AuthorKendra Arriaga Castellanos
Breena Taira, MD, MPH
Leo Alonso, DO; Aristides Orue, NP; Orlando Morales, MD; Hemang Acharya, MD
Barriers and Facilitators to Emergency Medicine Residency Program Development in Latin America and The Caribbean
Global Short-Term Training Program
Other Program (if not listed above)
Emergency Medicine (EM) is rapidly growing specialty in Central America; countries such as Costa Rica, Guatemala, and Nicaragua have introduced EM residency programs within the last 20 years. Amidst the COVID-19 pandemic, the need for emergency care has been magnified and stakeholders in Honduras are interested in investing in the development of the EM specialty within their healthcare system. Although EM is rapidly expanding in Latin America, there has been no formal evaluation of the implementation of recently established EM training programs to guide the process in Honduras.
We aim to describe the barriers and facilitators of developing an EM training program within Latin American and Caribbean countries to identify and disseminate the relevant “lessons learned.” The information will be used to guide development of the EM residency in Honduras and disseminated for use in other Latin American or Caribbean universities seeking to establish EM training programs.
Study Design: We conducted semi-structured, virtual, individual qualitative interviews with emergency physicians and other key stakeholders involved in the development of EM residency programs in countries across Latin America, with an emphasis on Central American countries.
Participants: Potential participants were identified via snowball sampling leveraging initial contacts through members of the American College of Emergency Physician (ACEP) International Ambassador program, Asociación Nicaragüense de Medicina de Emergencia (ANME), and Federación Latinoamérica de Medicina de Emergencias (FLAME).
Process: Interviews were performed according to a preconstructed interview guide in either Spanish or English based on the preference of the participant. Interviews were recorded, transcribed, and checked for accuracy. Analysis took place in the original interview language. A subset of interviews was team-coded to establish the code book.
Analysis: We chose the Consolidated Framework for Implementation Research (CFIR) to design the interview guide and establish the deductive approach to the data. Data was analyzed using Atlas.ti Cloud. The Consolidated Framework for Implementation Research (CFIR) provided a systemic approach to identifying barriers and facilitators within five major categories of novel program implementation: inner setting, outer setting, individuals involved, implementation process, and intervention characteristics.
Ten interviews have been completed and analyzed, including four participants from Nicaragua, one from Guatemala, one from Chile, one from Mexico, one from Argentina, and two from Haiti. While we are still in the process of analyzing completed interviews, several themes have been identified as barriers and facilitators in the five major implementation categories defined by the CFIR framework.
Inner setting: Across all countries, a major barrier is a lack of EM-trained physicians within the teaching faculty. Additional issues arise from resistance from other specialties, and lack of general acceptance and support which may lead to feelings of isolation for the EM residents. In contrast, facilitators in the inner setting include formation of national EM associations, growth of local EM-trained faculty as residents graduate and take on teaching roles, adapting curriculum models to local needs, and formal feedback processes for program improvement.
Outer setting: Barriers stemmed from lack of autonomy from the government (such as the Ministry of Health) and limited public and health system awareness of the role of EM as a specialty. The COVID-19 pandemic has served as facilitator in the outer setting as it brought recognition and legitimacy to EM as a specialty because of the relevant skill sets of EM physicians. Financial help and additional educational opportunities from foreign organizations also served as a facilitator.
Individuals involved: although key individuals served as champions who advocated for the implementation of the EM specialty and were the catalyst for the program implementation in their respective countries, other individuals (such as non-EM physicians) also served as a barrier to the growth of EM by attempting to discourage or lure residents away from this novel specialty.
Implementation process: Lack of resources (functional equipment, EM-trained faculty, textbooks and other literature in residents’ language), lack of program accreditation from government at the time of the program’s initiation, and minimal engagement of teaching staff and applicants due to limited exposure of specialty. Facilitators in the implementation process included recognition and program approval from the Ministry of Health and the “grandfathering” process to establish first local EM faculty.
Intervention characteristics: Participants identified language barriers as major obstacles, both with the available literature and foreign EM physicians that served as faculty. Providing the residents a sufficient salary, or sometimes providing any salary, was difficult for the new programs . For other EM residency programs, funding from the government or external entities, such as foreign or private organizations, was a substantial facilitator. Additionally, a curriculum document outlining EM-specific objectives to both the residents and faculty enabled consistent, targeted training for the EM residents.
Although each program had their unique barriers, there were common threads among the analyzed interviews that identified significant common themes that should be considered when developing a new EM residency program within Latin America and the Caribbean. These themes include the absence of stable, EM-trained faculty at the time of the program’s onset; the need for appropriate language-based resources; the importance of social and financial support from the government, external organizations, or individuals; and facilitation of the growth of EM development by establishing EM associations and growing public awareness of the specialty.
Future Directions: We will continue interviewing until thematic saturation is reached. We plan to develop a report of “lessons learned” to guide the implementation of future EM training programs that will be open access and available in both Spanish and English.