs (40%). Only 25 programs (26%) required their residents to conduct a project while abroad. Forty-nine programs (48%) reported no formal debriefing session, and no formal feedback was collected from returning residents in 57 of 102 (59%) programs. Conclusion: The majority of EM residencies have residents participating in international electives. However, the programs report variable preparation, requirements, and resident supervision. These results suggest a need for an expanded and more structured approach to international electives undertaken by EM residents. Ó 2014 Elsevier Inc.
INTRODUCTION In recent years, Emergency Medicine (EM) residents have expressed a growing interest in international electives. Only 62 of 113 EM programs (55%) reported participation in international projects in the 1999 study by Alagappan et al. (1). By 2002, Dey et al. found that 86% of EM residents were interested in international health and actually ranked residency programs that offered international experience higher (2). Likewise, major EM organizations, including the American College of Emergency Physicians and the Society for Academic Emergency Medicine, now include specific sections and interest groups dedicated to international EM (3). To accommodate the rising interest in global health, many EM residency programs are offering international electives. King et al. found that 91% (101 out of 111 programs that responded) offered international electives, and 80% of the 111 programs had graduating residents completing an international elective during their EM training at the time of survey (4). International experience during residency has numerous benefits, such as improved cultural competency and clinical skills, as well as resident physician exposure to cost-effective ways of practicing medicine (5).
RECEIVED: 13 June 2013; FINAL SUBMISSION RECEIVED: 21 September 2013; ACCEPTED: 17 November 2013 1
2
T. Havryliuk et al.
However, it remains uncertain what degree of formal global health education and supervision (e.g., didactics, mentoring, postelective feedback, and project completion requirements) are available to interested EM residents. One study found that preparation for international electives ranged from none to an organized international medicine curriculum among the 161 (65%) of 248 pediatric residency programs that were surveyed (6). Even the limited number of residency programs that offer residency specialty tracks or ‘‘mini-fellowships’’ in global health have variable requirements (7). Lack of preparation can lead to burdens on the host institution in a resource-limited setting, negative impact on patients and community, and concerns for best resource utilization and project sustainability (8,9). MATERIALS AND METHODS Study Design This project consisted of a short survey to explore the current state of global health education in the United States among EM residents who participate in international electives. One hundred ninety-two EM residency program directors (156 Accreditation Council for Graduate Medical Education [ACGME]-accredited and 36 non ACGME-accredited) were surveyed between June 2012 and January 2013. SurveyMonkey.com (SurveyMonkey, Palo Alto, CA) was used to create the 12-question survey and collect and collate responses. The survey was distributed twice using the Council of Emergency Medicine Residency Directors (CORD) listserv. The text in the e-mail provided a description of the survey, and an option to forward the survey to a qualified global health/international EM faculty contact to answer the survey if more appropriate than completion by the program director. The program directors or designated global health/international EM fellowship directors or faculty at the residency programs that did not initially fill out the survey were additionally contacted individually via e-mail. The last question of the survey asked for the name of the residency program solely for the purpose of tracking
programs. The Institutional Review Board deemed this study exempt. Methods of Measurement The survey contains 12 questions assessing the number of residents participating in international electives in the past academic year vs. 5 years ago, and the type of preparation, project requirements, and supervision of the participating residents. Also collected was information on the availability of or plan to develop an international EM/global health fellowship at the residency program. The complete survey is available in the Appendix. Data Analysis Data were collected via SurveyMonkey and exported into Excel (Microsoft Corporation, Redmond, WA) format. RESULTS Participation One hundred two of 192 (53%) EM residency programs completed the survey. Resident participation in international electives is high overall and increasing over the last 5 years. Forty-three (42%) programs report no funding for residents to participate in international electives. See Table 1 for full results. There was a trend showing correlation between the funding availability and resident participation in international electives. Preparation Residents receive variable preparation for international electives. Forty-one (40%) programs offer no preparation at all. Twenty-three (23%) programs provide safety training, and six (6%) conduct a preparation course for the residents. The remaining programs report a mix of lectures, conferences, checklists, travel health consultation, assigned readings, and mentoring to prepare their residents for international electives (Table 2).
Table 1. Resident Participation in International Electives and Funding Availability
Number of Residents 0 1–2 3–5 >5 Total answered IE = international electives.
Number (%) of Programs Reporting Resident Participation in IE in 2005–2006
Number (%) of Programs Reporting Resident Participation in IE in 2010–2011
Number (%) of Programs Reporting Available Funding for 2010–2011
32 (31) 41 (40) 20 (20) 9 (9) 102 (100)
27 (27) 29 (28) 27 (27) 19 (19) 102 (100)
43 (42) 25 (24) 15 (15) 19 (19) 102 (100)
Global Health Education in Emergency Medicine Residency Programs Table 2. Preparation Received by Residents Prior To an International EM Elective Answer Options
Number of Programs (%)
No preparation Lectures Courses Conferences Checklists Safety training Travel health consultation Required readings (books, handouts) US-based mentoring International mentoring Total answered
41 (40) 20 (20) 6 (6) 12 (12) 31 (30) 23 (23) 41 (40) 15 (15) 44 (43) 33 (32) 102 (100)
EM = emergency medicine; US = United States.
Feedback and Requirements Upon return from an international elective, 57 (52%) programs conduct formal debriefing sessions, most often with a mentor (68%) or program director (50%). Most programs (59%) collect no formal feedback from resident physicians after their elective. A minority, 25 of 97 (26%) programs, require their residents to complete an educational or research project while on elective, and 50 (47%) require formal presentation by the resident on the international experience. Fifty-nine of 95 (57%) programs reported that at least one resident had completed an international project in the 2010–2011 academic year, regardless of program requirements, equaling a rate roughly double the presentations that were required by the residency programs. International EM Fellowships As reflected in the growing number of international EM/ global health fellowships (IEM/GH), the number of EM residents seeking formal international health education is also on the rise. Thirty-two of 97 (33%) programs have an IEM/GH fellowship, the majority of which were initiated in the last 5 years. Furthermore, 11 residency programs reported plans to start new IEM/GH fellowships at their institutions. DISCUSSION It is clear that there is a growing interest and involvement of EM residents in global health. This survey shows that 74% of EM residency programs had at least one resident participate in an international elective in the last academic year. This is similar to the 2012 study by King et al. showing 80% participation (4). To our knowledge, there are no available data to date systematically assessing the type of preparation, debriefing,
3
requirements and feedback that EM residents involved in international work undergo. This study found that 40% of programs surveyed offer no preparation of any type and the remaining programs offer a variable combination of courses, lectures, and readings. Importantly, only 23% provide residents with safety training prior to travel. These results suggest a concerning lack of formal global health education provided to EM residents who engage in international electives. It is likely that a more structured curriculum would greatly benefit residents going on international electives, as well as the patients and medical colleagues with whom they interact while abroad. Structured preparation would provide residents with cultural context and realistic expectations for their international experience. Safety training can teach them core competencies in the case of political, environmental, or health crises as well as general measures required while working clinically abroad. Project requirements would not only provide residents with a focus, but could also encourage production of potentially valuable work that could be published or presented to share their experiences and expand the field of global health. Ensuring access to a mentor would also allow residents to obtain guidance prior to, during, and after their endeavors abroad. Furthermore, collecting feedback from returning residents could be utilized to improve and help facilitate more worthwhile experiences for their successors. Further study is needed to assess the actual benefits of the aforementioned suggested improvements. Drain et al. advocate that global health training can be better achieved by offering global health tracks or educational pathways with set educational and practical requirements (5). With the increased trend in resident interest and participation in international electives, it will likely become imperative for residency review committees to develop overreaching global health training competencies and policies in the future (5). The Working Group on Ethics Guidelines for Global Health Training has published a set of consensus guidelines to minimize the ethical pitfalls inherent to global heath work. The 33 recommendations for trainees, host and home institutions, and sponsors emphasize the importance of preparation (e.g., safety training and cultural competency), supervision/mentorship, and the development of clear objectives and expectations prior to embarking on international electives (10). Limitations Small number of respondents. Only 102 of the 192 (53%) EM program directors or global health faculty completed the survey despite multiple inquiries sent via the CORD listserv and direct individual e-mails to the programs.
4
T. Havryliuk et al.
Our goal was to achieve at least a 50% completion rate, which was accomplished. It is possible that our data would be different if more programs participated. It seems reasonable to consider that residency program directors with more programmatic involvement in global health would be more likely to take our survey. Thus, it is feasible that some of our results are overinflated. To evaluate for the effect of selection bias, we compared responses for initial responders, those that took the survey after the first inquiry, and late responders, those that answered the survey after the second inquiry. It would be rational to assume that the late responders would be more similar to nonresponders and likely less interested in the topic surveyed. However, our analysis showed that late responders reported more resident participation, funding availability, and preparation for international work in comparison to the initial responders. This would suggest that nonresponders, being more similar to the late responders, likely did have comparable involvement in international work. It is less likely that their nonparticipation skewed our results.
4. King RA, Liu KY, Talley BE, et al. Availability and potential impact of international rotations in emergency medicine residency programs. J Emerg Med 2012;44:499–504. 5. Drain PK, Holmes KK, Skeff KM, et al. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med 2009;84:320–5. 6. Torjesen K, Mandalakas A, Kahn R, et al. International child health electives for pediatric residents. Arch Pediatr Adolesc Med 1999; 153:1297–302. 7. Anandaraja N, Hahn S, Hennig N, et al. The design and implementation of a multidisciplinary global health residency track at the Mount Sinai School of Medicine. Acad Med 2008;83:924–8. 8. Jesus JE. Ethical challenges and considerations of short- term international medical initiatives: an excursion to Ghana as a case study. Ann Emerg Med 2010;55:17–22. 9. Suchdev P, Ahrens K, Click E, et al. A model for sustainable shortterm international medical trips. Ambul Pediatr 2007;7:317–20. 10. Crump JA, Sugarman J, Working Group on Ethics Guidelines for Global Health Training (WEIGHT). Ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg 2010;83:1178–82.
Survey method. There is an inherent bias in utilizing the survey method, as it relies on self-reporting. The program directors might unintentionally inflate their programs’ achievements and opportunities or provide a nonevidence-based ‘‘best-guess’’ answer if unsure. Furthermore, many of the program directors might not have held their position 5 years ago and thus, gave unreliable answers pertaining to that time period. Some of the questions could have also been misunderstood, as anonymous surveys do not provide opportunities for questions or clarification.
Given increased resident involvement in the fields of Global Health and International Medicine, there is also a greater demand for structured GH education. This survey aims to explore the current state of GH education among Emergency Medicine residents who participate in international projects.
CONCLUSION EM resident involvement in international electives is continuing to rise. Formal preparation and education offered to such residents, however, is either lacking or very variable, as shown in this study. A more structured curriculum will likely provide great benefit to the resident physicians, their patients, and the overall residency programs in the future. REFERENCES 1. Alagappan K, Somoza C, Kahoun J, et al. Participation in international EM by U.S. EM residencies [abstract]. Acad Emerg Med 1999;6:411. 2. Dey CC, Grabowski JG, Gebreyes K, et al. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med 2002;9:679–83. 3. Kirsch TD, Holliman CJ, Hirshon JM, et al. The development of international emergency medicine: a role for U.S. emergency physicians and organizations. SAEM international interest group. Acad Emerg Med 1997;4:996–1001.
APPENDIX: GLOBAL HEALTH EDUCATION IN EMERGENCY MEDICINE RESIDENCY PROGRAMS SURVEY
1. Approximately how many residents in your program participated in an international elective in the last academic year (2010–11)? __0 __1–2 __3–5 __>5 2. Approximately how many residents in your program participated in an international elective 5 years ago? __0 __1–2 __3–5 __>5 3. For how many residents per year is your residency program able to provide any financial support to participate in an international elective? __0 __1–2 __3–5 __>5 4. What kind of preparation, if any, do your residents receive prior to going abroad? Check as many boxes as apply __lectures __courses __conferences __checklists __safety training __travel health consultation __required readings (books, handouts) (Continued )
Global Health Education in Emergency Medicine Residency Programs
5
Appendix. Continued
Appendix. Continued
__individual mentoring __United States-based mentor __international mentor 5. After returning from the field site, is there a formal debriefing session with returning resident? __Yes, face time with __mentor, __ program director, __ senior resident, __other: __Yes, written with __mentor, __ program director, __ senior resident, __other: __No 6. Are all of your residents required to complete a project (educational or research) during their international elective? __Yes __No 7. Are returning residents required to present their experience? __Yes, write-up __Yes, presentation __No 8. How many residents completed an international project during the last academic year? __0 __1–2 __3–5 __>5
9. How many had a publication or a presentation at a local/regional/national conference as a result of this project? __0 __1–2 __3–5 __>5 10. Do you formally collect resident feedback upon residents’ return? __Yes __No If so, how? 11. Is there an international emergency medicine fellowship at your site? __Yes __No If yes, in what year it was started? _____ If no, are there plans to start international emergency medicine fellowship at your site in the next 5 years? __Yes __No 12. Please provide the name of your residency program below. This information will only be used to track survey completion, and will not be published, used in data analysis, or for comparison among programs.
(Continued )
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T. Havryliuk et al.
ARTICLE SUMMARY 1. Why is this topic important? There is a growing interest in global health and international emergency medicine (EM) among EM residents. However, the degree of participation, among residents and type of support provided by the residency program is unclear. 2. What does this study attempt to show? This study explores the current state of global health education among EM residents who participate in international electives. 3. What are the key findings? The majority of EM residencies have residents participating in international electives, however, the programs report variable, and in many cases very limited, preparation, requirements, and resident supervision. 4. How is patient care impacted? We believe that a more structured curriculum for residents going on international electives will greatly benefit the residents and their patients.
