166 Barriers and Facilitators to Emergency Medicine Residency Program Development in Latin America and the Caribbean

Abstract

Although EM is rapidly expanding in Latin America and the Caribbean, there has been no formal evaluation of the implementation of recently established EM training programs to guide the process in other countries. We aimed to describe the barriers and facilitators of developing an EM residency training program in Latin American and Caribbean countries to identify and disseminate the relevant “lessons learned.” Methods: Semi-structured, virtual, individual qualitative interviews with key stakeholders involved in the development of EM residency programs in Latin America and the Caribbean. Interviews were in English or Spanish, recorded and transcribed. The Consolidated Framework for Implementation Research (CFIR) guided the interview and analysis using 5 constructs applied systematically to the varying program implementations: inner setting, outer setting, individuals involved, implementation process, and intervention characteristics. Fourteen interviews were completed with physicians from Nicaragua, Guatemala, Chile, Mexico, Argentina, Haiti, Peru, and Brazil. Inner setting: Major barriers included lack of EM-trained physicians in the teaching faculty, resistance from other specialties, and lack of general support which caused feelings of isolation for the initial EM residents. Facilitators included the formation of national EM associations, cultivation of local EM-trained faculty as residents graduated, adapting curriculum to local needs, and formal feedback processes for program improvement. Outer setting: Barriers included lack of autonomy of the medical schools from the government and limited public and health system awareness of the role of EM. The COVID-19 pandemic was a facilitator as it brought recognition and legitimacy to EM due to the relevant skill sets of Emergency physicians. Financial help and additional educational opportunities from foreign organizations were helpful in some cases. Individuals involved: Key individuals served as champions who advocated for the implementation of the EM specialty and served as the catalyst for the program implementation in their countries. Some non-Emergency physicians were considered a barrier because of discouraging or luring residents away from EM. Implementation process: Barriers included lack of resources (functional equipment, textbooks), lack of program accreditation, and difficulty engaging applicants due to limited exposure of specialty. Facilitators included recognition and program approval from the Ministry of Health and “grandfathering” to establish first local EM faculty. Intervention characteristics: Barriers included the language of the available EM literature and lack of relevant language skills of the volunteer foreign EM faculty. Lack of funding to provide sufficient salary or any salary at all for the initial EM residents was another hurdle. Facilitators included funding from the government or external entities, and a curriculum document outlining EM-specific objectives enabled consistent, targeted training. Countries and organizations planning to initiate new EM training programs in Latin American and the Caribbean may benefit from the shared experience, including common barriers and facilitators to program establishment described by key stakeholders of recently developed programs in the region. Dissemination of these findings will avoid institutions “re-inventing the wheel”.