Fellowships in International Emergency Medicine in the USA
Fellowships in International Emergency Medicine in the USA
Acquiring core curriculum competencies is germane to the success of both fellows and fellowship programmes. Our survey shows that neither PDs nor fellows believe that fellows have achieved an adequate level of capacity (minimum score of 3) in any of the six core curriculum components studied: EM systems development, EM education development, humanitarian aid, public health, EMS and disaster medicine. After completing a 1- or 2-year IEM fellowship, it is unlikely that a graduate would master all six core curriculum areas. However, the fact that having an average score of 3 (perfect amount) in any of the six curriculum areas was reported neither by PDs or fellows is an interesting finding which begets the question whether IEM fellowship are trying to achieve 'too much', stacking the deck with more core competencies than they can achieve within the allocated time frame.
Another interesting finding was that the lowest score among these six areas was in the field of emergency medical services (EMS) with PDs score mean of 2.21 and fellows mean score of 1.78 (out of 4 maximum points). One of the main reasons for these low scores is likely the lack of focus on EMS, which has a 2-year dedicated EM fellowship exclusively dedicated to that one area, and is ACGME-accredited with a well-described curriculum.
Another major finding is the statistically significant discrepancy in capacity perception between PDs and fellows, in three different competencies: humanitarian aid, public health and disaster medicine. In all three areas, the average score was higher among PDs than it is among fellows (humanitarian aid: 2.5 vs 2.03 (p<0.05); public health 2.88 vs 2.19 (p<0.01); disaster medicine 2.63 vs 1.97 (p<0.01), respectively). These results may be due to several factors. First, PDs and fellows may not agree on goals to demonstrate competency in these core curriculum areas. Second, the lack of objective measures or metrics to evaluate the capacity of fellows makes it difficult to demonstrate competencies in these areas. Third, there may be an inherent reporting bias among the PDs who understandably want to attract applicants and are more likely to overestimate their programme's features and their fellows' capacity.
Adding to the complexity and heterogeneity of the matter, previous studies show that the majority of fellowship applicants do not know well their programme's curriculum prior to starting fellowship. This fact may contribute to the discrepancy described above. One solution to this challenge may be to frequently update curriculum information in a clearly accessible public forum and making it visible to all applicants. By doing so, potential fellows will be aware of the experiences they may expect from each respective institution. Knowing the details of the curriculum, fellows may even opt to pursue a combined or further subspecialised fellowship, as has been recently described in the literature. While many IEM academicians debate whether a standardised IEM fellowship curriculum is paramount, others promote an individualised approach tailored to the institution, to the fellow or both; each host institution should instead offer training derived from their existing relationships and projects to their fellows.
Regardless of whether core curriculum requirements are established, maintaining an open environment for communication between fellows and PDs during fellowship is also paramount. This disagreement in responses may also be due to lack of communication between fellows and PDs. With the clinical and travel schedules of international emergency physicians, and without established checkpoints within the fellowship, it may be difficult to foster frequent and open interaction. Future research may include finding out whether fellows actually have a formal way to give feedback and suggestions about their fellowship experience to their PD. Without the external validation of ACGME accreditation, some fellows may not feel comfortable requesting changes in their fellowship curricula. Perhaps they are concerned that they will give an impression of criticising their employer, or that such changes would put existing global relationships and funding sources at risk. Fellows with these concerns are less likely to promote original and potentially productive strategies to diversify their curriculum.
Some of the possible barriers to fulfilling core curriculum components may include: lack of funding, lack of time, lack of resources and/or networking connections, lack of enforcement by PDs. Lack of funding and/or time may be more of an issue at government-funded hospitals. Fellows at these institutions may need to work more clinical hours and thereby end up with very little time to cover core curriculum components. One solution to this problem would be lengthening the fellowship to 3 years. Lack of resources may include an absence of a school of public health or lack of established connections in the fields of the core curriculum components; for example, a programme may not have any faculty focusing on international EM system development. In this scenario, programmes with this deficiency could collaborate with other schools of public health or programmes that have faculty working in the fields in which they are lacking. The issue of lack of enforcement by PD could be solved by standardising core curriculum components for all IEM fellowships. In this case, fellowship directors and fellows would be required to submit formal documentation of completion of each core curriculum component.
While core curriculum requirements are still not formally established, the authors encourage IEM fellowship programmes to foster transparency of their curricula. Keeping curricula up to date, accurate and accessible to applicants is paramount. Diversity in training can be favourable provided that fellows are aware of what each fellowship offers prior to signing a contract. The academic IEM community should actively promote open communication among fellows, PDs and the host institution. Regular internal review of a programme by its PD, administrative assistants and coordinators, and fellows will promote the evolution and diversification of IEM fellowships. Such constructive criticism of our curricula should be encouraged.
This study was limited by its small sample size. The field of academic IEM, and in particular IEM fellowship training, is quite specialised; thus, there are currently only 34 active programmes, most of which have only graduated a handful of fellows, many of whom have gone on to become PDs. In addition, there was an incomplete response (82% for PDs and 76% for fellows); this response rate may be explained in part by outdated contact information for fellowship graduates, and in part by the number of recent fellowship graduates who are now PDs. Also, even though we informed participants about the de-identification of data, there may be additional lingering concerns regarding lack of anonymity and potential ramifications of their responses that can contribute to some degree of information bias, especially among physicians still employed by their host institution.
Additionally, our descriptive categories ('got my feet wet', 'the perfect amount' and 'more than I needed') might have been interpreted differently by various participants and hence the answers may be affected by that element of subjectivity. Furthermore, the scoring on the Likert scale is assumed to be an interval scale; that is, equidistant points between each of the scale elements, which may not be the case. Both issues above are not specific to our study and are shared by other survey-type research. Our methodology could have been improved by asking for uniformly objective measures such as the percentage of time spent on each of the core competencies; however, such an approach may lend itself to the threat of data unavailability.
Other fellowship training programmes have studied whether their fellowships meet the perceived needs and objectives of physicians graduating from their programmes. Future work includes surveying graduates on whether IEM fellowships meet the perceived needs and objectives of physicians entering careers in IEM. Further study could also include surveying PDs and fellows on what barriers they feel are contributing to their not completing proposed core curriculum components.
Discussion
Acquiring core curriculum competencies is germane to the success of both fellows and fellowship programmes. Our survey shows that neither PDs nor fellows believe that fellows have achieved an adequate level of capacity (minimum score of 3) in any of the six core curriculum components studied: EM systems development, EM education development, humanitarian aid, public health, EMS and disaster medicine. After completing a 1- or 2-year IEM fellowship, it is unlikely that a graduate would master all six core curriculum areas. However, the fact that having an average score of 3 (perfect amount) in any of the six curriculum areas was reported neither by PDs or fellows is an interesting finding which begets the question whether IEM fellowship are trying to achieve 'too much', stacking the deck with more core competencies than they can achieve within the allocated time frame.
Another interesting finding was that the lowest score among these six areas was in the field of emergency medical services (EMS) with PDs score mean of 2.21 and fellows mean score of 1.78 (out of 4 maximum points). One of the main reasons for these low scores is likely the lack of focus on EMS, which has a 2-year dedicated EM fellowship exclusively dedicated to that one area, and is ACGME-accredited with a well-described curriculum.
Another major finding is the statistically significant discrepancy in capacity perception between PDs and fellows, in three different competencies: humanitarian aid, public health and disaster medicine. In all three areas, the average score was higher among PDs than it is among fellows (humanitarian aid: 2.5 vs 2.03 (p<0.05); public health 2.88 vs 2.19 (p<0.01); disaster medicine 2.63 vs 1.97 (p<0.01), respectively). These results may be due to several factors. First, PDs and fellows may not agree on goals to demonstrate competency in these core curriculum areas. Second, the lack of objective measures or metrics to evaluate the capacity of fellows makes it difficult to demonstrate competencies in these areas. Third, there may be an inherent reporting bias among the PDs who understandably want to attract applicants and are more likely to overestimate their programme's features and their fellows' capacity.
Adding to the complexity and heterogeneity of the matter, previous studies show that the majority of fellowship applicants do not know well their programme's curriculum prior to starting fellowship. This fact may contribute to the discrepancy described above. One solution to this challenge may be to frequently update curriculum information in a clearly accessible public forum and making it visible to all applicants. By doing so, potential fellows will be aware of the experiences they may expect from each respective institution. Knowing the details of the curriculum, fellows may even opt to pursue a combined or further subspecialised fellowship, as has been recently described in the literature. While many IEM academicians debate whether a standardised IEM fellowship curriculum is paramount, others promote an individualised approach tailored to the institution, to the fellow or both; each host institution should instead offer training derived from their existing relationships and projects to their fellows.
Regardless of whether core curriculum requirements are established, maintaining an open environment for communication between fellows and PDs during fellowship is also paramount. This disagreement in responses may also be due to lack of communication between fellows and PDs. With the clinical and travel schedules of international emergency physicians, and without established checkpoints within the fellowship, it may be difficult to foster frequent and open interaction. Future research may include finding out whether fellows actually have a formal way to give feedback and suggestions about their fellowship experience to their PD. Without the external validation of ACGME accreditation, some fellows may not feel comfortable requesting changes in their fellowship curricula. Perhaps they are concerned that they will give an impression of criticising their employer, or that such changes would put existing global relationships and funding sources at risk. Fellows with these concerns are less likely to promote original and potentially productive strategies to diversify their curriculum.
Some of the possible barriers to fulfilling core curriculum components may include: lack of funding, lack of time, lack of resources and/or networking connections, lack of enforcement by PDs. Lack of funding and/or time may be more of an issue at government-funded hospitals. Fellows at these institutions may need to work more clinical hours and thereby end up with very little time to cover core curriculum components. One solution to this problem would be lengthening the fellowship to 3 years. Lack of resources may include an absence of a school of public health or lack of established connections in the fields of the core curriculum components; for example, a programme may not have any faculty focusing on international EM system development. In this scenario, programmes with this deficiency could collaborate with other schools of public health or programmes that have faculty working in the fields in which they are lacking. The issue of lack of enforcement by PD could be solved by standardising core curriculum components for all IEM fellowships. In this case, fellowship directors and fellows would be required to submit formal documentation of completion of each core curriculum component.
While core curriculum requirements are still not formally established, the authors encourage IEM fellowship programmes to foster transparency of their curricula. Keeping curricula up to date, accurate and accessible to applicants is paramount. Diversity in training can be favourable provided that fellows are aware of what each fellowship offers prior to signing a contract. The academic IEM community should actively promote open communication among fellows, PDs and the host institution. Regular internal review of a programme by its PD, administrative assistants and coordinators, and fellows will promote the evolution and diversification of IEM fellowships. Such constructive criticism of our curricula should be encouraged.
Limitations
This study was limited by its small sample size. The field of academic IEM, and in particular IEM fellowship training, is quite specialised; thus, there are currently only 34 active programmes, most of which have only graduated a handful of fellows, many of whom have gone on to become PDs. In addition, there was an incomplete response (82% for PDs and 76% for fellows); this response rate may be explained in part by outdated contact information for fellowship graduates, and in part by the number of recent fellowship graduates who are now PDs. Also, even though we informed participants about the de-identification of data, there may be additional lingering concerns regarding lack of anonymity and potential ramifications of their responses that can contribute to some degree of information bias, especially among physicians still employed by their host institution.
Additionally, our descriptive categories ('got my feet wet', 'the perfect amount' and 'more than I needed') might have been interpreted differently by various participants and hence the answers may be affected by that element of subjectivity. Furthermore, the scoring on the Likert scale is assumed to be an interval scale; that is, equidistant points between each of the scale elements, which may not be the case. Both issues above are not specific to our study and are shared by other survey-type research. Our methodology could have been improved by asking for uniformly objective measures such as the percentage of time spent on each of the core competencies; however, such an approach may lend itself to the threat of data unavailability.
Future Directions
Other fellowship training programmes have studied whether their fellowships meet the perceived needs and objectives of physicians graduating from their programmes. Future work includes surveying graduates on whether IEM fellowships meet the perceived needs and objectives of physicians entering careers in IEM. Further study could also include surveying PDs and fellows on what barriers they feel are contributing to their not completing proposed core curriculum components.