This medium duration, 6-month certificate program in Haiti, represents a novel approach to address gaps in human resources for health and can be replicated for emergency care and other new specialties in similar settings. Notably, the program improved participants’ EM knowledge and was well received by participants, the Haitian government, and the national medical school.
Critical components for success
Several structural components were critical to the program’s success. First, the engagement of the Haitian Ministry of Health and National Medical School allowed official certification of the program and facilitated participation of physicians from multiple public hospitals. Second, training physicians from throughout the country disseminated knowledge, enhanced recognition of EM as a specialty, and fostered an EM professional network.
Third, we recruited both international EPs and national non-EP specialists as program faculty. Visiting EPs were crucial for teaching core EM content and role-modeling the clinical approach to the emergency patient. For select topics, national specialists from other disciplines taught didactic content related to their expertise, with explicit guidance on learning objectives important for EPs. For example, a Haitian obstetrician-gynecologist lectured on first trimester obstetric emergencies. This involvement in the program increased recognition of EM among other specialties, and their lectures were inherently adapted to local context.
Fourth, the continuous presence and leadership of a course director was essential, facilitating coordination and real-time management of contingencies, as well as orienting international EPs to the local standards of care, knowledge level of participants, and successful teaching strategies. This allowed successive visiting faculty to maintain consistent focuses on the strengths and weaknesses of individual participants and difficult content areas. Course directors provided consistency for participants, ensuring that requirements were met and adapting the curriculum as needed.
Finally, clinical supervision and simulation were essential to the program’s success. Direct clinical supervision helped participants learn the approach to the emergency patient and apply knowledge from didactics. Topics covered briefly during didactics, such as image interpretation, were explored in depth at the bedside. Importantly, case logs facilitated clinical supervision, gave objective performance measures, and structured the relationship between participants and visiting faculty. In addition, simulation taught simultaneous stabilization, diagnosis, and treatment with a focus on low-frequency, but high-risk emergencies. Simulation also offered a safe environment for students to learn without posing risk to patients.
Areas for improvement
The program could be improved by structuring more flexibility into the curriculum to accommodate events from illnesses to unforeseen opportunities for specialist lectures. Further, some didactic areas (e.g., ECG interpretation) required more time than anticipated. Similarly, due to clinical variability during ED shifts, not all participants met the pre-specified procedure targets, and we offered flexibility in this requirement.
Future programs could group participants by baseline knowledge level; the varied baseline knowledge level among our participants necessitated adapting lectures to ensure content was appropriate for all learners. Lastly, translation provided an unexpected challenge, as the hospital English-French translators lacked sufficient medical knowledge to interpret nuanced clinical concepts. In the end, our participants provided real-time translation themselves (by those fluent in English) to maximize group education.
Regarding sustainability, our conclusion at the end of the program was that the 6-month certificate alone is not sufficient as a train-the-trainer model. While students improved their clinical EM skills—the primary objective of the course—they did not reach a level sufficient to become teachers themselves. Future iterations should consider alternate ways to develop local trainers, either by repeating the course multiple times, providing additional clinical supervision and accompaniment before or after the course, and/or pairing the certificate program with residency training, so that local residency-trained EPs could ultimately run the certificate course.
Future directions
Medium-duration certificate programs offer a novel approach to address the need for qualified emergency providers in LMICs by offering greater breadth and depth than traditional short courses while expeditiously training more providers than a residency: in the same 13 years needed to graduate 50 residency-trained EPs, an annual certificate program could train 180 providers. In most of Haiti, like many LMICs, generalist physicians with limited training provide front-line emergency care. Even though Haiti now has an EM residency program, placing specialists in remote hospitals will not be realistic anytime in the foreseeable future. Certificate-trained generalist providers could help bridge these human resource gaps. Further, this program could help link remote generalist providers to teaching hospitals where the training is run to create long-term educational support and transfer networks. For these reasons, the Haitian Ministry of Health and National Medical School have requested that the emergency certificate course be offered on an ongoing basis.
Some questions remain unanswered. Our program was designed to meet Haiti’s needs. We anticipate the content is generalizable to other LMICs, but this warrants further evaluation, as does knowledge retention after the course. Additionally, the role of a certificate program in a country with a new EM residency is undetermined. The coexistence of certificate-trained and residency-trained physicians could impact the new specialty as it seeks professionalization. Finally, this program was successful for generalist and specialist physicians with no prior EM training, over half of whom had worked in EDs for less than a year. Thus, we anticipate that this program is relevant to all physicians, particularly recent graduates and those with limited prior EM experience. The adaptability of this curriculum to other cadres of providers, such as nurses or midlevel providers, remains to be seen. However, the program’s design, covering core EM content, may allow easy modification for medical students, residents in other specialties, and/or midlevel providers to facilitate task-shifting.