International EM

Global Perspective on EM Residency: A Guide to Maximizing an Elective Global Emergency Medicine as a Resident

It is very easy to get swept up into residency.

You start off residency drinking from a fire hose; you dedicate nearly all of your time and energy to the profession, and thousands of hours later you are ready to graduate. However, there is still potential for personal fulfillment outside of your strictly defined residency program. As doctors, we are driven to help others. We also want to strengthen our community and propel our fields forward. I sought this fulfillment by involving myself in a medical project abroad.

EM in Global Context

In the context of academic medicine, emergency medicine is new, and global emergency medicine (GEM) is newer still. While medical emergencies are as old as humans, in the systematic approach we use, the theory and practice of emergency medicine as a defined medical specialty is only about half a century old. Since the 1970s, GEM started to develop as a way for physicians from areas where EM was initially developed, namely Europe and the United States, to practice across borders and help with the greatest need. For example, MSF (Doctors without Borders) has its foundations in 1971 for French physicians to provide humanitarian aid during the Nigerian Civil War.1

The efforts of GEM programs primarily focus on countries with underdeveloped and developing EM systems.2 GEM programs allow one to pursue specific goals, primarily focusing on EM specialty development (education and skills training), public health and capacity building (EMS/Emergency services), disaster relief, humanitarian aid, or academic research.3 As a resident in emergency medicine, there are roles to play in each of these goals within the broader objectives of a GEM program.

Personal Motivation to Rotate in Global Emergency Medicine

Midway through residency I knew I wanted to get involved in an elective abroad, but I didn’t know where to start. I wanted to challenge myself to experience medicine with an entirely different patient population, resource availability, and medical culture. By the same token I wanted to give back. I was looking for a project, however small, that would be humanitarian in nature, helping to deliver emergency medicine to communities in need, while also elevating that community with mutual respect and collegiality. This is when I was introduced to GEM and their tremendous efforts to do just that. 

It is difficult to find a more noble cause than GEM. These programs are building the entire EM infrastructure of countries, has profound impact for the patients being treated through them, and will make a difference in the way medicine will be practiced for generations to come. It is also difficult to appreciate the scale of impact these programs have on the number of patients treated.

Build Your Elective as a Resident

As a resident looking to get involved in the broader scope of a GEM program during your residency, first start by researching programs. There are dozens of phenomenal GEM fellowship programs in the U.S., and many of them have meaningful ways for residents to contribute. Depending on where the funding is from, many of these programs will cover all transportation and accommodation, which makes it much more realistic to pursue on a resident budget.

The most crucial barrier to overcome in trying to work out a project abroad is time. During residency it is hard to envision a scenario where you are able to dedicate 100% of your time in another part of the world. Planning ahead is key, often over one year in advance to help facilitate all the steps necessary for a successful project. Every EM residency in the U.S. has dedicated elective time, as well as dedicated vacation time. In my residency, we have a single four-week block in our senior year as well as vacation time taken in 2-week segments. By planning a year in advance, I was able to shift my schedule so that my elective block was attached to my vacation block, which allowed me to spend a total of 6 weeks participating in a GEM project in India.

Another good point to keep in mind when scheduling your blocks with an elective abroad is overlap with a local conference. For instance, the Asian Conference of Emergency Medicine is an international conference that meets every 2 years, and in 2019 it was hosted in Delhi, India.4,5 Knowing the dates of this conference influenced the scheduling of my GEM elective, so that I could further utilize my time abroad to present a poster at an international conference (a case report on paroxysmal ventricular standstill).  When selecting a GEM program itself, see what they offer and where they offer it with the above in mind.

Research GEM programs to see what they offer and where they offer it. I found what I was looking for in George Washington University and the Ronald Reagan Institute of Emergency Medicine. They have many programs around the world, and what I found most interesting was their master’s in emergency medicine (MEM) program in India. In a nutshell, their primary objective is to develop the educational infrastructure of emergency medicine in India so that it can eventually be self-sustaining. They do this through developing residencies throughout the country. GW has developed a curriculum that is followed by all EM programs in the country. Through it, they send educators from the United States who give lecture series as well as provide bedside learning.6 These educators consist of GEM Fellows, attendings, and senior residents in EM.

The need for EM is there. As of 2018, there were only 194 available training positions for emergency medicine in the entirety of India, a country of more than 1.3 billion citizens. In comparison, the United States filled 2,278 EM training positions that year, in a country of approximately 330 million. At the current rate of population growth, and with so few training positions, there will never be enough EM physicians in India. One of the largest barriers to this is that the pump needs to be primed. EM trainees need EM physicians to train them, and with EM only being nationally recognized in India as of 2008, there are very few EM trained physician educators in India. Thus, the GWU GEM program developed a model to propagate the field exponentially through locally training home-grown emergency physicians that can then be leaders in the field and educate future generations of EM physicians.7 The program is a large endeavor with many moving parts, and herein lies the opportunity to contribute as a resident.

Daily Experience in India and Bridging the Gap

During my own elective, I spent 6 weeks in India giving lectures and bedside teaching at 5 different hospitals throughout the country that were affiliated with GWU. Their curriculum was set far in advance and my time there overlapped blocks in orthopedics and procedures. Before going I made lectures in these topics covering their respective chapters in Tintinalli and questions out of Rosh Review. On a typical day, I would arrive at the hospital at 08:00 and lecture until noon. Lectures would consist of PowerPoints on topics for their current blocks, jeopardy style questions, oral boards cases, and Q&A sessions. After breaking for lunch, we would return to the department to round on patients and had bedside teaching as well as training in ultrasound when a machine was available.

On a day-to-day level, my experience there was bringing fundamentals of emergency medicine to a motivated and intellectual community of doctors. These residents sit for an annual US in-service exam through the GW program, and take the UK boards upon graduation. Therefore the lectures were focused on teaching EM in the perspective of the written and oral boards, with the larger goal of expanding that to real-world application.

The purpose of my elective abroad wasn’t to go there to tell them how we do emergency medicine in the U.S., but to bridge the gap by offering knowledge and experience and tailoring it to what they can use and what will help them in India. They have different patient populations, different medical supplies, different dispositions, and different payment structures. They, just like any EM doc in the west, must practice medicine within the confines of their resources. For example: medical management of myocardial infarction due to cost effectiveness and no available catheterization center.

I was fortunate to see much of India, from the placid countryside to the bustling cities. India is an ancient land with very diverse people made up of dozens of languages, ethnicities, and religions. Society is complex in India, and like all other countries, the medical infrastructure is not without flaws. However, India has been theorizing and practicing medicine long before most of the world was able to put ink to paper. This was important to keep in mind.

Bringing It Back Home

I am extraordinarily fortunate to have had this opportunity. During my senior year of residency, I was able to break away for 6 weeks and go to the opposite side of the planet, to teach and to learn in an entirely new way.  This experience reaffirmed many things, namely that medicine is not best practiced in the framework of absolutes. Practicing medicine requires an understanding of the setting and resources available. There is a finesse to this whole thing.

There were cases I saw in India that I would likely never see in the U.S.:

  • Organophosphate poisoning, common in agricultural accidents
  • Dengue and malaria, endemic and seasonal
  • Snake and scorpion envenomation, which have a wide variety of presentation depending on the species
  • STEMI in patients in their 30s
  • Trocar chest tubes are faster compared with our standard practice in the U.S.
  • Motorcycle EMS are available in most emergency departments. They can respond to the scene faster, as they can bypass gridlock traffic, but pose danger for EMS personnel themselves

Experiencing a practice setting abroad that was outside of my comfort zone gave me a new appreciation for communicating efficiently, as well as the virtue of patience in navigating differences of perspective. This mentality was useful to bring home because it also applies to communicating with consultants, colleagues, and patients. Also importantly, as I write this article, our society is in the midst of the COVID-19 pandemic, and we are learning to practice in new ways every day. I feel this experience has prepared me to be more adaptable when facing the many challenges presented by the current global pandemic.

The experience of traveling to India has given me a new appreciation for our field, a camaraderie with our international colleagues, and affirmation that no matter the setting our driving purpose is to help others, do the least harm, and do the most good. 

As the poet Saadi once said:

"Human beings are members of a whole, since in their creation they are of one essence. When the conditions of the time bring a member to pain, the other members will suffer.”

 


References

  1. Bortolotti, D. Hope in Hell: Inside the World of Doctors Without Borders, Firefly Books; 2004. ISBN 1-55297-865-6.
  2. Arnold J. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med. 1999;33(1):97-103.
  3. Bandolin NS, Reardon JM, Joseph R. In: Shafer K, Stuntz B, Sherman, eds. EMRA Fellowship Guide 2018. 2nd Edition. Irving, TX: EMRA; 2018:96-104. (https://www.emra.org/books/fellowship-guide-book)
  4. www.asiansem.org
  5. www.acem2019delhi.in
  6. https://smhs.gwu.edu/reaganinstitute/international/faculty-development
  7. Douglass K, Gidwani S, Mehta S, et al. White Paper on Emergency Medicine Education and Training in India: Where are we now and where should we go next? 2018. 

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