International, Global EM Fellowships, International EM

Advice on Preparing for a Career Abroad

Introducing the Expert

Dr. Stephanie Kayden, MD, MPH, Chief, Division of International EM and Humanitarian Programs, Brigham and Women's Hospital, Harvard Medical School, Boston, MA

Stephanie grew up in a small town with little opportunity to travel. During her college years at Harvard, she worked as a travel writer; it was then that she decided on an international career. After completing residency at Yale, she went on to the Harvard International Emergency Medicine Fellowship, and has been happily employed in Boston ever since.

Dr. Kayden's fellowship experience has shaped many of the projects she shares with her fellows. Her work on mental and physical health in child soldiers and victims in post-conflict Liberia was one of the first studies to demonstrate a high rate of sexual violence against men in conflict zones. Today, she and her fellows have an ongoing project in Karachi, Pakistan to improve the response to local terrorist bombings, which strike on average once every three days.


Q. What types of international elective rotations do you suggest that IEM fellowship candidates do? Is your advice different for those in a residency with an established rotation versus programs without?

A. Any rotation in policy, research, or clinical work can be a positive experience. Clinical experience may be the most useful because of the health system insights it provides. If your residency offers an international program, fellowship directors will expect you to have taken advantage of those resources. If not, it could be a red flag. But don't sweat it if you are from a program without international resources. It is a positive on your application to show that you independently arranged an overseas elective despite a lack of resources. Bootstrappers like this have been some of my most successful fellows.

Q. What can I do to enhance my fellowship application?

A. As a fellowship director, I am looking for how well an applicant understands the field, and what insights they have drawn from their international experiences. All applicants should take the opportunity to speak with leaders in international emergency medicine to get an idea of what this career is like. Also, try to attend the meetings of the ACEP International Section or SAEM's Global Emergency Medicine Academy. Network there to gain a better understanding of the practice.

In your fellowship application, share any insights you have about your international experiences to display what you learned from your time abroad. What did you gather about the local health system? If you think changes are needed, why do you think they haven't already been made?

Many people ask about board score cut-offs; we don't have them. We're more interested in your drive, your demonstrated potential, and your ability to be a good ambassador for our work. During interviews I ask myself, “Is this someone who could represent us well to a foreign minister of health?” In the end, it comes down to which candidate is the best fit for our program.

Q. Can you start a project in residency that can carry over to fellowship?

A. Absolutely! It is a key skill to be able to find a project, fund it, and keep it going over time. Ask prospective fellowship directors if you can bring your own project to the fellowship, but expect few to say “no.”

Q. How can you go about getting funding for electives in residency if your program cannot provide them?

A. You may need to get creative. EMRA and the Global Emerency Medicine Academy (GEMA) offer funding opportunities, and some residency programs have seed grants. Certain departments provide funding for resident international projects. In-country costs can be very inexpensive, but the airfares are a major cost. I have seen residents build websites to ask friends and family for money; others have done moonlighting to fund their projects. For fellowship applications, add the grants you have applied for, even if you did not receive funding. It enhances your application to have written a grant proposal.

Q. What options exist for residents who want to get involved in global EM research, specifically if there aren't any projects at their residency program?

A. Global EM research is possible to do on your own, but the logistics can be difficult. Project delays, security issues, and funding challenges often derail plans. With a master's degree in public health or experience in study design, you could do an independent project, but it may need to be small in scope given the time constraints and fixed schedule of residency. It may be wise to hold off on international research until you get to fellowship. Instead, look for a high-quality research experience based at your home institution. Many of the skills you learn will carry over to international research later.

If mentorship is what you are lacking, seek out faculty at other residencies or in other departments: infectious disease, internal medicine, or public health. They can be great assets even though they are not from your specialty. Just remember to leave enough time to plan your project. You should start planning at least a year before your trip.

Q. Who should do a fellowship?

A. IEM fellowships are best for two kinds of people.

First, those who want to go into academic international emergency medicine. Fellowship is a great time to hone your research skills and develop your IEM network. Plus, there are so many IEM fellowships out there now that your future chair may wonder about someone who applies in IEM without one. There are very few academic IEM positions open each year, and the competition is fierce. Fellowships give you the time to jump-start your academic career.

Second, those who want to make a career in humanitarian work with aid agencies like Doctors Without Borders or the World Health Organization. In this case, be sure to choose a fellowship with opportunities in international relief.

Individuals who can skip the fellowship are those who want a typical emergency medicine career, but want to travel for short projects or medical missions a couple of times a year. Also, those who want to help develop emergency medicine in a single country over their careers may benefit from an MPH, but don't necessarily need to do a fellowship. The MPH will teach you about health systems and health economics in a way that is useful for EM systems builders.

Q. What statistical or research skills should be developed during residency, and what's the best way to obtain them?

A. There is no specific prerequisite for statistical or research skills; the fellowship and MPH degree will teach you those. That said, if you are working on a research project, you should understand the biostatistics needed for that project. If you do an international research project during residency, make sure you understand the project in its entirety; study design, funding, international coordination, methodology, data collection, and writing up the publication. Although it is rare for a resident to complete a whole international project from “soup to nuts” during residency, you should try to get some exposure to research, even if it's just data collection or background research for an article.

Q. Is it possible or advisable to work on foreign language learning during residency?

A. Foreign language study always helps — and I've studied quite a few – but ask yourself what your goals are. If you know you want to only work in a certain region for your entire career, it is helpful to be proficient in the native language. If your career will span multiple countries, then learning enough to be polite and to navigate your travels through each country is probably sufficient.

Rather than trying to learn every language, I believe it is better to learn how to speak English so that non-native speakers can easily understand you. Also, learn to work with translators. They will accompany you on many projects abroad, and knowing how to use them is essential to communicating well. And don't forget to read up on cultural norms and the basic history of the place you're visiting; browse the introductory pages of a good travel guide.”

Q. How does one balance the academic strength of a program with its particular geographical affiliations? For instance, if I really want to work in a particular country/countries in Africa, should I only apply to the programs that have existing affiliations there, or apply more broadly and plan to move later?

A. Geographical affiliations can change for all programs depending on project flow. If you know that you want to build your career working in a certain country and need to develop your professional network there, then the geographical affiliation can be an important consideration.

That said, the quality of the training is most critical. When applying for programs, consider how well you'll be trained to start programs, write grants, and develop a sustainable academic career. You will need to learn how to work by yourself, be proficient in your research skills, and be able to educate individuals abroad.

One of the major functions of a fellowship is establishing your professional network – this will guide where you will likely practice following residency – so building those connections is key. One of the most difficult things to find in an IEM fellowship program is a true breadth of international experiences, which is critical for those who are not quite sure what their career niche should be. With a solid skill base and broad exposure to the field, most fellows find a career path they love.

Q. Do you have any closing thoughts you would like to share with those pursuing a career in IEM?

A. Global health fellowships have changed and become more competitive, but I encourage those truly interested to apply because the experience gained can lead to a very rewarding career!