emergency medicine training in ldcs

Emergency Medicine Training

PNG and Nepal – examples from least developed countries

Chris CurryAssoc. Professor, University of Western Australia

Fremantle Hospital

contents

Least developed countriesEM program structuresCurriculaBotswanaSupervisionAssessment

Least Developed CountriesUN 2010

Africa : 33 of 48 LDCs, of 58 African countries

AngolaBeninBurkina FasoBurundiCentral African RepublicChadComoros CongoDjibouti Equatorial GuineaEritrea

Ethiopia Gambia GuineaGuinea-Bissau Lesotho Liberia Madagascar Malawi MaliMauritania Mozambique

NigerRwandaSao Tome and PrincipeSenegal Sierra Leone Somalia SudanTogo UgandaTanzania Zambia

Least Developed CountriesUN 2010

Asia : 8 of 48 LDCs

AfghanistanBangladesh Bhutan Cambodia

Laos Myanmar Nepal Yemen

Least Developed CountriesUN 2010

Pacific : 6 of 48 LDCs

Kiribati SamoaSolomon Islands

Timor-LesteTuvaluVanuatu

(Haiti makes 48)

Human Development Index HDI

• “A composite index measuring average achievement in three basic dimensions of human development—a long and healthy life, knowledge and a decent standard of living.”

Human Development Report 2011 (published 2nd November)

• Papua New Guinea – 153 out of 187 countries

• Nepal – 157 out of 187 countries

Australia : 2 of 187

PNG : 153 of 187 1980 – 2010: HDI rose 1.3% annually

Nepal : 157 of 187 1980 – 2010: HDI rose 2.4% annually

Australiahttp://hdr.undp.org/en/data/profiles/

PNG

Nepal

Health indicatorsAustralia PNG Nepal

GDP per capita (US$ 2008)

$40,286 $2,395 $1,189

Maternal mortality/100,000 live births

8

= 1 in 12,500

250

= 1 in 400

380

= 1 in 263

Under 5 mortality/1000 live births

6

= 1 in 167

69

= 1 in 14

51

= 1 in 20

rural populationsovercrowding in EDs

limited resources in EDs

ED Bed Occupancy at 3pm, 13Nov.Bed No. Male Female Total

1 1 2 3

2 1 1 2

3 2 2 4

4 1 2 3

5 2 2

6 1 3 4

7 2 2 4

8 1 1 2

9 2 1 3

10 2 1 3

11 2 1 3

12 1 1

13 2 2

14 1 1

15 1 1

Total 15 Total 38

Program management

PNG Postgraduate Committee School of Medicine and Health Sciences University of Papua New Guinea

Nepal Institute of Medicine Tribhuvan University Teaching Hospital Tribhuvan University

Years of training

Australasia PNG Nepal (IOM)

undergraduate 4 - 6 5 4.5

PGY1 intern intern intern

PGY2 RMO intern MO

PGY3 Provisional MO MD GP

PGY4 Advanced MO MD GP

PGY5 Advanced MMedEM MD GP

PGY6 Advanced MMedEM DM EM

PGY7 Advanced MMedEM DM EM

PGY8 (or more) MMedEM DM EM

PGY9 (or more)

PGY10

PNG MMedEMrotations months concurrentsurgery 12 Part 1 exams (surgery)

Research project

Part 2 exams

medicine > 4

paediatrics > 4

O&G > 4

anaesthesia > 4

emergency department > 6

ENT 1

ophthalmology 1

Diplomas: child health, G&O, anaesthesia

12 each

TOTAL 4-6 years

Nepal MD GP

rotations months concurrent

surgery (4) + ortho (2)

6 dermatology 10 x ½ day

medicine 6 oral 10 x ½ daydistrict hospital 6 forensic 10 x ½ daypaediatrics 5 ENT 10 x ½ dayO&G 4 ophthalmology 2 weeksED + GP OPD 4 family practiceanaesthesia 3 imagingpsychiatry 1elective 1

Nepal DMs and MChs

Doctor of Medicine Master of Chirurgie (Surgery)

cardiology cardiothoracic and vascular surgery

nephrology urology

gastroenterology gastroenterologic surgery

neurology neurosurgery

Nepal DM EMrotations months concurrent

emergency 24 research thesis proposal in first 6 months

complete in 36 months

anaesthesia 3

ICU 3

elective 6

Curricula

• PNG - ACEM curriculum - Contents of PNG guides for acute care

– medicine, paediatrics, O&G - 35 pages

• Nepal - IFEM model curricula – undergraduate and postgraduate.

(EMA 2011; 23: 541-553) - 34 pages

IFEM model curriculum

“..these (17) seemingly different curricula specify nearly the same specialist with nearly the same competencies, despite differences in length, style and content..

..the epidemiology and caseloads of patients who present to EDs around the world show many more similarities than differences.”

(EMA 2011; 23: 527)

Development of Emergency Medicine in Botswana

Developpement de la medecine d’urgence au Botswana

Ngaire Caruso *, Amit Chandra, Andrew Kestler

Department of Emergency Medicine, University of Botswana School of Medicine,

Private Bag 00713, Gaborone, Botswana

Available online 12 September 2011

Botswana: 118 of 187

Botswana

Australia 2 Botswana 118

PNG 153 Nepal 157

Australia 2 Botswana 118

PNG 153 Nepal 157

Health indicatorsAustralia Botswana PNG Nepal

GDP per capita (US$ 2008)

$40,286 $12,154 $2,395 $1,189

Maternal mortality/100,000 live births

8

= 1 in 12,500

190

= 1 in 526

250

= 1 in 400

380

= 1 in 263

Under 5 mortality/1000 live births

6

= 1 in 167

57

= 1 in 18

69

= 1 in 14

51

= 1 in 20

Botswana MMedEMrotations months concurrentemergency 30 researchsurgery (1) + ortho (2) 3medicine 3anaesthesia 3ICU 3paediatrics 3O&G 2prehospital 1

Comparison PNG, Nepal, Botswana

PNG Nepal Botswana

Entrance PGY5 PGY3 PGY3 Minimums (months)emergency 6 30 30surgery 12 6 3medicine >4 6 3anaesthesia/ICU >4 (12) 9 6paediatrics >4 (12) 5 3O&G >4 (12) 4 2district hospital/prehospital

6 1

others 2 7Totals 48-72 72 48

Supervision

PNG HODs of surgery, medicine, paediatrics, O&G, anaesthesia, visiting emergency physicians

Nepal professor of GP&EMHODs of rotationsvisiting emergency physicians ?

Botswana emergency physicians x4 (FACEM x2)

ACEM contributors to PNG over a decadePeter Aitken, Michael Augello, Colin Banks, Peter Barnett, Michael Bastick, Andrew Bezzina, Antony Chenhall, Chris Curry, Will DaviesKatrina DeningAndrew Dent,Steve Dunjey, David Eddey, Jeremy Furyk, Steve Grainger, Naren Gunja,

Jamie Hendrie, Jack Hodge,Rachel Hoyle, Phil Hungerford, Sandy Inglis, Simon Jensen,Pip KeirJohn Kennedy, Farida KhawajaChris Kruk, Marian Lee, Sally McCarthy, Mark Millar, Gerard O’Reilly, Georgina Phillips, Kate Porges,

Luke Pritchard, Sandra Rennie,Guy Sansom,Nick Ryan, Niall Small,Paul Spillane, David Symmons,Peter Thompson, Ric Todhunter, Greg Treston, Chris Trethewy, Simon Young, Bryan Walpole, James Wheeler, Danielle Wood,Matthew Wright,x 48

Assessment

• PNG Part 1 – surgeryPart 2 – SAQ, VAQ, cases x8, vivas x5

(similar to ACEM)Visiting examiner – FACEM

• Nepal MD (most likely GP)Annual SAQ, MCQ.Final exams including cases x4, vivas x4Visiting examiner

• Botswana South African system

Summary• LDCs operate within challenging constraints• Increasingly, they want to improve delivery of

acute care• They need to build programs and processes

within their own structures and resources• They can borrow extensively from other

sources, and modify• EM competencies are similar everywhere• FACEMs can contribute usefully

Conclusions

• “the emerging role of International Emergency Medicine should be to suggest and inform standards and final competencies, leaving the fine details of selection, training, methods and evaluation to individual countries...”Mulligan T, Hobgood C, Cameron P. EMA 2011; 23: 528

• LDCs benefit from EP contributions made in-country

• EPs contributing from more developed systems may have more to learn than to teach.

,

Thank you