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Emergency Medicine Australasia (2014) 26, 630–634
doi: 10.1111/1742-6723.12321
TRAINEE FOCUS
Training in global health and international emergency medicine: Where to next? Jennifer JAMIESON,1 Rob MITCHELL,2 Andrew PERRY,3 Joe-Anthony ROTELLA4 and Gerard O’REILLY1 1 Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia, 2Emergency Department, Modilon General Hospital, Madang, Papua New Guinea, 3Department of Emergency Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia, and 4 Department of Emergency Medicine, Austin Health, Melbourne, Victoria, Australia
The Trainee Focus section in this edition of Emergency Medicine Australasia explores training in global health (GH) and international emergency medicine (IEM). In the article by Thurtle et al., several emergency medicine (EM) registrars describe the benefits and challenges of working in resource-limited settings, and Phillips provides insights based on her experience as a mentor and remote supervisor.1 This introductory piece outlines recent developments in GH training, and reflects on the IEM learning opportunities currently available to Australasian EM trainees.
Global health training GH has been defined as an area of study, research and practice that places a priority on improving health and achieving health equity for all. It involves many disciplines within and beyond the health sciences, and synthesises population-based prevention with individual-level care.2 Clinicians involved in GH activities require skills, knowledge and attributes that might not be acquired in the course of a conventional medical education. This has given rise to the concept of GH training, a process by which health professionals develop the
competencies necessary for practice in international and cross-cultural environments.3–6 GH training is most developed in North America, where primary and specialist medical education programmes increasingly provide opportunities for trainees to undertake rotations in resource-poor environments. More mature programmes incorporate a broader range of GH learning activities, including teaching in public health and participation in research projects.3–5 In Australasia, there is limited integration between GH training and postgraduate medical education.7 Only recently has one College Faculty drafted a specific GH curriculum,8 and opportunities for accredited training in low and middle-income countries (LMICs) are rare. An example of innovation in this area is a partnership between the Royal Australasian College of Physicians and Médecins Sans Frontières (MSF), which allows infectious diseases registrars to undertake a 12 month capacity-building placement in a tuberculosis control project in Uzbekistan. Through a remote supervision arrangement, trainees are able to have 6 months accredited towards their non-core training.9
Correspondence: Dr Jennifer Jamieson, Emergency and Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia. Email: missjennyjamieson @gmail.com Jennifer Jamieson, MBBS, BBiomedSc, Emergency Registrar; Rob Mitchell, MBBS (Hons), BMedSc (Hons), MPH&TM, Emergency Registrar; Andrew Perry, MBBS, FACEM, Staff Specialist; Joe-Anthony Rotella, MBBS, BSc, Emergency Registrar; Gerard O’Reilly, MBBS, MPH, MBiostat, FACEM, Emergency Physician, Head of International Programs. Accepted 26 September 2014
Although the benefits of rotations in resource-poor environments are selfevident,3–7,10 GH placements are not without risk to the host community, the trainee and the training institutions in both countries (Table 1).6,7,10,11 The same applies to short-term medical missions undertaken outside of mature and sustainable partnerships, a phenomenon commonly referred to as ‘voluntourism’.12,13 Host communities are vulnerable, but implementation of risk management strategies and observance of ethical guidelines can ameliorate the potential for harm.5–7
International emergency medicine IEM is a sub-specialty of EM focused on global emergency care (GEC) development activities, disaster response and the provision of medical assistance during complex emergencies.14,15 The discipline has been conceptualised as a subset of GH, in part because it is centred on the delivery of healthcare in resource-limited environments. 15 Although there is no agreed definition, IEM practice typically encompasses all aspects of emergency care, including clinical service, teaching and training, systems development, quality improvement, leadership, advocacy and research. The value of strengthening emergency healthcare systems in LMICs has been extensively described, particularly in terms of the growing global burden of non-communicable diseases and injury.15–18 More data are emerging regarding the positive impact of timely intervention on a range of
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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EMERGENCY MEDICINE TRAINING
TABLE 1. Summary of benefits and risks of trainee placements in resource-poor environments Benefits
Host community
Training institutions† Trainee
Risks
Host community
Training institutions†
Trainee
• Knowledge exchange between medical practitioners • Additional human resources • Opportunities for bilateral exchange • Establishment of sustainable and mutually beneficial partnerships • Personal and professional development opportunities • Appreciation of unique challenges encountered within a different healthcare setting • Enhanced cultural competence and cross-cultural communication • Deviation from local health priorities • Displacement of local practitioners or trainees • Move towards Western models of care not endorsed by the local community • Inequitable partnerships with imbalance in decision-making • Unsafe or culturally inappropriate clinical practice • Deterrent from investing in sustainable local medical workforce • Financial losses • Potential liability if relationship with host organisation breaks down • Damage to reputation • Suboptimal training • Inadequate supervision or support • Financial stress • Strains on physical and mental health • Threats to physical safety
†Hospital, university or specialty college in source and host country. Adapted from Mitchell et al.7
illnesses and injuries that is common in LMICs, and this evidence base is helping to define the place of emergency care in the broader health system strengthening agenda.16–18 IEM activities in Australasia are increasingly formalised. The ACEM International Emergency Medicine Special Interest Group (IEMSIG) provides a vehicle for sharing knowledge and experience in IEM, and regularly publishes newsletters that describe the positive contributions of ACEM Fellows to GEC initiatives.19 High-profile projects include the development of postgraduate EM training in Myanmar and Fiji, long-term capacity-building programmes in Papua New Guinea (PNG) and Nepal, and the delivery of acute
care short courses in Sri Lanka and Mongolia.19 There is also significant local experience in disaster response, which has become more apparent through the centralisation of training and deployment processes for Australian and New Zealand medical assistance teams.20,21 In keeping with this, the National Critical Care and Trauma Response Centre in Darwin has recently facilitated deployments to the Philippines and the Solomon Islands.22
Training in international emergency medicine Consistent with the availability of GH training in other disciplines, the USA
offers a large number of educational opportunities in IEM. Many of these are formalised through IEM fellowship programmes, which are undertaken by emergency physicians following completion of specialty training. Fellowship programmes typically last 12–24 months, during which participants undertake a range of activities, including overseas fieldwork, operational research, and postgraduate studies in public health and/or tropical medicine.23–25 Despite the widespread take-up, IEM educators in the USA still have a range of unanswered questions about the effectiveness of GH experiences during postgraduate training.26 Growth in IEM training has facilitated better definition of the skills and knowledge required for IEM practice. Core technical components of IEM fellowship programmes in the USA include EM systems development, humanitarian relief, disaster management, public health, travel and field medicine, programme (project) administration, and academic skills.25 In the absence of an IEM fellowship in Australasia, a previous article in this journal has described how ACEM trainees and Fellows can acquire skills in each of these domains through local courses and regional activities.15 Among Australasian Colleges, ACEM has been relatively progressive in supporting trainees to undertake accredited rotations in resource-poor settings. IEMSIG newsletters frequently highlight the opportunities available to EM registrars, and trainees have provided reflections on accredited rotations in PNG, Nepal and, through MSF, in South Sudan.27–29 Among these, the Visiting Clinical Lecturer Program in Madang, PNG, stands out as an example that delivers a rich IEM educational experience in the context of an established capacity-building project.29,30 This placement is now formalised as part of the Australian Government’s Australian Volunteers for International Development scheme.31 As the following article describes,1 the process of seeking prospective approval for training overseas is not without its challenges. For this reason, IEMSIG is developing a guideline for special skills terms in GH and IEM.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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J JAMIESON ET AL.
It is expected that this document will clarify supervision requirements and clearly define the expectations of trainees, supervisors and host organisations. In the meantime, the College has published application guidelines for the Visiting Clinical Lecturer Program in Madang, 31 and similar documents might appear for other ongoing rotations in Asia and the Pacific. Trainees who are interested in undertaking terms in resource-limited environments should also review the checklist in Box 1.
Demand for international emergency medicine training Despite these positive developments, the demand among EM trainees for IEM training experiences has not been established. There is only surrogate evidence of interest through trainee takeup of the established rotations in Nepal and PNG, 28–31 deployments with organisations, such as MSF, and attendance at relevant conferences (such as ‘DevelopingEM’ and the ‘International Emergency Care Symposium’).32,33 It is likely that interest in this area will continue to grow. At university level, there is extensive evidence of GH engagement, with increasing membership of global health groups34 and rising attendance at the annual Australian Medical Students’ Association Global Health Conference. 35 Interns and residents are also accessing global health learning and networking activities, such as the ‘Global Health Gateway’ (an online resource) and ‘Global Health Connect’ (an experience-sharing forum in Sydney and Melbourne).36,37 One of the challenges for globally minded ACEM trainees and Fellows is remaining engaged during their registrar and early consultant years. Even if opportunities arise, trainees face difficulties engaging in international emergency placements because of the competing demands of clinical training, exams, research and domestic commitments. 3,7,26 Addressing these barriers is part of the challenge in creating training pathways for clinicians interested in IEM.
BOX 1.
Pre-departure checklist
Before embarking on a placement in a resource-limited setting, have you: • Thought about why you wish to work abroad? • Read the Global Health Gateway’s Ten Ethical Principles for Working Overseas, and considered the potential for unintended consequences?39 • Defined your personal and professional goals? Does the placement have any specific development objectives? • Found out if you can be granted leave from your workplace? • Enquired whether your training programme might accredit this placement? • Considered if there are any registration, employment and industrial requirements, such as visas, medical indemnity and credentialing processes? • Determined if further training is required? Would it be useful to undertake a refresher course in Advanced Life Support, Advanced Paediatric Life Support, or Advanced Life Support in Obstetrics? Would there be value in undertaking further training in ultrasound, anaesthetics or medical education? • Conducted a financial analysis, listing sources of expenditure and income while away? • Investigated what level of supervision is required? Who will be your support person on the ground? Do you need to consider additional remote support and mentoring? • Investigated the potential for security issues? Have you consulted with your host hospital or organisation, local non-governmental organisation consortia, foreign government sources and the Australian Government’s smartraveller website? • Recognised that travel health is vital? Have you had a medical review with your general practitioner and organised any necessary vaccinations? What supports will be available for your physical and mental health while you are away? • Looked into what forms of pre-departure and post-placement debriefing are available? • Considered the value of self-reflection? How do you plan to incorporate this into your daily working schedule while away? • Thought about your plan for re-entry, and the potential need for assistance with decompression and debriefing? • Read The Guide to Working Abroad for Australian Medical Students and Junior Doctors, which provides in-depth advice on all of the above?40
Where to next? Despite the opportunities currently available to ACEM trainees, there is no defined path for those interested in pursuing IEM as a substantial component of their practice. Some trainees and Fellows might be satisfied with a single rotation to a resource-poor environment, but others might be looking for more comprehensive education and training.
The recent International Emergency Care Symposium in Melbourne facilitated a range of discussions on the future of IEM in Australasia, including the potential value in a more explicit training pathway (such as a local IEM fellowship for ACEM Fellows, analogous to the north America model).33 Attendees were supportive of this direction, but did not want formalised training to become a barrier
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EMERGENCY MEDICINE TRAINING
to participation. These discussions occurred in the context of increasing focus on standards in IEM practice, including the development of international guidelines for foreign medical teams responding to disasters and complex emergencies.38 In the context of the growing burden of non-communicable diseases and injury, there is greater clarity around the place of GEC in the broader international health and development agenda. As a consequence, the demand for clinicians with the skills and knowledge to develop emergency healthcare systems in LMICs is unlikely to abate. It is timely, therefore, to consider if trainee access to GH experiences is sufficient, and whether there is a role for more formalised training pathways in IEM. A range of other questions also needs to be answered, including the extent of trainee demand and the capacity for GH training experiences to achieve meaningful educational and development outcomes. Whatever evolves, it is crucial that training and capacity-building programmes are underpinned by sound ethical principles and long-term, mutually beneficial partnerships. Australasia is well positioned to become a leader in emergency care development in the Asia-Pacific, and a generation of trainees is waiting to accept the challenge.
Competing interests JJ, RM, AP and J-AR are section editors for Emergency Medicine Australasia.
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References 1. Thurtle N, Phillips G, Keage J, Wallis A, Mitchell R, Jamieson J. Perspectives on working and training in global health and international emergency medicine. Emerg. Med. Australas. 2014; 26: 635–8. 2. Koplan J, Bond T, Merson M et al. Consortium of Universities for Global Health. Towards a common definition of global health. Lancet 2009; 373: 1993–5. 3. Drain PK, Holmes KK, Skeff KM et al. Global health training and international clinical rotations during
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residency: current status, needs, and opportunities. Acad. Med. 2009; 84: 320–5. Battat R, Seidman G, Chadi N et al. Global health competencies and approaches in medical education: a literature review. BMC Med. Educ. 2010; 10: 94. Chase J, Evert J, eds. Global Health Training in Graduate Medical Education: A Guidebook, 2nd edn. San Francisco: Global Health Education Consortium, 2011. Crump JA, Sugarman & the Working Group on Ethics Guidelines for Global Health Training (WEIGHT). Ethics and best practice guidelines for training experiences in global health. Am. J. Trop. Med. Hyg. 2010; 83: 1178–82. Mitchell RD, Jamieson J, Parker J et al. Global health training and postgraduate medical education in Australia: the case for greater integration. Med. J. Aust. 2013; 198: 316–9. Australasian Faculty of Public Health Medicine. Draft AFPHM Curriculum to prepare Fellows for Global Health Practice. AFPHM eBulletin – 4 November 2011 (page 3). AFPHM, Sydney. 2011. Alfred Health. Infectious Diseases / Microbiology Registrars. Medecins Sans Frontieres Infectious Diseases Fellow. [Cited 19 Sep 2014.] Available from URL: http://www .alfredhealth.org.au/Page.aspx?ID =533 Vermund S, Audet C, Martin M, Heimburger D. Training programmes in global health. BMJ 2010; 341: 1231–2. Reisch R. International service learning programs: ethical issues and recommendations. Dev. World Bioeth. 2011; 11: 93–8. Martiniuk AL, Manouchehrian M, Negin JA et al. Brain Gains: a literature review of medical missions to low and middle-income countries. BMC Health Serv. Res. 2012; 12: 134. Snyder J, Dharamsi S, Crooks VA. Fly-By medical care: conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists. Global Health 2011; 7: 6. Arnold JL. International emergency medicine and the recent develop-
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ment of emergency medicine worldwide. Ann. Emerg. Med. 1999; 33: 97–103. Sistenich V. International emergency medicine: how to train for it. Emerg. Med. Australas. 2012; 24: 435–41. Razzak JA, Kellerman AL. Emergency medical care in developing countries: is it worthwhile? Bull WHO 2002; 80: 900–5. Anderson P, Petrino R, Halpern P, Tintinalli J. The globalization of emergency medicine and its importance for public health. Bull WHO 2006; 84: 835–9. Hsia R, Razzak J, Tsai AC, Hirshon JM. Placing emergency care on the global agenda. Ann. Emerg. Med. 2010; 56: 142–9. 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 National Critical Care and Trauma Response Centre. AUSMAT. [Cited 20 Sep 2014.] Available from URL: http://www.nationaltraumacentre .nt.gov.au/what-we-do/disaster -management/ausmat New Zealand Ministry of Health. NZ Medical Assistance Team. [Cited 20 Sep 2014.] Available from URL: http://www.health.govt.nz/our-work/ new-zealand-medical-assistance -team National Critical Care and Trauma Response Centre. News. [Cited 20 Sep 2014.] Available from URL: http://www.nationaltraumacentre .nt.gov.au/news International Emergency Medicine Fellowships Consortia. IEM Fellowship Programs. [Cited 20 Sep 2014.] Available from URL: http://www . iemfellowships . com / programs .php Bledsoe GH, Dey CC, Kabrhel C, VanRooyen MJ. Current status of International Emergency Medicine fellowships in the United States. Prehospital Disaster Med. 2005; 20: 32–5. Bayram J, Rosborough S, Bartels S et al. Core curricular elements for fellowship training in international
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emergency medicine. Acad. Emerg. Med. 2010; 17: 748–57. Tupesis JP, Jacquet GA, Hilbert S et al. The role of graduate medical education in global health: proceedings from the 2013 Academic Emergency Medicine consensus conference. Acad. Emerg. Med. 2013; 20: 1216– 23. Tan W. A Mission with Médecins Sans Frontières (MSF) that earned accreditation. IEMSIG Newsletter of ACEM 2010; 6: 8–9. Hsiao KH. Nepal – international emergency medicine in Nepal: expect the unexpected. IEMSIG Newsletter of ACEM 2014; 10: 20–3. Dening K. An advanced trainee’s adventure. emergency medicine in Madang, Papua New Guinea. IEMSIG Newsletter of ACEM 2010; 6: 3–4. Phillips G, Hendrie J, Atua V, Manineng C. Capacity building in emergency care: an example from Madang, Papua New Guinea. Emerg. Med. Australas. 2012; 24: 547–52.
31. 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/ddd753219a58-41c6-b335-763a1df2d07b/ How-to-Apply_Visiting-Clinical -Lecturer-Program-PNG.pdf.aspx 32. Developing EM. Developing EM – A Conference with a Conscience. [Cited 21 Sep 2014.] Available from URL: http://developingem.com 33. The Alfred Emergency & Trauma Centre. International Emergency Care Symposium. [Cited 21 Sep 2014.] Available from URL: http://www .cvent.com/events/internationalemergency-care-symposium-2014/ custom-17-73188b8413c44875b 596dd1ebcf98064.aspx 34. Fox GJ, Thompson JE, Bourke VC, Moloney G. Medical students, medical schools and international health. Med. J. Aust. 2007; 187 536–9. 35. Australian Medical Students’ Association. AMSA Global Health Con-
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ference. [Cited 21 Sep 2014.] Available from URL: https:// www.amsa.org.au/events/global -health-conference/ Global Health Gateway. Global Health Gateway. [Cited 21 Sep 2014.] Available from URL: http:// www.globalhealthgateway.org.au Global Health Connect. Global Health Connect. [Cited 21 Sep 2014.] Available from URL: http:// www.globalhealthconnect.com.au World Health Organization. Foreign Medical Team Working Group. [Cited 21 Sep 2014.] Available from URL: http://www.who.int/hac/ global_health_cluster/fmt/en/ Global Health Gateway. 10 Ethical Principles. [Cited 21 Sep 2014.] Available from URL: http://www .globalhealthgateway.org.au/ index.php/for-students/start-here/ 10-ethical-principles Parker J, Mitchell R, Mansfield S et al. A guide to working abroad for medical students and junior doctors. Med. J. Aust. 2011; 194: eS1–95.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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Emergency Medicine Australasia (2014) 26, 630–634
doi: 10.1111/1742-6723.12321
TRAINEE FOCUS
Training in global health and international emergency medicine: Where to next? Jennifer JAMIESON,1 Rob MITCHELL,2 Andrew PERRY,3 Joe-Anthony ROTELLA4 and Gerard O’REILLY1 1 Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia, 2Emergency Department, Modilon General Hospital, Madang, Papua New Guinea, 3Department of Emergency Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia, and 4 Department of Emergency Medicine, Austin Health, Melbourne, Victoria, Australia
The Trainee Focus section in this edition of Emergency Medicine Australasia explores training in global health (GH) and international emergency medicine (IEM). In the article by Thurtle et al., several emergency medicine (EM) registrars describe the benefits and challenges of working in resource-limited settings, and Phillips provides insights based on her experience as a mentor and remote supervisor.1 This introductory piece outlines recent developments in GH training, and reflects on the IEM learning opportunities currently available to Australasian EM trainees.
Global health training GH has been defined as an area of study, research and practice that places a priority on improving health and achieving health equity for all. It involves many disciplines within and beyond the health sciences, and synthesises population-based prevention with individual-level care.2 Clinicians involved in GH activities require skills, knowledge and attributes that might not be acquired in the course of a conventional medical education. This has given rise to the concept of GH training, a process by which health professionals develop the
competencies necessary for practice in international and cross-cultural environments.3–6 GH training is most developed in North America, where primary and specialist medical education programmes increasingly provide opportunities for trainees to undertake rotations in resource-poor environments. More mature programmes incorporate a broader range of GH learning activities, including teaching in public health and participation in research projects.3–5 In Australasia, there is limited integration between GH training and postgraduate medical education.7 Only recently has one College Faculty drafted a specific GH curriculum,8 and opportunities for accredited training in low and middle-income countries (LMICs) are rare. An example of innovation in this area is a partnership between the Royal Australasian College of Physicians and Médecins Sans Frontières (MSF), which allows infectious diseases registrars to undertake a 12 month capacity-building placement in a tuberculosis control project in Uzbekistan. Through a remote supervision arrangement, trainees are able to have 6 months accredited towards their non-core training.9
Correspondence: Dr Jennifer Jamieson, Emergency and Trauma Centre, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia. Email: missjennyjamieson @gmail.com Jennifer Jamieson, MBBS, BBiomedSc, Emergency Registrar; Rob Mitchell, MBBS (Hons), BMedSc (Hons), MPH&TM, Emergency Registrar; Andrew Perry, MBBS, FACEM, Staff Specialist; Joe-Anthony Rotella, MBBS, BSc, Emergency Registrar; Gerard O’Reilly, MBBS, MPH, MBiostat, FACEM, Emergency Physician, Head of International Programs. Accepted 26 September 2014
Although the benefits of rotations in resource-poor environments are selfevident,3–7,10 GH placements are not without risk to the host community, the trainee and the training institutions in both countries (Table 1).6,7,10,11 The same applies to short-term medical missions undertaken outside of mature and sustainable partnerships, a phenomenon commonly referred to as ‘voluntourism’.12,13 Host communities are vulnerable, but implementation of risk management strategies and observance of ethical guidelines can ameliorate the potential for harm.5–7
International emergency medicine IEM is a sub-specialty of EM focused on global emergency care (GEC) development activities, disaster response and the provision of medical assistance during complex emergencies.14,15 The discipline has been conceptualised as a subset of GH, in part because it is centred on the delivery of healthcare in resource-limited environments. 15 Although there is no agreed definition, IEM practice typically encompasses all aspects of emergency care, including clinical service, teaching and training, systems development, quality improvement, leadership, advocacy and research. The value of strengthening emergency healthcare systems in LMICs has been extensively described, particularly in terms of the growing global burden of non-communicable diseases and injury.15–18 More data are emerging regarding the positive impact of timely intervention on a range of
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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EMERGENCY MEDICINE TRAINING
TABLE 1. Summary of benefits and risks of trainee placements in resource-poor environments Benefits
Host community
Training institutions† Trainee
Risks
Host community
Training institutions†
Trainee
• Knowledge exchange between medical practitioners • Additional human resources • Opportunities for bilateral exchange • Establishment of sustainable and mutually beneficial partnerships • Personal and professional development opportunities • Appreciation of unique challenges encountered within a different healthcare setting • Enhanced cultural competence and cross-cultural communication • Deviation from local health priorities • Displacement of local practitioners or trainees • Move towards Western models of care not endorsed by the local community • Inequitable partnerships with imbalance in decision-making • Unsafe or culturally inappropriate clinical practice • Deterrent from investing in sustainable local medical workforce • Financial losses • Potential liability if relationship with host organisation breaks down • Damage to reputation • Suboptimal training • Inadequate supervision or support • Financial stress • Strains on physical and mental health • Threats to physical safety
†Hospital, university or specialty college in source and host country. Adapted from Mitchell et al.7
illnesses and injuries that is common in LMICs, and this evidence base is helping to define the place of emergency care in the broader health system strengthening agenda.16–18 IEM activities in Australasia are increasingly formalised. The ACEM International Emergency Medicine Special Interest Group (IEMSIG) provides a vehicle for sharing knowledge and experience in IEM, and regularly publishes newsletters that describe the positive contributions of ACEM Fellows to GEC initiatives.19 High-profile projects include the development of postgraduate EM training in Myanmar and Fiji, long-term capacity-building programmes in Papua New Guinea (PNG) and Nepal, and the delivery of acute
care short courses in Sri Lanka and Mongolia.19 There is also significant local experience in disaster response, which has become more apparent through the centralisation of training and deployment processes for Australian and New Zealand medical assistance teams.20,21 In keeping with this, the National Critical Care and Trauma Response Centre in Darwin has recently facilitated deployments to the Philippines and the Solomon Islands.22
Training in international emergency medicine Consistent with the availability of GH training in other disciplines, the USA
offers a large number of educational opportunities in IEM. Many of these are formalised through IEM fellowship programmes, which are undertaken by emergency physicians following completion of specialty training. Fellowship programmes typically last 12–24 months, during which participants undertake a range of activities, including overseas fieldwork, operational research, and postgraduate studies in public health and/or tropical medicine.23–25 Despite the widespread take-up, IEM educators in the USA still have a range of unanswered questions about the effectiveness of GH experiences during postgraduate training.26 Growth in IEM training has facilitated better definition of the skills and knowledge required for IEM practice. Core technical components of IEM fellowship programmes in the USA include EM systems development, humanitarian relief, disaster management, public health, travel and field medicine, programme (project) administration, and academic skills.25 In the absence of an IEM fellowship in Australasia, a previous article in this journal has described how ACEM trainees and Fellows can acquire skills in each of these domains through local courses and regional activities.15 Among Australasian Colleges, ACEM has been relatively progressive in supporting trainees to undertake accredited rotations in resource-poor settings. IEMSIG newsletters frequently highlight the opportunities available to EM registrars, and trainees have provided reflections on accredited rotations in PNG, Nepal and, through MSF, in South Sudan.27–29 Among these, the Visiting Clinical Lecturer Program in Madang, PNG, stands out as an example that delivers a rich IEM educational experience in the context of an established capacity-building project.29,30 This placement is now formalised as part of the Australian Government’s Australian Volunteers for International Development scheme.31 As the following article describes,1 the process of seeking prospective approval for training overseas is not without its challenges. For this reason, IEMSIG is developing a guideline for special skills terms in GH and IEM.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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J JAMIESON ET AL.
It is expected that this document will clarify supervision requirements and clearly define the expectations of trainees, supervisors and host organisations. In the meantime, the College has published application guidelines for the Visiting Clinical Lecturer Program in Madang, 31 and similar documents might appear for other ongoing rotations in Asia and the Pacific. Trainees who are interested in undertaking terms in resource-limited environments should also review the checklist in Box 1.
Demand for international emergency medicine training Despite these positive developments, the demand among EM trainees for IEM training experiences has not been established. There is only surrogate evidence of interest through trainee takeup of the established rotations in Nepal and PNG, 28–31 deployments with organisations, such as MSF, and attendance at relevant conferences (such as ‘DevelopingEM’ and the ‘International Emergency Care Symposium’).32,33 It is likely that interest in this area will continue to grow. At university level, there is extensive evidence of GH engagement, with increasing membership of global health groups34 and rising attendance at the annual Australian Medical Students’ Association Global Health Conference. 35 Interns and residents are also accessing global health learning and networking activities, such as the ‘Global Health Gateway’ (an online resource) and ‘Global Health Connect’ (an experience-sharing forum in Sydney and Melbourne).36,37 One of the challenges for globally minded ACEM trainees and Fellows is remaining engaged during their registrar and early consultant years. Even if opportunities arise, trainees face difficulties engaging in international emergency placements because of the competing demands of clinical training, exams, research and domestic commitments. 3,7,26 Addressing these barriers is part of the challenge in creating training pathways for clinicians interested in IEM.
BOX 1.
Pre-departure checklist
Before embarking on a placement in a resource-limited setting, have you: • Thought about why you wish to work abroad? • Read the Global Health Gateway’s Ten Ethical Principles for Working Overseas, and considered the potential for unintended consequences?39 • Defined your personal and professional goals? Does the placement have any specific development objectives? • Found out if you can be granted leave from your workplace? • Enquired whether your training programme might accredit this placement? • Considered if there are any registration, employment and industrial requirements, such as visas, medical indemnity and credentialing processes? • Determined if further training is required? Would it be useful to undertake a refresher course in Advanced Life Support, Advanced Paediatric Life Support, or Advanced Life Support in Obstetrics? Would there be value in undertaking further training in ultrasound, anaesthetics or medical education? • Conducted a financial analysis, listing sources of expenditure and income while away? • Investigated what level of supervision is required? Who will be your support person on the ground? Do you need to consider additional remote support and mentoring? • Investigated the potential for security issues? Have you consulted with your host hospital or organisation, local non-governmental organisation consortia, foreign government sources and the Australian Government’s smartraveller website? • Recognised that travel health is vital? Have you had a medical review with your general practitioner and organised any necessary vaccinations? What supports will be available for your physical and mental health while you are away? • Looked into what forms of pre-departure and post-placement debriefing are available? • Considered the value of self-reflection? How do you plan to incorporate this into your daily working schedule while away? • Thought about your plan for re-entry, and the potential need for assistance with decompression and debriefing? • Read The Guide to Working Abroad for Australian Medical Students and Junior Doctors, which provides in-depth advice on all of the above?40
Where to next? Despite the opportunities currently available to ACEM trainees, there is no defined path for those interested in pursuing IEM as a substantial component of their practice. Some trainees and Fellows might be satisfied with a single rotation to a resource-poor environment, but others might be looking for more comprehensive education and training.
The recent International Emergency Care Symposium in Melbourne facilitated a range of discussions on the future of IEM in Australasia, including the potential value in a more explicit training pathway (such as a local IEM fellowship for ACEM Fellows, analogous to the north America model).33 Attendees were supportive of this direction, but did not want formalised training to become a barrier
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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to participation. These discussions occurred in the context of increasing focus on standards in IEM practice, including the development of international guidelines for foreign medical teams responding to disasters and complex emergencies.38 In the context of the growing burden of non-communicable diseases and injury, there is greater clarity around the place of GEC in the broader international health and development agenda. As a consequence, the demand for clinicians with the skills and knowledge to develop emergency healthcare systems in LMICs is unlikely to abate. It is timely, therefore, to consider if trainee access to GH experiences is sufficient, and whether there is a role for more formalised training pathways in IEM. A range of other questions also needs to be answered, including the extent of trainee demand and the capacity for GH training experiences to achieve meaningful educational and development outcomes. Whatever evolves, it is crucial that training and capacity-building programmes are underpinned by sound ethical principles and long-term, mutually beneficial partnerships. Australasia is well positioned to become a leader in emergency care development in the Asia-Pacific, and a generation of trainees is waiting to accept the challenge.
Competing interests JJ, RM, AP and J-AR are section editors for Emergency Medicine Australasia.
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