Lessons learned from international emergency medicine development

Impact of a 1-Year Pediatric Emergency Medicine Training Program for International Medical Graduates

OBJECTIVES

The Hospital for Sick Children in Toronto has offered a 1-year subspecialty residency training program in pediatric emergency medicine (PEM) to Canadian and internationally trained pediatricians and emergency physicians since 1993. The program is intended to support clinical service delivery while simultaneously offering a unique educational opportunity to Canadian and international physicians who desire 1 year of clinically focused training. We describe the experiences and career outcomes of participants who completed this program.

METHODS

Two surveys were sent to the 68 individuals who completed the clinical fellowship program from its inception in 1993 until 2014. A blinded survey focused on the fellowship experience and subsequent career activities. A nonblinded survey subsequently determined whether participants had served as a medical director or training program director.

RESULTS

Sixty of the 68 participants (88%) completed the blinded survey. Ninety-one percent were in practice in emergency medicine. Twenty-five percent of the participants were living in Canada, compared with 17% before completing the program. This net migration of 8% was not significant (P = 0.26). Thirty-six of the 50 participants (72%) who applied from outside Canada responded to the nonanonymous survey; 18 (50%) had served as an emergency department medical director, and 18 (50%) reported serving as a PEM training program director.

CONCLUSIONS

Many participants attained leadership positions in PEM in countries outside of North America and/or participated in training program development. There was no significant change in the proportion of participants living in North America at the time of application compared with the time of survey completion.

Emergency Medicine Around the World: Analysis of the 2019 American College of Emergency Physicians International Ambassador Country Reports

OBJECTIVE

The specialty of emergency medicine and recognition of the need for emergency care continue to grow globally. The specialty and emergency care systems vary according to context. This study characterizes the specialty of emergency medicine around the world, trends according to region and income level, and challenges for the specialty.

METHODS

We distributed a 56-question electronic survey to all members of the American College of Emergency Physicians International Ambassador Program between March 2019 and January 2020. The Ambassador Program leadership designed the survey covering specialty recognition, workforce, system components, and emergency medicine training. We analyzed results by country and in aggregate using SAS software (SAS Institute Inc). We tested the associations between World Bank income group and number of emergency medicine residency-trained physicians (RTPs) and emergency medicine specialty recognition using non-parametric Fisher's exact testing. We performed inductive coding of qualitative data for themes.

RESULTS

Sixty-three out of 78 countries' teams (80%) responded to the survey. Response countries represented roughly 67% of the world's population and included countries in all World Bank income groups. Fifty-four countries (86%) recognized emergency medicine as a specialty. Ten (16%) had no emergency medicine residency programs, and 19 (30%) had only one. Eight (11%) reported having no emergency medicine RTPs and 30 (48%) had <100. Fifty-seven (90%) had an emergency medical services (EMS) system, and 52 (83%) had an emergency access number. Higher country income was associated with a higher number of emergency medicine RTPs per capita (P = 0.02). Only 6 countries (8%) had >5 emergency medicine RTPs per 100,000 population, all high income. All 5 low-income countries in the sample had <2 emergency medicine RTPs per 100,000 population. Challenges in emergency medicine development included lack of resources (38%), burnout and poor working conditions (31%), and low salaries (23%).

CONCLUSIONS

Most surveyed countries recognized emergency medicine as a specialty. However, numbers of emergency medicine RTPs were small, particularly in lower income countries. Most surveyed countries reported an EMS system and emergency access number. Lack of resources, burnout, and poor pay were major threats to emergency medicine growth.

A Framework for Standardizing Emergency Nursing Education and Training Across a Regional Health Care System: Programming, Planning, and Development via International Collaboration

INTRODUCTION

The challenges related to providing continuing education and competence management for emergency nurses are not unique to any one organization, health system, or geographic location. These shared challenges, along with a desire to ensure high-quality practice of emergency nursing, were the catalyst for an international collaboration between emergency nurse leaders in Region Zealand, Denmark, and nurse leaders and educators from a large academic medical center in Boston, Massachusetts. The goal of the collaboration was to design a competency-based education framework to support high-quality emergency nursing care in Region Zealand. The core objectives of the collaboration included the following: (1) elevation of nursing practice, (2) development of a sustainable continuing education framework, and (3) standardization of training and nursing practice across the 4 emergency departments in Region Zealand.

METHODS

To accomplish the core objectives, a multi-phased strategic approach was implemented. The initial phase, the needs assessment, included semi-structured interviews, a self-evaluation of skills of all regional emergency nurses, and a survey regarding nursing competency completed by emergency nurse leadership. Two hundred ninety emergency nurses completed the self-evaluation. The survey results were utilized to inform the strategic planning and design of a regional competency-based education framework.

RESULTS

In 18 months, and through an international collaboration, emergency nursing education, training, and evaluation tools were developed and integrated into the 4 regional emergency departments. Initial feedback indicates that the education has had a positive impact. The annual competency day program has continued through 2021 and is now fully institutionalized within the regional emergency nursing continuing education program. Furthermore, use of this innovative education framework has expanded beyond the emergency department to other regional nursing specialties.

DISCUSSION AND CONCLUSION

Through this unique collaboration with regional and international participants, a sustainable, regional emergency nursing education program was developed that has elevated and standardized the practice of emergency nurses in Region Zealand, Denmark. This program development can serve as a model for region-wide or health care system-wide collaborations in other countries.

Emergency Medicine Training Programs in Low- and Middle-Income Countries: A Systematic Review

Background

Despite the growing interest in the development of emergency care systems and emergency medicine (EM) as a specialty globally, there still exists a significant gap between the need for and the provision of emergency care by specialty trained providers. Many efforts to date to expand the practice of EM have focused on programs developed through partnerships between higher- and lower-resource settings.

Objective

To systematically review the literature to evaluate the composition of EM training programs in low- and middle-income countries (LMICs) developed through partnerships.

Methods

An electronic search was conducted using four databases for manuscripts on EM training programs - defined as structured education and/or training in the methods, procedures, and techniques of acute or emergency care - developed through partnerships. The search produced 7702 results. Using a priori inclusion and exclusion criteria, 94 manuscripts were included. After scoring these manuscripts, a more in-depth examination of 26 of the high-scoring manuscripts was conducted.

Findings

Fifteen highlight programs with a focus on specific EM content (i.e. ultrasound) and 11 cover EM programs with broader scopes. All outline programs with diverse curricula and varied educational and evaluative methods spanning from short courses to full residency programs, and they target learners from medical students and nurses to mid-level providers and physicians. Challenges of EM program development through partnerships include local adaptation of international materials; addressing the local culture(s) of learning, assessment, and practice; evaluation of impact; sustainability; and funding.

Conclusions

Overall, this review describes a diverse group of programs that have been or are currently being implemented through partnerships. Additionally, it highlights several areas for program development, including addressing other topic areas within EM beyond trauma and ultrasound and evaluating outcomes beyond the level of the learner. These steps to develop effective programs will further the advancement of EM as a specialty and enhance the development of effective emergency care systems globally.

Position within the hospital and role in the emergency department of emergency physicians in the Netherlands: a national survey

Objectives

Emergency medicine (EM) in the Netherlands has developed rapidly and initially without central guidance. This has led to heterogeneity in current EM practice. Our aim was to quantify this heterogeneity by answering the following questions: (1) What is the current position of emergency physicians (EPs) within hospital organizations? (2) Which roles and responsibilities do EPs have across emergency departments (EDs)?

Methods

During 2018, we conducted a survey among all EM consultant bodies (CBs, n = 56) in the Netherlands. Data was analyzed using descriptive statistics.

Results

The response rate was 91.1%. Presence of EPs has been realized 24/7 in 23.1% of EDs. EPs were the main consultants for all ED patients in 9.8% of CBs, but never had this role in 13.7% of CBs. EPs supervised EM junior doctors in 78.5% of EDs, GPs in training in 80.0% of EDs, and junior doctors of other specialties in 41.5% of EDs. Procedures such as lumbar puncture (LP), procedural sedation and analgesia (PSA), and emergency ultrasound (US) were performed by all EPs in the CB in a range between 5.9 and 78.4%. In 36.9% of EDs, EPs did not analyze patients with presumed cardiac pathology due to a separate First Heart Aid.

Conclusion

We conclude that there is a high degree of heterogeneity between emergency CBs in regard to the position in the hospital and the role or responsibilities in the ED. Lack of uniformity might inhibit emancipation of the profession.

Towards developing a consensus assessment framework for global emergency medicine fellowships

Background

The number of Global Emergency Medicine (GEM) Fellowship training programs are increasing worldwide. Despite the increasing number of GEM fellowships, there is not an agreed upon approach for assessment of GEM trainees.

Main body

In order to study the lack of standardized assessment in GEM fellowship training, a working group was established between the International EM Fellowship Consortium (IEMFC) and the International Federation for Emergency Medicine (IFEM). A needs assessment survey of IEMFC members and a review were undertaken to identify assessment tools currently in use by GEM fellowship programs; what relevant frameworks exist; and common elements used by programs with a wide diversity of emphases. A consensus framework was developed through iterative working group discussions. Thirty-two of 40 GEM fellowships responded (80% response). There is variability in the use and format of formal assessment between programs. Thirty programs reported training GEM fellows in the last 3 years (94%). Eighteen (56%) reported only informal assessments of trainees. Twenty-seven (84%) reported regular meetings for assessment of trainees. Eleven (34%) reported use of a structured assessment of any sort for GEM fellows and, of these, only 2 (18%) used validated instruments modified from general EM residency assessment tools. Only 3 (27%) programs reported incorporation of formal written feedback from partners in other countries. Using these results along with a review of the available assessment tools in GEM the working group developed a set of principles to guide GEM fellowship assessments along with a sample assessment for use by GEM fellowship programs seeking to create their own customized assessments.

Conclusion

There are currently no widely used assessment frameworks for GEM fellowship training. The working group made recommendations for developing standardized assessments aligned with competencies defined by the programs, that characterize goals and objectives of training, and document progress of trainees towards achieving those goals. Frameworks used should include perspectives of multiple stakeholders including partners in other countries where trainees conduct field work. Future work may evaluate the usability, validity and reliability of assessment frameworks in GEM fellowship training.

Bystander Assistance for Trauma Victims in Low- and Middle-Income Countries: A Systematic Review of Prevalence and Training Interventions

OBJECTIVE

Lack of organized prehospital care may contribute to the disproportionate burden of trauma-related deaths in low- and middle-income countries (LMICs). The World Health Organization (WHO) recommends bystander training in basic principles of first aid and victim transport; however, prevalence of bystander or layperson assistance to trauma victims in LMICs has not been well-described, and organized reviews of existing evidence for bystander training are lacking. This systematic review aims to 1) describe the prevalence of bystander or layperson aid or transport for trauma victims in the prehospital setting in LMICs and 2) ascertain impacts of bystander training interventions in these settings.

METHODS

A systematic search of OVID Medline, Cochrane Library, and relevant gray literature was conducted. We included 1) all studies detailing prevalence of bystander-administered aid or transport for trauma victims in LMICs and 2) all randomized controlled trials and observational studies evaluating bystander training interventions. We extracted study characteristics, interventions, and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Sixty-two studies detailed prevalence of bystander transport and aid. Family members, police, and bus or taxi drivers commonly transported patients; a majority of patients, up to >94%, received aid from bystanders. Twenty-four studies examined impacts of training interventions. Only one study looked at transport interventions; the remainder addressed first aid training. Interventions varied in content, duration, and target learners. Evidence was generally of low quality, but all studies demonstrated improvements in layperson knowledge and skills. Five studies reported a mortality reduction.

CONCLUSIONS

Heterogeneity in data reporting and outcomes limited formal meta-analysis. However, this review shows high rates of bystander involvement in prehospital trauma care and transport in LMICs and highlights the need for bystander training. Bystander training in these settings is feasible and may have an important impact on meaningful outcomes such as mortality. Categories of involved bystanders varied by region and training interventions should be targeted at relevant groups. "Train the trainer" models appear promising in securing community engagement and maximizing participation. Further research is needed to examine the value of bystander transport networks in trauma.

The train the trainer model for the propagation of resuscitation knowledge in limited resource settings: A systematic review

BACKGROUND

The Train the Trainer (TTT) model is increasingly used in limited resource settings as a mechanism to disseminate resuscitation knowledge and skills among providers. Anecdotally, however, many resuscitation programs that use this model fail to achieve sustainability.

OBJECTIVE

We aim to systematically review the literature to describe the evidence for the TTT method of knowledge dissemination for resuscitation courses in limited resource settings.

METHODS

We conducted a systematic review of the literature in accordance with PRISMA guidelines of the PubMed, Cochrane Library, MEDLARS online (MEDLINE), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases.

RESULTS

Eleven manuscripts met inclusion criteria, the majority (7/11) focused on neonatal resuscitation. We found strong evidence for the TTT model for imparting knowledge and skills on providers, however, little evidence exists for the impact of these programs on patient outcomes or long term sustainability. Facilitators associated with successful programming include the use of language and resource appropriate materials, support from the Ministry of Health of the country, and economic support for supplies and salaries.

CONCLUSION

While the TTT model of programming for the dissemination of resuscitation education is promising, further research is necessary especially relating to sustainability and impact on patient outcomes. Familiarity with the local environment, language, culture, resources and economic realities prior to the initiation of programming is key to success.

Postgraduate Emergency Medicine Training in India: An Educational Partnership with the Private Sector

BACKGROUND

Emergency medicine (EM) is a recently recognized specialty in India, still in its infancy. Local training programs are developing, but remain very limited. Private, for-profit hospitals are an important provider of graduate medical education (GME) in India, and are partnering with United States (US) universities in EM to expand training opportunities.

OBJECTIVE

Our aim was to describe current private-sector programs affiliated with a US university providing postgraduate EM training in India, the evolution and structure of these programs, and successes and challenges of program implementation.

DISCUSSION

Programs have been established in seven cities in India in partnership with a US academic institution. Full-time trainees have required didactics, clinical rotations, research, and annual examinations. Faculty members affiliated with the US institution visit each program monthly. Regular evaluations have informed program modifications, and a local faculty development program has been implemented. Currently, 240 trainees are enrolled in the EM postgraduate program, and 141 physicians have graduated. A pilot survey conducted in 2012 revealed that 93% of graduates are currently practicing EM, 82% of those in India; 71% are involved in teaching, and 32% in research. Further investigation into programmatic impacts is necessary. Challenges include issues of formal program recognition both in India and abroad.

CONCLUSIONS

This unique partnership is playing a major early role in EM GME in India. Future steps include official program recognition, expanded numbers of training sites, and a gradual transition of training and education to local faculty. Similar partnership programs may be effective in other settings outside of India.

The development of sustainable emergency care in ghana: physician, nursing and prehospital care training initiatives

BACKGROUND

Ghana's first Emergency Medicine residency and nursing training programs were initiated in 2009 and 2010, respectively, at Komfo Anokye Teaching Hospital in the city of Kumasi in association with Kwame Nkrumah University of Science and Technology and the Universities of Michigan and Utah. In addition, the National Ambulance Service was commissioned initially in 2004 and has developed to include both prehospital transport services in all regions of the country and Emergency Medical Technician training. Over a decade of domestic and international partnership has focused on making improvements in emergency care at a variety of institutional levels, culminating in the establishment of comprehensive emergency care training programs.

OBJECTIVE

We describe the history and status of novel postgraduate emergency physician, nurse, and prehospital provider training programs as well as the prospect of creating a board certification process and formal continuing education program for practicing emergency physicians.

DISCUSSION

Significant strides have been made in the development of emergency care and training in Ghana over the last decade, resulting in the first group of Specialist-level emergency physicians as of late 2012, as well as development of accredited emergency nursing curricula and continued expansion of a national Emergency Medical Service.

CONCLUSION

This work represents a significant move toward in-country development of sustainable, interdisciplinary, team-based emergency provider training programs designed to retain skilled health care workers in Ghana and may serve as a model for similar developing nations.

Creating change through collaboration: a twinning partnership to strengthen emergency medicine at Addis Ababa University/Tikur Anbessa Specialized Hospital--a model for international medical education partnerships

BACKGROUND

Morbidity and mortality due to the lack of an organized emergency medical care system are currently high in Ethiopia. Doctors, nurses, and other medical staff often have limited or no formal training on how to handle emergencies. Because of insufficient human and resource capacity needed to assess and treat acutely ill patients, many who are injured may die unnecessarily, at the site of injury, during transport, or at the hospital.

OBJECTIVES

This article describes the development of a twinning partnership between Addis Ababa University (AAU), the University of Wisconsin-Madison (UW), and the nonprofit organization People to People (P2P), to strengthen emergency care at Tikur Anbessa Specialized Hospital (TASH) and increase the number of trained emergency medical professionals.

METHODS

The partnership applied the six-phase twinning partnership model, with the overall goal of enhancing and strengthening emergency and trauma care by building institutional and human resource capacity. This was achieved by 1) developing local leaders in emergency medicine (EM), 2) creating training modules adapted to the Ethiopian context, 3) launching an emergency training center, and 4) supporting academic program development. The authors evaluated the program's effectiveness based on our achievements toward these goals.

RESULTS

Results include: 1) eight Ethiopian faculty completed a condensed EM fellowship in the United States. Now six Ethiopian physicians serve as EM faculty and two as pediatric EM faculty. 2) Nine emergency training modules were adapted to the Ethiopian context. 3) An emergency training center was opened in 2010 and to date has trained over 4,000 Ethiopian medical professionals. 4) Two academic training programs (EM residency and masters nursing programs) were initiated.

CONCLUSIONS

With many complex factors affecting the burden of emergency care, innovative and interdisciplinary collaborations are needed in Ethiopia to train medical workers, build local leadership capacity, strengthen infrastructure, and inform policies. The short-term achievements of this twinning model could suggest that long-term, institution-to-institution collaborations that are driven by local stakeholders are an effective strategy to create equitable relationships and build sustainable health systems and may serve as a model for other global health partnerships.

The effectiveness of a 'train the trainer' model of resuscitation education for rural peripheral hospital doctors in Sri Lanka

BACKGROUND

Sri Lankan rural doctors based in isolated peripheral hospitals routinely resuscitate critically ill patients but have difficulty accessing training. We tested a train-the-trainer model that could be utilised in isolated rural hospitals.

METHODS

Eight selected rural hospital non-specialist doctors attended a 2-day instructor course. These "trained trainers" educated their colleagues in advanced cardiac life support at peripheral hospital workshops and we tested their students in resuscitation knowledge and skills pre and post training, and at 6- and 12-weeks. Knowledge was assessed through 30 multiple choice questions (MCQ), and resuscitation skills were assessed by performance in a video recorded simulated scenario of a cardiac arrest using a Resuci Anne Skill Trainer mannequin.

RESULTS/DISCUSSION/CONCLUSION

Fifty seven doctors were trained. Pre and post training assessment was possible in 51 participants, and 6-week and 12-week follow up was possible for 43, and 38 participants respectively. Mean MCQ scores significantly improved over time (p<0.001), and a significant improvement was noted in "average ventilation volume", "compression count", and "compressions with no error", "adequate depth", "average depth", and "compression rate" (p<0.01). The proportion of participants with compression depth ≥40mm increased post intervention (p<0.05) and at 12-week follow up (p<0.05), and proportion of ventilation volumes between 400-1000mls increased post intervention (p<0.001). A significant increase in the proportion of participants who "checked for responsiveness", "opened the airway", "performed a breathing check", who used the "correct compression ratio", and who used an "appropriate facemask technique" was also noted (p<0.001). A train-the-trainer model of resuscitation education was effective in improving resuscitation knowledge and skills in Sri Lankan rural peripheral hospital doctors. Improvement was sustained to 12 weeks for most components of resuscitation knowledge and skills. Further research is needed to identify which components of training are most effective in leading to sustained improvement in resuscitation.

Effective teaching and feedback skills for international emergency medicine "train the trainers" programs

BACKGROUND

As the specialty of Emergency Medicine (EM) develops around the world, it has become common for practitioners from countries with mature EM systems to assist those in regions with developing systems. One effective and frequently used model is "train the trainers," in which a group of consultant teachers instructs a cadre of clinicians in the host region to then become the future teachers of EM in that area. This model has the advantage of overcoming cultural barriers to instruction and can lead to providing a lasting training infrastructure in the region. A key to a successful program is the use of effective and culturally appropriate teaching and feedback skills.

OBJECTIVES

The goal of this article is to bring together experts in adult education with experts in training in the international setting to present teaching and feedback skills and how they can be applied in different settings and cultures.

DISCUSSION

Cutting edge instruction and evaluation techniques that can be employed in intercultural "train the trainers" programs will be presented. The characteristics of successful programs, using specifics from actual programs, will also be shared.

CONCLUSION

Applying the described teaching and evaluation skills with modifications based on local culture will help empower newly trained teachers who will contribute in turn to the longevity of EM in the region and set a high teaching standard that will benefit generations of future colleagues.

Academic emergency medicine in India

OBJECTIVES

Emergency medicine (EM) was recognized as a specialty by the Medical Council of India (MCI) in July 2009. As India undergoes urbanisation, cost-effective transition from managing infectious diseases to emergency management of trauma and cardio-respiratory diseases is crucial. Trained emergency healthcare workers are needed to respond effectively to these challenges. The objective was to determine the current status of academic EM training and related issues in India, and to discuss those that need to be addressed.

METHODS

The authors conducted electronic literature searches for articles published over an 18 year period from January 1994 to February 2013 using PubMed, Google and Yahoo databases. The references listed in the publications identified from these databases were also reviewed.

RESULTS

Electronic literature searches revealed a multitude of 1 to 3 year training programmes, many affiliated with various foreign universities. The majority of these training programmes are offered in private healthcare institutions. MCI recognition has opened the doors for medical colleges to set up Indian specialty training programmes. Two separate Academic Councils are currently looking at EM training.

CONCLUSION

The variety of programmes and separate efforts on academic development begets a need to address the issues of short-term courses being passed off as specialty training programmes, and a need for working together on national curriculum development, certification, accreditation systems and common examinations. The different organisations and academic councils could collaborate to give EM a unified scope for development.

A review of published literature on emergency medicine training programs in low- and middle-income countries

Background

The objective of this review is to identify and critically evaluate the published literature on emergency medicine (EM) training programs in resource-limited health-care settings in order to provide insight for developing EM training programs in such health systems.

Methods

A literature search was conducted up to the end of April 2011 using MEDLINE, EMBASE, The Cochrane Library, EBM Reviews, Healthstar and Web of Science databases, using the following search terms: Emergency Medicine, Emergency Medicine Services, Education Training Residency Programs, Emergency Medical Systems and Medical Education, without limitation to income countries as outlined in the World Bank World Trade Indicators classification 2009-2010 (World Trade Indicators Country Classification by Region and Income, July 2009-July 2010). As the intent of the review was to identify and critically evaluate the literature readily available (published) to LMICs developing EM programs, the gray literature was not searched.

Results

The search yielded 16 articles that met the final inclusion criteria. As the majority of articles provide a narrative description of the processes and building blocks used in developing the residency programs reported, we present our results in narrative format. By providing a summary of the lessons learned to date, we hope to provide a useful starting point for other resource-limited settings interested in establishing emergency medicine specialty training programs and hope to encourage further information exchange on this matter.

Conclusions

The results of the review indicate that EM training is in its infancy in resource-constrained health-care systems. There are few detailed reports of these programs successes and limitations, including efforts to optimize graduate retention. Despite the paucity of currently published data on the development of EM residency training programs in these settings, this review demonstrates the need for encouraging further information exchange to aid in such efforts, and the authors make specific recommendations to help guide future authors on reporting on such efforts.

Perceptions of graduates from Africa's first emergency medicine training program at the University of Cape Town/Stellenbosch University

OBJECTIVE

Africa's first postgraduate training program in emergency medicine (EM) was established at the University of Cape Town/Stellenbosch University (UCT/SUN) in 2004. This study of the UCT/SUN EM program investigated the backgrounds, perceptions, and experiences of its graduates.

METHODS

This was a cross-sectional descriptive study. The study population was the 30 graduates from the first four classes in the UCT/SUN EM program (2007-2010). We employed a scripted interview with a combination of closed and open-ended questions. Data were analyzed using the thematic method of qualitative analysis.

RESULTS

Twenty-seven (90%) graduates were interviewed. Initial career goals were primarily (78%) to practice EM in a nonacademic clinical capacity. At the time of the interview, 52% held academic positions, 15% had nonacademic clinical positions, and 33% had temporary positions and were looking for other posts. The three most commonly cited strengths of their program were diversity of clinical rotations (85%), autonomy and procedural experience (63%), and importance of being pioneers within Africa (52%). The three most commonly cited weaknesses were lack of bedside teaching in the ED (96%), lack of career options after graduation (74%), and lack of preparation for academic careers (70%).

CONCLUSIONS

The lessons identified from structured interviews with graduates from Africa's first EM training include the importance of strong clinical training, difficulty of ensuring bedside teaching in a new program, the necessity of ensuring postgraduation positions, and the need for academic training. These findings may be useful for other developing countries looking to start EM training programs.

Challenges in international medicine: ethical dilemmas, unanticipated consequences, and accepting limitations

While personal and organizational challenges occur in every area of health care, practitioners of international medicine face unique problems and dilemmas that are rarely discussed in training programs. Health professions schools, residency and fellowship programs, nongovernmental organizations (NGOs), and government programs have a responsibility to make those new to international medicine aware of the special circumstances that they may face and to provide methods for understanding and dealing with these circumstances. Standard "domestic" approaches to such challenges may not work in international medicine, even though these challenges may appear to be similar to those faced in other clinical settings. How should organizations ensure that well-meaning health intervention efforts do not cause adverse unintended sequelae? How should an individual balance respect for cultural uniqueness and local mores that may profoundly differ from his or her own beliefs, with the need to remain a moral agent true to one's self? When is acceptance the appropriate response to situations in which limitations of resources seem to preclude any good solution? Using a case-based approach, the authors discuss issues related to the four major international medicine domains: clinical practice (postdisaster response, resource limitations, standards of care), medical systems and systems development (prehospital care, wartime casualties, sustainable change, cultural awareness), teaching (instruction and local resources, professional preparation), and research (questionable funded studies, clinical trials, observational studies). It is hoped that this overview may help prepare those involved with international medicine for the challenges and dilemmas they may face and help frame their responses to these situations.

Africa's first emergency medicine training program at the University of Cape Town/Stellenbosch University: history, progress, and lessons learned

Africa's first residency training program in emergency medicine (EM) was established at the University of Cape Town (UCT)/Stellenbosch University (SUN) in 2004. There have since been four classes for a total of 29 graduates from this program who are practicing, teaching, and leading EM. This article describes the structure of the program and discusses the history and major drivers behind its founding. We report major changes, cite ongoing challenges, and discuss lessons learned from the program's first 7 years that may help advise other nascent training programs in developing countries.

Characterizing emergency departments to improve understanding of emergency care systems

International emergency medicine aims to understand different systems of emergency care across the globe. To date, however, international emergency medicine lacks common descriptors that can encompass the wide variety of emergency care systems in different countries. The frequent use of general, system-wide indicators (e.g. the status of emergency medicine as a medical specialty or the presence of emergency medicine training programs) does not account for the diverse methods that contribute to the delivery of emergency care both within and between countries. Such indicators suggest that a uniform approach to the development and structure of emergency care is both feasible and desirable. One solution to this complex problem is to shift the focus of international studies away from system-wide characteristics of emergency care. We propose such an alternative methodology, in which studies would examine emergency department-specific characteristics to inventory the various methods by which emergency care is delivered. Such characteristics include: emergency department location, layout, time period open to patients, and patient type served. There are many more ways to describe emergency departments, but these characteristics are particularly suited to describe with common terms a wide range of sites. When combined, these four characteristics give a concise but detailed picture of how emergency care is delivered at a specific emergency department. This approach embraces the diversity of emergency care as well as the variety of individual emergency departments that deliver it, while still allowing for the aggregation of broad similarities that might help characterize a system of emergency care.

Emergency medicine in the developing world: a Delphi study

OBJECTIVES

Emergency medicine (EM) as a specialty has developed rapidly in the western world, but remains largely immature in developing nations. There is an urgent need for emergency services, but no clear guidelines are available on the priorities for establishing EM in the developing world. This study seeks to establish consensus on key areas of EM development in developing world settings, with respect to scope of EM, staffing needs, training requirements, and research priorities.

METHODS

A three-round Delphi study was conducted via e-mail. A panel was convened of 50 EM specialists or equivalent, with experience in or interest in EM in the developing world. In the first round, panelists provided free-text statements on scope, staffing, training, and research priorities for EM in the developing world. A five-point Likert scale was used to rate agreement with the statements in Rounds 2 and 3. Consensus statements are presented as a series of synopsis statements for each of the four major themes.

RESULTS

A total of 168 of 208 statements (81%) had reached consensus at the end of the study. Key areas in which consensus was reached included EM being a specialist-driven service, with substantial role for nonphysicians. International training courses should be adapted to local needs. EM research in developing countries should be clinically driven and focus on local issues of importance.

CONCLUSIONS

The scope and function of EM and relationships with other specialties are defined. Unambiguous principles are laid out for the development of the specialty in developing world environments. The next step required in this process is translation into practical guidelines for the development of EM in developing world settings where they may be used to drive policy, protocols, and research.

The Eight Cs: a guide to success in an international emergency medicine educational collaboration

The Tuscan Emergency Medicine Initiative (TEMI) is a comprehensive emergency medicine (EM) training program designed to build an EM training infrastructure in Tuscany, Italy. The program has successfully trained a team of instructors using a train-the-trainers model, certified 350 physicians who are already practicing in emergency departments (EDs), and established a master's program as a bridge to specialty training at the region's three universities. Using lessons learned from this program, the authors identify eight factors (The Eight Cs) that can serve as a guide to implementing a collaborative EM program in other environments: collaboration, context, culture, credibility, consulting, consistency, critique, and conclusion. Each of these topics is described in detail and may be useful to other international interventions.

An attempt to measure the spread of emergency medicine internationally

OBJECTIVE

To determine the feasibility of using the internet to track the spread of emergency medicine internationally.

OVERVIEW

This was an attempt to perform a descriptive cross-sectional study employing a web-based survey.

SUBJECTS

Potential respondents were identified from multiple sources.

OBSERVATIONS

The primary outcome was the response to 16 questions about EM care and the setting in which it was delivered for acute cardiac, paediatric, obstetrical illnesses and trauma. The questions were divided into six general areas and elicited for urban, semi-urban and rural settings. A series of four e-mails soliciting completion of the survey were sent to potential respondents.

ANALYSIS

Simple descriptive statistics.

RESULTS

We identified 358 potential respondents with valid e-mail addresses over a period of three years. Overall, 145 (41%) responded and 117 (33% 95% CI 28-38%) of them were complete and interpretable. There was one response from 54 and two responses from 29 countries, representing an overall response rate by country surveyed of 65% (95% CI 57-73%), but of all existing countries of only 43% (95% CI 36-50%). Based on sparse data, it appears that in urban areas, 47% (obstetrics) to 65% (paediatric) of acutely sick or injured patients are taken to an ED-equivalent. For rural areas, this range was 19% (obstetrical) to 40% (trauma). CT scans are available in 78% of urban ED-equivalents but 12% of rural ones. Haematocrits are available in 72% of rural settings. In 60% of responding nations, some type of EM training was available, and in 42% physicians went abroad to study EM.

CONCLUSIONS

A survey of international EM is challenging to achieve because of difficulty in both identifying and in contacting potential respondents. Based on sparse data, population density (urban, rural) appears to be related to both the location to which acutely ill patients are taken for their care and to the level of technology available. The specialty of EM is now recognised internationally and education in EM is common.

A comparison between the efficacy of lectures given by emergency and non-emergency physicians in an international emergency medicine educational intervention

OBJECTIVE

The Tuscan Emergency Medicine Initiative is an international collaboration designed to create a sustainable emergency medicine training and qualification process in Tuscany, Italy. Part of the program involves training all emergency physicians currently practicing in the region. This qualification process includes didactic lectures, clinical rotations and practical workshops for those with significant emergency department experience. Lectures in the didactic portion were given by both emergency medicine (EM) and non-EM faculty. We hypothesized that faculty who worked clinically in EM would give more effective lectures than non-EM faculty.

METHODS

Fifty-one emergency physicians from the hospitals surrounding Florence completed the course, which included 48 one-hour lectures. Twenty lectures were given by practicing emergency physicians and 28 were given by non-EM faculty. Participants completed an evaluation at the end of each session using a 5-point Likert scale describing the pertinence of the lecture to EM, the efficacy and clarity of the presentation, the accuracy of the information and the didactic ability of the lecturer.

RESULTS

A mean of 38.5 evaluations was completed for each lecture. Every factor was significantly higher for lectures given by EM faculty: the pertinence of the lecture to EM (4.46 vs. 4.16, p < 0.001), the efficacy of the faculty (4.10 vs. 3.91, p < 0.001), the accuracy of the lecture content (4.16 vs 3.96, p < 0.001), and the didactic ability of the instructors (4.02 vs. 3.85, p = 0.001).

CONCLUSIONS

When teaching EM, evaluations of lectures in this training intervention were higher for lectures given by EM faculty than by non-EM faculty.