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Global health and the Royal College of Emergency Medicine: a cross-sectional survey of members and fellows
  1. Emma Fernandez1,
  2. Najeeb Rahman2,
  3. James Hayton3,
  4. Claire Crichton4,
  5. Victoria DeWitt1,
  6. Giles Cattermole5,
  7. Olivia Corn6,
  8. Shweta Gidwani7,
  9. Hooi-Ling Harrison8,
  10. Richard Lowsby9,
  11. Stevan Bruijns10
  12. On behalf of Royal College of Emergency Medicine Global Emergency Medicine committee
  1. 1 Royal College of Emergency Medicine, London, UK
  2. 2 Emergency Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  3. 3 Emergency Department, North Cumbria University Hospitals NHS Trust, Whitehaven, UK
  4. 4 Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK
  5. 5 Emergency Department, Princess Royal University Hospital, Orpington, UK
  6. 6 Emergency Department, Newham University Hospital NHS Trust, London, UK
  7. 7 Emergency Department, Chelsea and Westminster Hospital, London, UK
  8. 8 Emergency Department, King's College Hospital NHS Trust, London, UK
  9. 9 Emergency Department, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, UK
  10. 10 Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
  1. Correspondence to Dr Stevan Bruijns, Division of Emergency Medicine, University of Cape Town, Cape Town 7925, South Africa; Stevan.bruijns{at}uct.ac.za

Abstract

Background There is growing interest in global health participation among emergency care doctors in the UK. The aim of this paper was to describe the demographics of members and fellows of the Royal College of Emergency Medicine involved in global health, the work they are involved in, as well as the benefits and barriers of this work.

Methods We conducted a survey to include members and fellows of the Royal College of Emergency Medicine describing the context of their global health work, funding arrangements for global health work and perceived barriers to, and benefits of, global health work.

Results The survey collected 1134 responses of which 439 (38.7%) were excluded. The analysis was performed with the remaining 695 (61.3%) responses. Global health involvement concentrated around South Asia and Africa. Work contexts were mainly direct clinical service (267, 38%), curriculum development (203, 29%) and teaching short courses (198, 28%). Activity was largely self-funded, both international (539, 78%) and from UK (516, 74%). Global health work was not reported to contribute to appraisal by many participants (294, 42.3%). Funding (443, 64%) and protected time (431, 62%) were reported as key barriers to global health productivity.

Discussion Participants largely targeted specialty development and educational activities. Lack of training, funding and supported time were identified as barriers to development. Galvanising support for global health through regional networks and College support for attracting funding and job plan recognition will help UK-based emergency care clinicians contribute more productively to this field.

  • communications
  • education
  • emergency care systems
  • global health

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Key messages

What is already known on this subject

  • No formally recorded evidence of global health activity of fellows and members of the Royal College of Emergency Medicine exists.

  • Involvement, although assumed widespread, is anecdotal.

What this study adds

  • This study provides a narrative of global health involvement of fellows and members of the Royal College of Emergency Medicine.

  • A fair number of college fellows and members are involved in global health work.

  • Main challenges include lack of funding and recognition of global health work.

Introduction

There is growing interest in global health participation among emergency care doctors in high-income countries.1–3 Public Health England define global health as: Improving health and achieving health equity for all people worldwide—meaning working towards the absence of avoidable, unfair or remediable differences among groups of people. Several World Health Assembly resolutions have recognised the importance of emergency care globally, calling on all member states to establish an emergency care system.4 Although emergency medicine (EM) is developing rapidly as a specialty globally—with EM training programmes now established in many low/middle-income countries (LMIC)—essential emergency care services are not readily available in the majority of these settings.5 6 As emergency care encompasses a very particular skillset (highly transferable to limited-resource settings, disaster and humanitarian response) high-income countries, such as the UK are becoming more and more engaged global emergency care.6–8

The USA in particular has seen a proliferation of opportunities for global health work for emergency care doctors. This was best described through Jacquet et al’s survey of members of the Society for Academic Emergency Medicine, the American College of Emergency Physicians’ International Section and the American Academy of Emergency Medicine’s International Section.9

Anecdotally there appears to be substantial involvement of UK emergency care doctors in global health work. However, the extent of this work is not known. Other UK Royal Colleges have well developed internal structures supporting members involved in this work.10–13 A review of UK postgraduate medical curricula found very few specific global health competencies, and called for this gap to be addressed.14 Although there are well established opportunities for training in global EM in the USA, there is as yet no formal provision or recognition for this in the UK.3 15

It is unclear what the extent of global health involvement is for UK emergency care doctors. Understanding the various roles UK emergency care doctors occupy in global health and its extent can support better organisation of global health efforts. This will likely improve the UK’s global emergency care impact.

The aim of this paper was to describe the demographics of members and fellows of the Royal College of Emergency Medicine involved in global health, the global health work they are involved in, as well as the benefits of and barriers to those who participate in this work.

Methods

A survey was conducted by the Royal College of Emergency Medicine’s Global Emergency Medicine committee between 23 January 2019 and 24 February 2019 for members and fellows of the Royal College of Emergency Medicine to describe their involvement in global health. The Global Emergency Medicine committee was founded in August 2017 in order to develop and promote the College’s global health objectives.

The survey was adapted from the US survey by Jacquet et al to similarly describe the demographics of participants, the content/context of their global health work, funding arrangements for global health work, academic productivity related to global health work and perceived barriers to/benefits of global health work.9 Demographic descriptors included age, gender, job grade, Royal College of Emergency Medicine membership status, base country and country(ies) where participant is/was active in global health work. We used an age of below or over 40 to define participants with an early–mid-career interest and mid–late career interest, respectively. Content/context descriptors included: main focus and type of global health work, time spent on global health work and training for global health role(s). Funding descriptors included funding in base country and country(ies) where participant is/was active in global health work. Academic productivity descriptors included global health related publications, conference presentations, appraisal and recognition as professional activity. We also described the professional skills and competencies participants felt have improved through working in global health, as well as the perceived barriers to developing a career in global health.

The survey tool was piloted between October and December 2018 through the Royal College of Emergency Medicine’s newsletter. The introduction to the survey provided a brief explanation of global EM: emergency related activities in international settings, and an invitation for members and fellows with global emergency medicine related activities to participate (online supplementary appendix A). It was not specifically promoted in order to keep numbers low for the pilot. It was completed by 83 participants of which 32 (38.6%) were consultants, 41 (49.4%) were specialist trainees and 63 (75.9%) were based in the UK. The final survey tool required only very minor modifications from the pilot. The survey tool is included as a data supplement (online supplementary appendix A). Data collection was promoted as follows: a link to the survey was provided in the Royal College of Emergency Medicine’s newsletter which was sent to all members and fellows. The survey was promoted at regular intervals through Global Emergency Medicine committee’s Twitter and Facebook accounts. A link to the survey was sent from the Royal College of Emergency Medicine to all its members and fellows in a dedicated email promoting the survey.

Supplemental material

Since the extent of global health work within the Royal College of Emergency Medicine was not clearly defined, we decided on a convenience data collection strategy: data were collected between 23 January 2019 and 24 February 2019. We included only members or fellows (including retired) of the Royal College of Emergency Medicine who participated in the survey. We also included the members and fellows who had taken part in the pilot, given that only minor modifications were made for the final survey tool (duplicates were removed prior to analysis). Due to the open data collection strategy, we expected some non-members and fellows to participate. These entries were excluded from the sample prior to analysis. We also excluded data sets where demographics were incomplete or only the demographics section was completed.

Data were downloaded into an Office Excel (Microsoft Corporation) spreadsheet for analysis. Data are described providing counts and proportions for different categories. Important findings are highlighted using tables and figures. We did not compare groups statistically. Although we did examine subgroups, this is not described in the main results. We did not perform any inferential statistics on the sample.

Results

The survey collected 1134 responses. Of these 24 (2.1%) participants were not affiliated with the college, 370 (32.6%) participants completed only the demographic section and 45 (4.0%) provided incomplete answers. These were excluded from further analysis. The rest of the analysis was performed with the remaining 695 (61.3%) responses.

Assuming all responses included in the analysis were from participants with at least some interest in global health, responses indicated 7.5% (695 responses/9314 members) global health participation, interest or involvement of participants with a College affiliation (assuming the college membership numbers described in table 1). There were 215 (30.9%) participants who described current involvement in a global health project, and 152 (21.9%) participants who are not; 328 (47.2%) participants did not answer this question.

Table 1

Key demographics of included survey participants as n (%)

Demographic descriptors are provided in table 1 and figure 1.

Figure 1

Map of countries where fellows and members are involved in global health projects.

Figure 1 provides a map, indicating countries where fellows and members are involved in global health projects.

Figure 2 describes participants’ main global health focus and the main type of global health activities engaged in.

Figure 2

(A) Participants’ main global health focus. (B) The main type of global health activities engaged in.

There were 85 (12.2%) participants who indicated they spent more than 12 months outside the UK engaged in global health work over the past 5 years, 46 (6.6%) who spent 6–11 months, 32 (4.6%) who spent 3–6 months, 51 (7.3%) who spent 1–3 months, 58 (8.3%) who spent 2–4 weeks and 54 (7.8%) who spent <2 weeks. There were 337 (48.5%) participants who spent no time outside the UK engaged in global health work over the past 5 years; 32 (4.6%) participants did not answer the question.

There were 49 (7.1%) participants who indicated they spend more than 8 hours per week engaged in global health work, 17 (2.4%) who spend 4–8 hours per week, 91 (13.1) who spend 1–4 hours per week and 217 (31.2%) who spend less than 1 hour per week. There were 286 (41.2%) who spend no time per week engaged in global health work; 35 (5.0%) participants did not answer the question.

There were 149 (21.4%) participants who indicated that they have undertaken training in global health, while 38 (5.5%) indicated that they have not and 508 (73.1%) did not answer the question.

Figure 3 describes the main sources of funding for global health outside the UK work as specified by participants and the main sources of funding for global health work in base (home) country.

Figure 3

(A) The main sources of funding for global health work outside the UK as specified by participants. (B) The main sources of funding for global health work from base (home) country. NGO, Non-governmental organisation.

There were 73 (10.5%) participants who had contributed towards at least one peer-reviewed article, 98 (14.1%) who had presented at least one abstract/poster, 171 (24.6%) who had presented at least one lecture, 127 (18.3%) who had contributed to at least one project outside the UK, 52 (7.5%) who had been successful in raising external funding for at least one project related to global health. There were 44 (6.3%) participants who listed other activities and 133 (19.1%) who indicated the question did not apply to them; 249 (35.8%) participants did not answer the question.

There were 219 (31.5%) participants who indicated that global health contributed to their academic productivity, of which 113 (16.3%) felt that it contributed significantly; 62 (8.9%) participants did not answer the question. There were 221 (31.8%) participants who indicated that global health contributed to their annual appraisal and continuing professional development, of which 76 (10.9%) felt that it contributed significantly; 65 (9.4%) participants did not answer the question.

There were 237 (34.1%) participants who indicated that their career progression benefited from their global health work, 23 (3.3%) who felt global health work detracted from their career progression and 308 (44.3%) who felt global health work neither benefited or detracted from their career progression; 127 (18.3%) participants did not answer the question.

Figure 4 describes the professional skills and competencies participants felt have improved through working in global health, the perceived barriers to developing a career in global health and desired College support for global health related activities.

Figure 4

(A) Professional skills and competencies participants felt have improved through working in global health, (B) the perceived barriers to developing a career in global health and (C) desired College support for global health related activities.

There were 364 (52.4%) participants who would like to see global health activity as a key focus of Royal College of Emergency Medicine activity; 233 (33.5%) participants did not answer the question. There were 215 (30.9%) participants who would be willing to contribute towards global health activities outside the UK by subscribing to a 5% levy to their annual membership fees; 280 (40.3%) participants did not answer the question.

Discussion

Most global health involvement of members and fellows of the Royal College of Emergency Medicine is in South Asia and Africa, perhaps reflecting the UK’s Commonwealth history and links (including the number of clinicians with a South Asian and African background working in the UK).16 The majority of respondents were involved in specialty development and educational activities. Remarkably, only a small proportion reported having completed any relevant training. Global health involvement was largely self-funded. Lack of funding and lack of protected time from base institutions were cited as key barriers to global health work. There is very little literature describing the involvement of emergency physicians in global health related work. Jacquet’s survey of US emergency physicians drew very similar conclusions to ours.6 Despite the size of the societies surveyed, its findings were based on 116 responses—smaller than ours. Similarly to our findings, lack of time and funding were most commonly cited barriers to a career in global health (64% and 55%, respectively). Self-funding was also cited as the most common source of funding (47%), with 16% of their respondents receiving grant support. Our survey suggests even greater reliance on self-funding.

The survey revealed a fair level of UK emergency care clinician involvement in global health, across a wide breadth of activities. It is also helpful to note that a fair number of participants saw global health work as beneficial to their career. Increased College support for global EM was supported by half of respondents.

A number of concerns are highlighted. There is relatively little training. Whether this is due to respondents not recognising a need to be trained, or a perceived lack of opportunities for training, is not clear. There is a growing global awareness of the need for appropriate global health training.4 15 The College is in a unique position to encourage, recognise and provide global health training, as well as support, network and publicise global health opportunities. Existing College member global health involvement in fair numbers suggest human capital is already available to kickstart networking, mentoring and training in global EM.

Respondents reported little funding. For global EM to develop, funding sources will need to be more accessible. Although respondents were evenly split on recommending a 5% levy on college membership fees to allow direct sponsorship, the College do wield soft power elsewhere. Academic and government grants are available; the College can assist by promoting these to members and lobby appropriate agencies for further grants. The College is also in a position to encourage NHS Trusts to provide opportunities such as recognised fellowships in global EM. These would enable members to develop their global EM interest in parallel to their NHS careers.17

There were several limitations with this survey. There was a large proportion of participants who started the survey but either stopped after the demographic section or provided incomplete answers. It is unclear why this is the case, although our best guess is that these were participants who stopped participating once they realised the survey did not apply to them. The alternative is that these were participants that the survey did apply to, but failed to complete it nonetheless. Future surveys should provide a clearer introduction to avoid participant error. Although we saw it as a strength to survey members and fellows of the Royal College of Emergency Medicine (the UK’s only representative body of emergency care clinicians) there may be many physicians working in emergency care in the UK who are not registered with the College, such as junior trainees, non-training grades or doctors recently arrived from outside the UK. It is also possible that membership currently includes those who are no longer involved in EM, or who have never been based in the UK. This study, therefore, is a survey of College membership, rather than of specifically UK emergency care clinicians. An open invitation to participate in the survey allowed non-members to respond. Only a small proportion of respondents were identified as not having affiliation with the College, and these were excluded. However, as the survey relied on self-reporting, some non-members may have been included. In the same vein, self-reporting may have affected the accuracy of responses, with participants overstating or understating their situation. Dependence on a web-based form is also a limitation, and may have excluded those working in areas with limited or non-existent internet connections—quite possible some of the very participants sought to be included. The response rate was low; that said, those uninterested in global health were less likely to complete the survey. Still, without knowing how many members are interested in global health, it is impossible to know whether the response rate was representative. Even so, this survey provides the best data on the topic to date. The College now records global health as a special interest during registration. Arguably, seeing how many members have not updated age or gender information this is likely to be a low-yielding strategy. The Global Emergency Committee’s ambitious plan to create regional networks throughout the UK for interested emergency care clinicians irrespective of College affiliation is likely to be a more productive pursuit.

Conclusion

There appears to be a fair amount of interest in global health work within the Royal College of Emergency Medicine. Global health involvement appears focused around South Asia and Africa, with participants largely targeting specialty development and educational activities. Lack of training, funding and supported time were identified as neglected areas for development. Galvanising support for global health through regional UK networks and College support for attracting funding and job plan recognition will help UK emergency care clinicians contribute more productively to this field. Future projects for the Global Emergency Medicine committee should include describing, mapping and linking up existing global health projects from mutual geographical locations, promoting and supporting global health careers (including portfolio careers, fellowships and so on), creating guidance for global health volunteering, and informing both undergraduate and postgraduate UK curricula.

Acknowledgments

The authors would like to acknowledge Christopher Wesley who created figure 1.

References

Footnotes

  • Handling editor Richard Body

  • Twitter @NajeebR777, @codingbrown

  • Contributors Substantial contributions from authors included the conception and design of the work (EF, NR, JH, CC and SB), the acquisition (VDW), analysis (EF and SB), interpretation of data for the work (all authors). SB wrote the first draft. All authors revised it critically for important intellectual content. All authors approved the version submitted to be published. All authors agreed to be accountable for all aspects of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Map disclaimer The depiction of boundaries on the map(s) in this article does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are available upon reasonable request.