There are currently over 30 International Emergency Medicine (IEM) and Global Emergency Medicine (GEM) Fellowship programs, with more being added every year. IEM is young enough that it is not yet a board-certified fellowship; there is no set-in-stone curriculum that governs all fellowships. Fellowship tracks are as varied as the programs that offer them. For instance, many fellowships center on an advanced degree such as a Masters in Public Health (MPH) while others incorporate formal training in tropical medicine and infectious diseases. Programs offer a variable amount of time and funding for out-of-the-country fieldwork. In addition, fellowship programs offer a wide variety of locations. Many offer multiple locations whereas a few programs focus on just one site. Most fellowship programs require fellows to work part time as clinical faculty at their teaching hospital or another affiliated hospital. If the academic track does not appeal to you, there are a few independent fellowships that offer the advantage of private Attending salary along with mentorship in international health.
The first step is to determine if the fellowship route is right for you. Spend some time clarifying your career goals. If you are interested in a career in academic medicine, a fellowship at an academic center will let you get involved in resident education and help you develop an academic niche. If your interest lies in research, a fellowship is a great way to get involved through collaboration with ongoing projects through your chosen program. Fellowship is an opportunity for networking, mentorship, and direction from IEM faculty. First-hand education from those who have experience in our unique field is priceless. IEM is still a small community where major players know each other. The personal relationships and connections you make during fellowship training will be a valuable resource for the rest of your career. During fellowship you are expected to be focused on developing international skills; this usually translates into scheduling flexibility with reduced shift load to accommodate possible degree work and international travel. Many, but not all programs, subsidize an advanced degree program and international travel, but this will rarely offset the amount of money you are giving up from working privately. Realize you may be giving up as much as $500,000 of Attending salary while completing a two-year fellowship. So the fellowship track is not a decision to be taken lightly.
In addition to the fellowship path, other options are available. Some physicians have to balance existing restrictions in location and family commitments with a desire to pursue research in global health. One option is working clinically and using your existing connections to undertake short-term international projects in your spare time. Others have opted to pursue an advanced degree, such as an MPH, while working full time. It is also possible to opt out of U.S. based clinical medicine altogether and engage with non-governmental organizations such as Medicine Sans Frontiers. The largest deficit in all these options is the lack of formalized mentorship that fellowship training is likely to offer.
If you decide you want to do a fellowship, start looking for the right program. You should begin the process of researching fellowships at least 18 months before graduation. A first step is to research programs on the online or with the aid of your existing global health mentors at your institution. Currently the application process for applying for an IEM Fellowship is more like applying for a job than for a residency position. Recently with the advent of the IEM Fellowship Consortium website (www.iemfellowships.com), the application process is improving and becoming more standardized each year.. The 2014 application season will be the second year where applicants will be able to apply using a common online application website with universal notification deadlines. The website also provides an overview of available programs and contact details for fellowship Program Directors.
Once you determine which programs interest you, you should contact the Program Directors, express your interest, and ask for more information. When you are looking at programs, note several things: length of program, clinical hours required, availability of MPH, funding of MPH (will you have to pay your own tuition?), the geographic locations of their current projects, travel funding for both the program’s projects as well as projects that you may develop on your own. All of these variables should be taken to account when you are comparing salaries. If you have a specific geographic region of interest (i.e. India, Africa, Latin America), look for programs that currently work in that part of the world to maximize opportunity. You will most likely spend a lot of your field time working on a project currently established by your potential program, as designing and completing a de-novo research project is difficult to accomplish during most two-year fellowships. Once you make contact with a program you may get a chance for a test drive by collaborating on a current project as a resident.
Create a robust application with a strong letters of recommendation. You should have your list of top potential fellowship programs narrowed down by the summer before your graduation year. Some programs will have interviews starting in September, however interview season typically extends into the fall. The acceptance notification deadlines are now uniform; details can be found on the IEM fellowship website. Each fellowship is unique and a successful experience hinges heavily on the compatibility of mutual interests and personalities between you and your fellowship Program Director. Thus it is important to represent yourself and your goals as truthfully as possible in your personal statement and during your interview day. It is also necessary to have some insight into the particular niches within global health that most interest you. You should also try to contact current and past fellows from your programs of interest. Fellows usually have a different prospective than program directors. Many of the program directors were never fellows and gained their skills from “doing international emergency medicine”. Just like residency program directors, fellowship Program Directors are trying to sell their program to a limited pool of applicants, so you may get a better picture from the fellow’s perspective.
How can I be a competitive applicant? Experience is a must. With years of medical school and residency restrictions your international experience may not be extensive, but you must have enough on your CV to show Program Directors that you know what to expect. It is great to have a specific area of interest or a region of interest, but many of us are not exactly sure what we want to do five years from now. This is what fellowship is about: to help us figure it out. At least have a vision of what you could be doing in the future with the training and experience you will gain. Program Directors are not looking for medical tourists but rather for doctors who will commit to a sustainable project; do not feel like you must have done medical work over half the globe to be considered. It will also help if you have used you residency scholarly activity or research project for international or public health. In most academic institutions publishing papers and writing grants are the currencies of advancement. If this interests you, it is important to get started while in residency. Get to know the players in IEM. Again, this is a small community. You will have a great chance to meet Program Directors if you attend IFEM, ACEP, SAEM conferences and other international symposiums. It is often hard to get a feel for the competiveness of IEM fellowships. Some of the more established fellowship programs are very competitive. That being said, if you are committed to doing an IEM fellowship, you should not have a problem getting a position. That being said, currently there are as many diverse fellowship tracks as there are programs. It is important to know want you to get out of you time and then thoughtfully seek out the best match for you.
Do I want a MPH? Many IEM Fellowship programs are focused around obtaining an MPH.. It is widely believed that since IEM is not a board-certified fellowship it is wise to have a degree to take away for you time of training. The MPH can be highly variable depending on your institution, however most programs allow you to develop an understanding of the larger issues in public health that are critical to international work. In addition, you can consider a Masters in Health Sciences (MHS) if you would like a research-focused career.
Do I want training in infectious and tropical diseases? Tropical and infectious diseases and hygiene are some of the predominate areas that cause morbidity and mortality in the developing world. Understanding unique local health ecology is essential for direct clinical care in international settings and is valuable in providing a context for policy development.
Am I interested in research? Realistically over a one- or two-year fellowship it will be very difficult to develop and complete your own independent large-scale research project, especially if IRB approval or grant funding is required. Most often you will assist in projects that are currently being performed by fellowship and institutional faculty while developing your own research and grant-writing skills.
Do I prefer clinical practice or health system development? Most fellowships are geared toward developing international leaders, policy makers, infrastructure development and research. If your interest lies primarily in clinical delivery or mission work, most often you can subsidize your training while in private practice or with independent agents. Instead of committing to a fellowship you may want to work with agencies as Doctors Without Borders, International Mission Boards or other NGOs.
Do I want to focus on another area of IEM such as EMS development or disaster relief medicine or displaced populations or maternal health? Each program will have its own flavor of IEM. Make sure to ask program directors about your special interests and whether or not they are capable of facilitating opportunities in these areas.
Do I have a specific regional interest? As mentioned before, if you have a specific region it is best to look for programs with a major presence in that area. Many programs have a specific location of cultural expertise and influence.
How much do I want to travel? Each program will vary in the amount of time and support that is dedicated to fieldwork. Fellowship programs with a MPH at the home institution tend to be lighter on travel.
What salary do I need? Salaries vary greatly and will always be less than what you earn in private practice. Make sure to take into account fringe benefits and program stipends. Completing a Masters in Public Health is expensive, so programs with a MPH may offer lower salary but may be of more value than programs that pay more yet are self-funded in regard to travel and/or educational expenses. Do not be afraid to ask about moonlighting opportunities. An IEM fellowship is a very expensive investment. Expenses for travel, conferences and classes add up quickly. If you have outstanding medical school loans and/or mortgages to pay on top of fellowship living expenses, your budget may be stretched.
Is a formal or independent fellowship the right fit for me? You may find that your career goals may be accomplished without joining a formal fellowship program. A viable option may be an independent fellowship that provides mentorship while offering better pay and standard of living.
Do I want a structured curriculum or develop my own path? Some programs are very structured in their educational curriculum and have years of experience with successful fellows. There are also programs that offer fellows a chance to formulate their own plan. There is also opportunity to help develop some of the newer programs and blaze the trail for future fellows to follow. Carefully examine your own personality and learning style and look for a program that is right for you.
We hope this summary is helpful. Having spent a lot of time and work in our fellowship search processes, we remember how overwhelming the experience can be. Good luck in your search for the right career, and—if it’s right for you—the right fellowship.
Written by: Nathan Ramsey, MD. Fellow, International Emergency Medicine, Division of Emergency Medicine, Department of Surgery, University of Texas Southwestern Medical Center
Edited by: Gabrielle A. Jacquet MD,MPH. Director, Global Health Section, Department of Emergency Medicine, Boston University School of Medicine; Steering Committee Member, IEM Fellowship Consortium; Former International Emergency Medicine and Public Health Fellow, Department of Emergency Medicine, Johns Hopkins University
Edited by: Bhakti Hansoti MBChB, MPH. Fellow, International Emergency Medicine and Public Health Fellow, Department of Emergency Medicine, Johns Hopkins University; Vice President, SAEM Global Emergency Medicine Academy