To the Editor:
As the scope of practice of wilderness medicine (WM) continues to evolve and expand, so too does the diversity of healthcare providers who express interest in completing graduate medical education (GME) fellowship opportunities in WM. Currently, 14 civilian WM fellowships are listed with the Society for Academic Emergency Medicine and the Emergency Medicine Residents’ Association.1,2 A majority of WM fellowships have only been available to graduates of residencies in emergency medicine (EM) with 2 exceptions: the Montana Family Medicine Residency has recently started a WM fellowship exclusively for family medicine (FM) graduates, sponsored by the Wilderness Medicine Society 3 ; and Madigan Army Medical Center’s Fellowship in Austere and Wilderness Medicine has included positions filled by both FM- and EM-trained military physicians since its start in 2010. 4
Following the developing trend of expanding WM fellowship eligibility beyond EM, we would like to report a successful integration of an FM-trained fellow into an existing EM-based, civilian WM fellowship at the University of California, San Francisco Fresno campus (UCSF-Fresno). We identified 2 major barriers to implementation: funding for the FM fellow and differences in training background for a FM-trained vs EM-trained fellow. To overcome the logistical challenge of funding, the FM-trained WM fellow was salaried though work in an urgent care facility (run by the emergency department) rather than shifts worked in the emergency department. In addition, a pre-fellowship gap analysis was completed to optimize the overall educational experience of the WM fellowship.
Lipman et al described the “Core Content for Wilderness Medicine Fellowship Training of Emergency Medicine Graduates,” and in doing so, stated that both fields of EM and WM share similar qualities in that they involve a broad range of medical knowledge, urgent and emergent application of diagnostic and therapeutic skills, ability to improvise in resource limited settings, and teamwork with other health care staff of varying qualifications. 5 Many of these skills are also foundational in certain primary care-oriented specialties, particularly in the field of FM. Curricular core content for all FM residents, as recommended and endorsed by both the American Academy of Family Physicians and the Accreditation Council for Graduate Medical Education (ACGME), includes “Disaster Medicine,” “Global Health,” and “Urgent and Emergent Care.”6,7 These are areas that allow development of knowledge, skills, and personal interest that can directly translate into the field of WM. With additional focus on injury prevention and accident avoidance, FM graduates often function and excel as travel consultants, particularly for those patients burdened with chronic disease. Integrating these ideas, several FM residency programs now offer elective tracks in WM, many of which are endorsed by the Wilderness Medicine Society. 8 As improvements in access and technology allow more and more people the ability to travel into austere environments each year, the demand for physicians with unique skill sets in both preventing and managing active illness in the wilderness should also increase. 9 It may therefore benefit the field of WM to expand GME fellowships to incorporate other specialties with skill sets that complement the existing core curriculum.
In August 2015, the UCSF-Fresno Emergency Medicine Residency’s Wilderness Medicine Fellowship program opened an additional GME fellowship position for an FM graduate, in addition to the existing WM fellowship for EM-trained physicians. The WM fellowship curriculum, expectations, and graduation requirements were planned to function in identical fashion for both the FM-trained and EM-trained WM fellows, with 2 major differences: First, the FM-trained fellow would work clinically in an urgent care setting, whereas the EM-trained fellow would work in the emergency department; and second, a gap analysis was performed for the FM-trained fellow to identify additional training needs.
Traditionally, EM fellow salaries are funded through clinical work in the emergency department. The FM-trained fellow is unable to function in an attending capacity in the emergency department because most shifts by attending providers in the emergency department at UCSF-Fresno involve supervision of EM residents; because the ACGME requires that EM residents be supervised by physicians who are board certified or board eligible in emergency medicine, the FM fellow cannot serve in an attending capacity in our emergency department. 10 However, the Department of Emergency Medicine at UCSF-Fresno has partnered with the Department of Family and Community Medicine to open an urgent care facility on campus that is staffed jointly by FM faculty and EM midlevel providers and faculty. Thus, the FM fellow is able to function at a fellow level in a clinical setting with supervision from the Department of Family and Community Medicine while performing fellowship activities that are identical to those of the EM-trained fellow.
From an educational standpoint, because the existing WM curriculum was developed to build from an EM background, it was not initially clear how well prepared a primary care-trained fellow would find him- or herself at the beginning of the fellowship year, what specific knowledge or skills gaps would need to be addressed, nor what curricular changes or additions would be necessary to fill these gaps. To better understand these knowledge and skills discrepancies, and in an effort to augment the WM fellowship curriculum for current and future FM-trained fellows, the first FM-trained WM fellow at UCSF-Fresno was asked to complete a self-assessment gap analysis of pre-fellowship clinical competence and knowledge as it pertains to the WM fellowship core curriculum identified by Lipman et al. 5 The gap analysis revealed several WM core content areas of strength as well as areas in need of supplemental education.
The fellow’s previous FM residency training allowed for a high degree of self-reported competence in the core areas of “expedition and travel medicine” as well as “bites, envenomations, zoonotic illnesses”—cases often encountered in an outpatient clinic. The fellow’s personal interests and prior experiences led to a high degree of preexisting knowledge in the areas of “altitude” as well as “survival and preparedness.” The core content area of “wilderness trauma” was most in need of supplemental education, particularly the procedural aspects of wilderness trauma care. This is not surprising, because trauma management is not an area of intense focus for most FM training programs. Trauma experience in FM residencies is often integrated into the 200 hours (or 2 months) of rotations through the emergency department required for FM residents by the ACGME. Some FM residents have the opportunity to gain additional trauma exposure while participating in trauma activations on a surgical service or through a trauma surgery elective or core rotation (residency program dependent). To rapidly remedy the identified cognitive and procedural deficits in trauma care, several supplemental activities were added to the FM fellow’s curriculum: completion of Advanced Trauma Life Support before starting fellowship, direct leadership and teaching of trauma skills at a 2-week medical student WM elective held 1 month into fellowship, and shadowing of trauma activations in the UCSF-Fresno emergency department. Upon completion of these activities 1 month later, the FM-trained WM fellow was asked to reassess trauma-related foundational competence, and reported significant improvement in knowledge and skill competency.
In conclusion, the successful expansion of WM fellowship opportunities for specialties outside of EM—particularly FM—is easily attainable. We used work in an urgent care facility to provide the FM fellow’s salary, as well as a pre-fellowship gap analysis followed by supplemental training as needed to optimize the fellowship experience. The competency and knowledge base of non-EM WM fellows will vary depending on their previous residency training core and elective experiences as well as pre-fellowship personal interests and experience, and it is the responsibility of both the WM fellow and fellowship faculty to augment the curriculum with additional training opportunities if needed.