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Emergency Medicine Australasia (2014) 26, 635–639
doi: 10.1111/1742-6723.12322
TRAINEE FOCUS
Perspectives on working and training in global health and international emergency medicine Natalie THURTLE,1 Georgina PHILLIPS,2,3 Jocelyn KEAGE,4 Amanda WALLIS,5 Rob MITCHELL6 and Jennifer JAMIESON7 1 Emergency Department and Department of Clinical Toxicology, St Thomas’ Hospital, London, UK, 2Emergency Department, St Vincent’s Hospital, Melbourne, Victoria, Australia, 3The University of Melbourne, Melbourne, Victoria, Australia, 4Emergency Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia, 5Department of Intensive Care, Western Hospital, Melbourne, Victoria, Australia, 6Emergency Department, Modilon General Hospital, Madang, Papua New Guinea, and 7Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
Working in global health (GH) and international emergency medicine (IEM) can be exceptionally rewarding, but also comes with significant personal and professional challenges. This article profiles ACEM advanced trainees who have worked in cross-cultural and resource-limited settings, and explores the unique learning experiences encountered in these environments. In addition, Georgina Phillips (a FACEM from Melbourne) provides insights from the perspective of a mentor and remote supervisor to trainees undertaking GH and IEM placements.
Dr Georgina Phillips (FACEM and supervisor) During 2009, I spent my sabbatical based at the Divine Word University (DWU) in Madang, Papua New Guinea (PNG), doing work for the university and supporting the nearby provincial hospital. Since then, I have made support visits to DWU every year. Having exposed many of the educational and clinical resource chal-
lenges at the university and hospital, it was clear that Australasian emergency medicine (EM) trainees could make a meaningful contribution. The university had many needs, and was a delightful and secure living environment. The ED at the provincial teaching hospital had a local emergency physician and provided excellent clinical exposure. Fortunately, I had the networks to create a sustainable model. The ‘pilot’ placement was the beginning of the Visiting Clinical Lecturer Program (VCLP).1,2 It evolved from being a flexible arrangement whereby EM trainees and FACEMs could spend 2 weeks or longer teaching on EM and related topics for the Rural Health Bachelor degree at the DWU and doing clinical work and peer support at the ED of the Madang Hospital. It is now a formal programme in partnership with ACEM and Australian Volunteers International (AVI). Before the formal partnership arrangement with AVI, I facilitated all of the logistics between the trainee and DWU, including predeparture briefing. The AVI partner-
Correspondence: Dr Jennifer Jamieson, Emergency and Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia. Email: missjennyjamieson @gmail.com Natalie Thurtle, MBChB, DTM&H, ED and Clinical Toxicology Fellow; Georgina Phillips, MBBS, FACEM, Emergency Physician, Coordinator of International Programs, Honorary Lecturer; Jocelyn Keage, MBBS, BMedSc, Emergency Registrar; Amanda Wallis, MBBS (Hons), BMedSc, ICU Registrar; Rob Mitchell, MBBS (Hons), BMedSc (Hons), MPH&TM, Emergency Registrar; Jennifer Jamieson, MBBS, BBiomedSc, Emergency Registrar. Accepted 26 September 2014
ship allowed clearer articulation of the selection criteria, roles and responsibilities, and anticipated outcomes of their work. It has also ensured much greater structures of support should any problems arise. Advanced trainee placements in the VCLP of 3 months or longer are accredited by ACEM. It has been a ground-breaking development for IEM placements, as it has not relied on an in-country FACEM, but rather has recognised the expertise of the local emergency physician as an appropriate supervisor for Australasian trainees. I have been fortunate to overlap with several of the trainees while they have been on their placement in PNG. This has enabled me to support them in-country, assist with critical reflection, and gain insights into strengths and weaknesses of the programme. It has also been important to provide ongoing support to the local emergency physicians who are taking responsibility for and supervising the Australasian trainees. I do feel a very strong sense of responsibility for all of the trainees as they go through this programme. By virtue of our excellent training, advanced trainees have a rich resource pool within themselves to draw from, and are familiar with different teaching styles and methods. EM trainees, in particular, are suited to clinical education in places where resources are limited, as they are taught to be flexible, adaptable, communicate effectively and to make the most of any situation. We are generalists and are
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
636
N THURTLE ET AL.
experts in a diverse range of clinical skills, with a sound knowledge of the basic medical sciences as well as specialty disciplines. At the advanced trainee stage, EM doctors have been exposed to a variety of clinical environments and have had to supervise junior doctors. All of these experiences and skills, plus some emotional maturity, mean that EM advanced trainees have terrific capacity for clinical education where resources are limited. However, without prior preparation and briefing, it can be a big challenge for an Australasian trainee to manage where resources are low. Risks always exist, but they should not be a focus. A poorly thought out placement without good support or engagement from the local clinicians and without adequate supervision is not going to be a positive learning experience for the trainee, and will not provide any meaningful benefit to the host environment. There are risks from the host perspective, too, mainly that the trainee is an extra burden rather than a useful contributor. But such placements will hopefully not be supported or accredited by the ACEM. The challenge of the supervisors (and trainees) is to allow reflection and learning on all of these things within a positive, respectful framework, rather than allowing judgment, cynicism and defeatism to become the prevailing discourse. Embedding the IEM placement well within a local context is vital, and utilising existing structures of support, such as volunteer and humanitarian organisations, can be very helpful. Working in a different cultural context other that your own ensures a wider and deeper understanding of our global community. It improves communication skills and enhances clinical skills as trainees learn to assess and manage patients within different cultural understandings of illness and different expectations of healthcare. Plus, there is the appreciation of making friendships across cultural boundaries and living within a different culture and context. For host communities, it is also an opportunity to learn about an Australasian perspective – and also to make connections and friendships that will hopefully last longer than the
placement. Trainees can bring fresh ideas and model different clinical and teaching practices that can be a stimulant in a local context that might have limited opportunities for exposure to the global community. The trainee has responsibility for his/ her own placement, but you, as the supervisor also have responsibility to ensure it has been successful; that the learning objectives were met and that the trainee was able to reflect meaningfully on his/her experiences. As the supervisor, you have some agency in how the IEM placement turns out (but not complete agency!), so that sense of responsibility, when not everything is under your control, can be quite a challenge. Ultimately, you want them to finish with a strong attachment to their placement and a commitment to global emergency care. You want them to develop a sophisticated and thoughtful response to the health injustices of the world.
Dr Natalie Thurtle (advanced trainee) I have spent periods of time overseas during my training, both before and after the primary exam, with Médecins Sans Frontières (MSF) as well as independently. My two missions with MSF were in Sri Lanka, during the civil war, and in Nigeria, as part of a response to a paediatric lead poisoning outbreak due to artisanal gold mining. Later, I spent almost a year at MSF’s Amsterdam and London headquarters looking after medical strategy, advocacy and research for the complex lead poisoning project. Part of my role at the headquarters involved guiding the write-up of the programme data collected during the lead poisoning outbreak; during this time, one of the papers was accepted as my 4.10 submission. More recently, I spent a few months as a volunteer in Gaborone, Botswana, working with a FACEM who is single-handedly supporting the EM training programme there. ACEM accredited 6 months of my time at MSF headquarters as ‘toxicology’. There was some toxicology, but there was also a lot of management, diplomacy, strategy; skills all useful to EM, but not falling easily into a Special Skills Term categorisation. I had great
support from my Director of Emergency Medicine Training who guided me through the accreditation process and acted as my remote supervisor. I was lucky enough to find a consultant willing to act as my direct supervisor in Europe, who was also very supportive. I know other people have struggled to get field time accredited as there is usually no suitable individual for direct supervision; as such I have not applied for accreditation for any of my field time and it is all ‘interrupted training’. Personally, I think for the right candidate these types of experiences do not require direct supervision and can have value without it, as long as there is appropriate remote supervision and learning objectives can be derived and revised as the process goes along. Hopefully, ACEM will adjust to this perspective in the future. It is difficult to prepare anyone to work in the kind of contexts where MSF usually operates. EM trainees are generally well suited as there are constantly curve balls associated with field work that can mirror a day in the ED to some extent. People from other specialties, where things go in a more orderly fashion, can be quite discombobulated by this. The area where I felt least prepared is in understanding the anthropological differences, the cultural challenges of providing care and managing staff in a context so different to your own. I enjoy and intend to go back to being in the field. Providing care that is life saving in a context where it was not previously accessible is a core value in MSF, and nowhere do you see that and do that more than in the field. Working with MSF means that you meet other people from MSF. My husband is from Canada and has worked for MSF for over a decade. Aligning our lives has been challenging; a lot of moving around within country, moving countries and time apart. Many of my close friends are similarly dispersed as they are fellow MSF-ers. My EM training has taken longer than most and been more disjointed. I feel a constant pull to return to MSF, whereas my head tells me to finish my training in EM first so I can be of more use and so I have something to come home to.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
637
PERSPECTIVES ON EMERGENCY MEDICINE TRAINING
I would not change anything about the way I have integrated work in developing countries with my training in EM. It has been circuitous, but also exciting and unexpected, particularly the research, which was not something I thought I would have the opportunity to meaningfully participate in as a trainee. I have had a lot of support along the way, both from FACEMs and from people in MSF, without which I would not have learnt as much or got through the tougher times.
Dr Jocelyn Keage (advanced trainee) As a resident (PGY2), I spent close to a month in East Timor volunteering at the Bairo Pite Clinic.3 This was a great experience and left me interested in IEM. Last year, as an advanced trainee, I spent 3 months in Madang, Papua New Guinea, as part of the VCLP. At Bairo Pite Clinic, my responsibilities were that of a junior doctor, which included helping with ward rounds, assessing deteriorating patients and attending outreach clinics. In Madang, my responsibilities were split between working in the ED and teaching health extension officer students. The most valuable experience was meeting colleagues working in very different conditions, and to discover new places and languages. Both placements were extremely career energising. Additionally, the VCL position is an accredited Special Skills post for advanced trainees. As emergency trainees, we have transferable knowledge and skills that are valuable even in resource-limited settings. We can provide support to colleagues working in resource-poor environments and learn a lot from their clinical practice, too. The implications of working in a different cultural context are vast. The main implication was patience. It takes time to discover how to be an effective and helpful person. Showing eagerness to learn language and culture is incredibly important. Making mistakes can open communication channels even if language is lacking. Many people questioned me as to whether I felt equipped to work in a resource-limited environment. If any-
thing, resource-limited environments highlight the value of simple skills and inexpensive equipment. Trying to establish how my knowledge and skills fitted into a new environment was one of the biggest challenges.
Amanda Wallis (advanced trainee) As a student, I spent time in rural South Africa and the highlands of Papua New Guinea. Since graduating, I have worked in Tanzania, rural Kenya and South Sudan. My responsibilities within these have been very varied, ranging from daily running of wards (including acute severe malnutrition and measles), to outreach primary care clinics, teaching, liaising with other non-governmental organisations (NGOs) and government, and many managerial duties. There have been many significant learning experiences during my various IEM placements. One of the most notable challenges includes lack of resources and their respective allocation, particularly knowing that your decisions will likely contribute to morbidity and mortality of some of your patients. Managing staff who have cultural barriers to a female being in a management position has been very challenging during some of my placements. I have gained insights into the importance of sensitivity to cultural beliefs and social constructs when considering patient management. Last, the importance of self-care in very emotionally, physically and mentally challenging environments is another challenge and cannot be underestimated. Unfortunately, I have not managed to accredit any of my IEM experiences toward my training. Partially, this is because it needs to be prospectively organised and I left emergently for a mission with MSF without knowing exactly what I was going to be doing, so I could not organise the relevant information and documentation. The most significant personal challenge I have faced has been treating my own husband when he was critically ill. I had to keep him medically stable in a resource-poor environment while waiting for a retrieval plane to reach
the remote airstrip where we were based in order to transfer him to an ICU. Feeling responsible for being unable to save many children’s lives was also very personally challenging and emotionally draining. Through working abroad, I have seen diseases that are rare, but important to recognise in Australia, such as measles, tetanus and tuberculosis (TB). Having seen these, it will help me (and indeed already has) identify these important diagnoses in a low prevalence environment (i.e. Australia). The managerial and resource allocation experience I have had is invaluable and are skills that we are expected to have as consultants, but that we rarely gain any real experience in before practising at that level. My conflict resolution skills have also grown, along with experience in liaising with different groups with differing levels of skill, resources and agenda. The importance of personal care and supporting those around you have also become very clear to me, which will hopefully help me be a better functioning clinician and more effective mentor and senior staff member in the future. Patience and an ability to consider things from alternative and less usual perspectives have also been skills gained through working overseas, including the knowledge that there are many ways of doing things, many of which work even if they are not what you would normally do! My experiences overseas have cemented a desire to continue to balance my career in Australia with work overseas, and thus encouraged me to actively gain a broad knowledge and skills base. It has also given me a desire to be able to evaluate my work and programmes I am involved in, and to be able to discern whether my broader management, involvement and decisions are effective. I have thus become interested in further study (particularly public health) and in education. The only negative consequence is that it is taking me longer than it would have otherwise to finish my training in EM!
Conclusion These perspectives highlight the benefits and challenges of training experiences in GH and IEM. Trainees who
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
bs_bs_banner
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N THURTLE ET AL.
are interested in undertaking placements in resource-limited environments should review Box 1 in the article by Jamieson et al.,4 and consult the ACEM International Emergency Medicine Special Interest Group (IEMSIG) for more information.5
Competing interests RM and JJ are section editors for Emergency Medicine Australasia.
References
Madang, Papua New Guinea. Emerg. Med. Australas. 2012; 24: 547–52. 2. Australasian College for Emergency Medicine. How to apply for the Visiting Clinical Lecturer Program – Madang, PNG. [Cited 21 Sep 2014.] Available from URL: https://www .acem.org.au/getmedia/ddd75321 -9a58-41c6-b335-763a1df2d07b/ How - to - Apply_Visiting-Clinical -Lecturer-Program-PNG.pdf.aspx 3. Bairo Pite Clinic. Bairo Pite Clinic. [Cited 23 Sep 2014.] Available from URL: http://bairopiteclinic.org
4.
Jamieson J, Mitchell R, Perry A, Rotella JA, O’Reilly G. Training in global health and international emergency medicine: where to next? Emerg. Med. Australas. 2014; 26: 630–4. 5. Australasian College for Emergency Medicine. International Emergency Medicine Special Interest Group. [Cited 19 Sep 2014.] Available from URL: https://www.acem . org . au / About -ACEM/ Special - Interest - Groups/ International-Emergency-Medicine -Special-Interest.aspx
1. Phillips G, Hendrie J, Atua V, Manineng C. Capacity building in emergency care: an example from
Best of the Web on global health and international emergency medicine Nepal Medics: Byron and Kim in Dharan A blog following the adventures of two ACEM advanced trainees currently volunteering in Dharan, Nepal. http://nepalmedics.wordpress.com Global Health Gateway A website dedicated to early career health professionals looking to develop skills and find opportunities in global health. http://www.globalhealthgateway.org.au Médecins Sans Frontières (MSF) Australia The Australasian section of MSF highlights stories, blogs and news straight from the field. http://www.msf.org.au/from-the-field.html The Guide to Working Abroad for Medical Students & Junior Doctors Parker J, Mitchell R, Mansfield S et al. Med. J. Aust. 2011; 194: eS1–95. A comprehensive e-book dedicated to planning and undertaking a term in a resource-challenged environment, written by Australian trainees. https://www.mja.com.au/journal/2011/194/12/guide-working-abroad-australian-medical-students-and-junior-doctors Ethical challenges in short-term Global Health Training A free online course from Stanford University Center for Global Health and the Johns Hopkins University Berman Institute of Bioethics. This course features case studies of trainees involved in difficult cultural and professional situations during overseas assignments. http://ethicsandglobalhealth.org Getting a Médecins Sans Frontières (MSF) mission accredited for training Moore A and Lee A. Newsletter of the International Emergency Medicine Special Interest Group of the Australasian College for Emergency Medicine 2010; 6 (2): 7. A trainee and remote supervisor’s account of applying to ACEM for accreditation of an MSF mission in Zalingei, the provincial Capital of West Darfur state in Sudan. https://www.acem.org.au/Standards-Publications/Publications-Papers.aspx doi: 10.1111/1742-6723.12323
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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Emergency Medicine Australasia (2014) 26, 635–639
doi: 10.1111/1742-6723.12322
TRAINEE FOCUS
Perspectives on working and training in global health and international emergency medicine Natalie THURTLE,1 Georgina PHILLIPS,2,3 Jocelyn KEAGE,4 Amanda WALLIS,5 Rob MITCHELL6 and Jennifer JAMIESON7 1 Emergency Department and Department of Clinical Toxicology, St Thomas’ Hospital, London, UK, 2Emergency Department, St Vincent’s Hospital, Melbourne, Victoria, Australia, 3The University of Melbourne, Melbourne, Victoria, Australia, 4Emergency Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia, 5Department of Intensive Care, Western Hospital, Melbourne, Victoria, Australia, 6Emergency Department, Modilon General Hospital, Madang, Papua New Guinea, and 7Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
Working in global health (GH) and international emergency medicine (IEM) can be exceptionally rewarding, but also comes with significant personal and professional challenges. This article profiles ACEM advanced trainees who have worked in cross-cultural and resource-limited settings, and explores the unique learning experiences encountered in these environments. In addition, Georgina Phillips (a FACEM from Melbourne) provides insights from the perspective of a mentor and remote supervisor to trainees undertaking GH and IEM placements.
Dr Georgina Phillips (FACEM and supervisor) During 2009, I spent my sabbatical based at the Divine Word University (DWU) in Madang, Papua New Guinea (PNG), doing work for the university and supporting the nearby provincial hospital. Since then, I have made support visits to DWU every year. Having exposed many of the educational and clinical resource chal-
lenges at the university and hospital, it was clear that Australasian emergency medicine (EM) trainees could make a meaningful contribution. The university had many needs, and was a delightful and secure living environment. The ED at the provincial teaching hospital had a local emergency physician and provided excellent clinical exposure. Fortunately, I had the networks to create a sustainable model. The ‘pilot’ placement was the beginning of the Visiting Clinical Lecturer Program (VCLP).1,2 It evolved from being a flexible arrangement whereby EM trainees and FACEMs could spend 2 weeks or longer teaching on EM and related topics for the Rural Health Bachelor degree at the DWU and doing clinical work and peer support at the ED of the Madang Hospital. It is now a formal programme in partnership with ACEM and Australian Volunteers International (AVI). Before the formal partnership arrangement with AVI, I facilitated all of the logistics between the trainee and DWU, including predeparture briefing. The AVI partner-
Correspondence: Dr Jennifer Jamieson, Emergency and Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia. Email: missjennyjamieson @gmail.com Natalie Thurtle, MBChB, DTM&H, ED and Clinical Toxicology Fellow; Georgina Phillips, MBBS, FACEM, Emergency Physician, Coordinator of International Programs, Honorary Lecturer; Jocelyn Keage, MBBS, BMedSc, Emergency Registrar; Amanda Wallis, MBBS (Hons), BMedSc, ICU Registrar; Rob Mitchell, MBBS (Hons), BMedSc (Hons), MPH&TM, Emergency Registrar; Jennifer Jamieson, MBBS, BBiomedSc, Emergency Registrar. Accepted 26 September 2014
ship allowed clearer articulation of the selection criteria, roles and responsibilities, and anticipated outcomes of their work. It has also ensured much greater structures of support should any problems arise. Advanced trainee placements in the VCLP of 3 months or longer are accredited by ACEM. It has been a ground-breaking development for IEM placements, as it has not relied on an in-country FACEM, but rather has recognised the expertise of the local emergency physician as an appropriate supervisor for Australasian trainees. I have been fortunate to overlap with several of the trainees while they have been on their placement in PNG. This has enabled me to support them in-country, assist with critical reflection, and gain insights into strengths and weaknesses of the programme. It has also been important to provide ongoing support to the local emergency physicians who are taking responsibility for and supervising the Australasian trainees. I do feel a very strong sense of responsibility for all of the trainees as they go through this programme. By virtue of our excellent training, advanced trainees have a rich resource pool within themselves to draw from, and are familiar with different teaching styles and methods. EM trainees, in particular, are suited to clinical education in places where resources are limited, as they are taught to be flexible, adaptable, communicate effectively and to make the most of any situation. We are generalists and are
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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N THURTLE ET AL.
experts in a diverse range of clinical skills, with a sound knowledge of the basic medical sciences as well as specialty disciplines. At the advanced trainee stage, EM doctors have been exposed to a variety of clinical environments and have had to supervise junior doctors. All of these experiences and skills, plus some emotional maturity, mean that EM advanced trainees have terrific capacity for clinical education where resources are limited. However, without prior preparation and briefing, it can be a big challenge for an Australasian trainee to manage where resources are low. Risks always exist, but they should not be a focus. A poorly thought out placement without good support or engagement from the local clinicians and without adequate supervision is not going to be a positive learning experience for the trainee, and will not provide any meaningful benefit to the host environment. There are risks from the host perspective, too, mainly that the trainee is an extra burden rather than a useful contributor. But such placements will hopefully not be supported or accredited by the ACEM. The challenge of the supervisors (and trainees) is to allow reflection and learning on all of these things within a positive, respectful framework, rather than allowing judgment, cynicism and defeatism to become the prevailing discourse. Embedding the IEM placement well within a local context is vital, and utilising existing structures of support, such as volunteer and humanitarian organisations, can be very helpful. Working in a different cultural context other that your own ensures a wider and deeper understanding of our global community. It improves communication skills and enhances clinical skills as trainees learn to assess and manage patients within different cultural understandings of illness and different expectations of healthcare. Plus, there is the appreciation of making friendships across cultural boundaries and living within a different culture and context. For host communities, it is also an opportunity to learn about an Australasian perspective – and also to make connections and friendships that will hopefully last longer than the
placement. Trainees can bring fresh ideas and model different clinical and teaching practices that can be a stimulant in a local context that might have limited opportunities for exposure to the global community. The trainee has responsibility for his/ her own placement, but you, as the supervisor also have responsibility to ensure it has been successful; that the learning objectives were met and that the trainee was able to reflect meaningfully on his/her experiences. As the supervisor, you have some agency in how the IEM placement turns out (but not complete agency!), so that sense of responsibility, when not everything is under your control, can be quite a challenge. Ultimately, you want them to finish with a strong attachment to their placement and a commitment to global emergency care. You want them to develop a sophisticated and thoughtful response to the health injustices of the world.
Dr Natalie Thurtle (advanced trainee) I have spent periods of time overseas during my training, both before and after the primary exam, with Médecins Sans Frontières (MSF) as well as independently. My two missions with MSF were in Sri Lanka, during the civil war, and in Nigeria, as part of a response to a paediatric lead poisoning outbreak due to artisanal gold mining. Later, I spent almost a year at MSF’s Amsterdam and London headquarters looking after medical strategy, advocacy and research for the complex lead poisoning project. Part of my role at the headquarters involved guiding the write-up of the programme data collected during the lead poisoning outbreak; during this time, one of the papers was accepted as my 4.10 submission. More recently, I spent a few months as a volunteer in Gaborone, Botswana, working with a FACEM who is single-handedly supporting the EM training programme there. ACEM accredited 6 months of my time at MSF headquarters as ‘toxicology’. There was some toxicology, but there was also a lot of management, diplomacy, strategy; skills all useful to EM, but not falling easily into a Special Skills Term categorisation. I had great
support from my Director of Emergency Medicine Training who guided me through the accreditation process and acted as my remote supervisor. I was lucky enough to find a consultant willing to act as my direct supervisor in Europe, who was also very supportive. I know other people have struggled to get field time accredited as there is usually no suitable individual for direct supervision; as such I have not applied for accreditation for any of my field time and it is all ‘interrupted training’. Personally, I think for the right candidate these types of experiences do not require direct supervision and can have value without it, as long as there is appropriate remote supervision and learning objectives can be derived and revised as the process goes along. Hopefully, ACEM will adjust to this perspective in the future. It is difficult to prepare anyone to work in the kind of contexts where MSF usually operates. EM trainees are generally well suited as there are constantly curve balls associated with field work that can mirror a day in the ED to some extent. People from other specialties, where things go in a more orderly fashion, can be quite discombobulated by this. The area where I felt least prepared is in understanding the anthropological differences, the cultural challenges of providing care and managing staff in a context so different to your own. I enjoy and intend to go back to being in the field. Providing care that is life saving in a context where it was not previously accessible is a core value in MSF, and nowhere do you see that and do that more than in the field. Working with MSF means that you meet other people from MSF. My husband is from Canada and has worked for MSF for over a decade. Aligning our lives has been challenging; a lot of moving around within country, moving countries and time apart. Many of my close friends are similarly dispersed as they are fellow MSF-ers. My EM training has taken longer than most and been more disjointed. I feel a constant pull to return to MSF, whereas my head tells me to finish my training in EM first so I can be of more use and so I have something to come home to.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
637
PERSPECTIVES ON EMERGENCY MEDICINE TRAINING
I would not change anything about the way I have integrated work in developing countries with my training in EM. It has been circuitous, but also exciting and unexpected, particularly the research, which was not something I thought I would have the opportunity to meaningfully participate in as a trainee. I have had a lot of support along the way, both from FACEMs and from people in MSF, without which I would not have learnt as much or got through the tougher times.
Dr Jocelyn Keage (advanced trainee) As a resident (PGY2), I spent close to a month in East Timor volunteering at the Bairo Pite Clinic.3 This was a great experience and left me interested in IEM. Last year, as an advanced trainee, I spent 3 months in Madang, Papua New Guinea, as part of the VCLP. At Bairo Pite Clinic, my responsibilities were that of a junior doctor, which included helping with ward rounds, assessing deteriorating patients and attending outreach clinics. In Madang, my responsibilities were split between working in the ED and teaching health extension officer students. The most valuable experience was meeting colleagues working in very different conditions, and to discover new places and languages. Both placements were extremely career energising. Additionally, the VCL position is an accredited Special Skills post for advanced trainees. As emergency trainees, we have transferable knowledge and skills that are valuable even in resource-limited settings. We can provide support to colleagues working in resource-poor environments and learn a lot from their clinical practice, too. The implications of working in a different cultural context are vast. The main implication was patience. It takes time to discover how to be an effective and helpful person. Showing eagerness to learn language and culture is incredibly important. Making mistakes can open communication channels even if language is lacking. Many people questioned me as to whether I felt equipped to work in a resource-limited environment. If any-
thing, resource-limited environments highlight the value of simple skills and inexpensive equipment. Trying to establish how my knowledge and skills fitted into a new environment was one of the biggest challenges.
Amanda Wallis (advanced trainee) As a student, I spent time in rural South Africa and the highlands of Papua New Guinea. Since graduating, I have worked in Tanzania, rural Kenya and South Sudan. My responsibilities within these have been very varied, ranging from daily running of wards (including acute severe malnutrition and measles), to outreach primary care clinics, teaching, liaising with other non-governmental organisations (NGOs) and government, and many managerial duties. There have been many significant learning experiences during my various IEM placements. One of the most notable challenges includes lack of resources and their respective allocation, particularly knowing that your decisions will likely contribute to morbidity and mortality of some of your patients. Managing staff who have cultural barriers to a female being in a management position has been very challenging during some of my placements. I have gained insights into the importance of sensitivity to cultural beliefs and social constructs when considering patient management. Last, the importance of self-care in very emotionally, physically and mentally challenging environments is another challenge and cannot be underestimated. Unfortunately, I have not managed to accredit any of my IEM experiences toward my training. Partially, this is because it needs to be prospectively organised and I left emergently for a mission with MSF without knowing exactly what I was going to be doing, so I could not organise the relevant information and documentation. The most significant personal challenge I have faced has been treating my own husband when he was critically ill. I had to keep him medically stable in a resource-poor environment while waiting for a retrieval plane to reach
the remote airstrip where we were based in order to transfer him to an ICU. Feeling responsible for being unable to save many children’s lives was also very personally challenging and emotionally draining. Through working abroad, I have seen diseases that are rare, but important to recognise in Australia, such as measles, tetanus and tuberculosis (TB). Having seen these, it will help me (and indeed already has) identify these important diagnoses in a low prevalence environment (i.e. Australia). The managerial and resource allocation experience I have had is invaluable and are skills that we are expected to have as consultants, but that we rarely gain any real experience in before practising at that level. My conflict resolution skills have also grown, along with experience in liaising with different groups with differing levels of skill, resources and agenda. The importance of personal care and supporting those around you have also become very clear to me, which will hopefully help me be a better functioning clinician and more effective mentor and senior staff member in the future. Patience and an ability to consider things from alternative and less usual perspectives have also been skills gained through working overseas, including the knowledge that there are many ways of doing things, many of which work even if they are not what you would normally do! My experiences overseas have cemented a desire to continue to balance my career in Australia with work overseas, and thus encouraged me to actively gain a broad knowledge and skills base. It has also given me a desire to be able to evaluate my work and programmes I am involved in, and to be able to discern whether my broader management, involvement and decisions are effective. I have thus become interested in further study (particularly public health) and in education. The only negative consequence is that it is taking me longer than it would have otherwise to finish my training in EM!
Conclusion These perspectives highlight the benefits and challenges of training experiences in GH and IEM. Trainees who
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
bs_bs_banner
638
N THURTLE ET AL.
are interested in undertaking placements in resource-limited environments should review Box 1 in the article by Jamieson et al.,4 and consult the ACEM International Emergency Medicine Special Interest Group (IEMSIG) for more information.5
Competing interests RM and JJ are section editors for Emergency Medicine Australasia.
References
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Best of the Web on global health and international emergency medicine Nepal Medics: Byron and Kim in Dharan A blog following the adventures of two ACEM advanced trainees currently volunteering in Dharan, Nepal. http://nepalmedics.wordpress.com Global Health Gateway A website dedicated to early career health professionals looking to develop skills and find opportunities in global health. http://www.globalhealthgateway.org.au Médecins Sans Frontières (MSF) Australia The Australasian section of MSF highlights stories, blogs and news straight from the field. http://www.msf.org.au/from-the-field.html The Guide to Working Abroad for Medical Students & Junior Doctors Parker J, Mitchell R, Mansfield S et al. Med. J. Aust. 2011; 194: eS1–95. A comprehensive e-book dedicated to planning and undertaking a term in a resource-challenged environment, written by Australian trainees. https://www.mja.com.au/journal/2011/194/12/guide-working-abroad-australian-medical-students-and-junior-doctors Ethical challenges in short-term Global Health Training A free online course from Stanford University Center for Global Health and the Johns Hopkins University Berman Institute of Bioethics. This course features case studies of trainees involved in difficult cultural and professional situations during overseas assignments. http://ethicsandglobalhealth.org Getting a Médecins Sans Frontières (MSF) mission accredited for training Moore A and Lee A. Newsletter of the International Emergency Medicine Special Interest Group of the Australasian College for Emergency Medicine 2010; 6 (2): 7. A trainee and remote supervisor’s account of applying to ACEM for accreditation of an MSF mission in Zalingei, the provincial Capital of West Darfur state in Sudan. https://www.acem.org.au/Standards-Publications/Publications-Papers.aspx doi: 10.1111/1742-6723.12323
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