The Eight Cs: A Guide to Success in an International Emergency Medicine Educational Collaboration
Address for correspondence and reprints: Scott G. Weiner, MD, MPH; e-mail: email@example.com.
The Tuscan Emergency Medicine Initiative (TEMI) is a comprehensive emergency medicine (EM) training program designed to build an EM training infrastructure in Tuscany, Italy. The program has successfully trained a team of instructors using a train-the-trainers model, certified 350 physicians who are already practicing in emergency departments (EDs), and established a master’s program as a bridge to specialty training at the region’s three universities. Using lessons learned from this program, the authors identify eight factors (The Eight Cs) that can serve as a guide to implementing a collaborative EM program in other environments: collaboration, context, culture, credibility, consulting, consistency, critique, and conclusion. Each of these topics is described in detail and may be useful to other international interventions.
ACADEMIC EMERGENCY MEDICINE 2008; 15:1–5 © 2008 by the Society for Academic Emergency Medicine
The specialty of emergency medicine (EM) is developing rapidly throughout the world as people and their governments begin to recognize its potential for improving public health conditions.1 To expedite its development, multiple international collaborations have been formed between countries with developed EM systems and those who wish to develop them.2–6 Although the projects vary from the participation of a few physicians to entire regions or countries, there is one common factor: clinicians from one system advise those seeking consultation on how best to develop their own EM system. Although such cross-country exchange can bring insight and improvement, problems such as language barriers, cultural differences, and lack of understanding of foreign systems can hinder progress.7–10
We participated in a collaborative international program called the Tuscan Emergency Medicine Initiative (TEMI). TEMI is a joint project involving the Region of Tuscany, Italy; the Universities of Florence, Pisa, and Siena; the Department of Emergency Medicine at Beth Israel Deaconess Medical Center; and Harvard Medical International. The program is funded by the Region of Tuscany and has the goal of creating a training infrastructure to teach existing and new physicians to provide competent emergency care throughout the region’s hospitals and ambulance systems. The resulting program has successfully trained a team of instructors using a train-the-trainers model, certified 350 physicians who are already practicing in emergency departments (EDs), and established a master’s program as a bridge to specialty training at the region’s three universities. The complete project has been described previously.11
The implementation of this program taught us many important lessons about EM development in an international collaboration. This article will discuss important points we learned to address, which can serve as a guideline for any group attempting to bring EM to a new area. We call these factors “The Eight Cs.” Using our program to provide specific examples, we have identified eight points to address in developing collaborative international EM training programs.
The most important and basic step is to establish collaboration. This is an obvious prerequisite for commencing a program, but must occur at many more levels than may be initially apparent. In our program, the initial collaboration was with the Tuscan Minister of Health and the Dean of the University of Florence Medical School. However, as our program expanded, we had to be inclusive of the deans of the other universities in the region and the leadership of all hospitals involved, whether university or community. We also found it particularly important to gauge the level of support or resistance from local non-EM physicians and came to recognize the political value of including them in the venture whenever possible.
The style of teaching should also reflect a collaborative spirit. We tried to avoid the impression that we were forcing an American system onto the Italian one, but rather that we were helping the Italians to improve their system, not to adopt our own. We taught with, and not to, the Italians. We ran workshops with both American and Italian physicians in the teaching role. We attempted to respect their style of teaching and practice, while suggesting new ideas and changes in such a way as to determine if they could be incorporated to improve their model, instead of imposing an “our way is better” approach. It was an iterative process where different teaching methods (e.g., high-fidelity simulation) and styles (e.g., practical emphasis over theoretical) were introduced, feedback was given, and the techniques were modified to suit the purposes of both the learners and host teachers.
When undertaking a project of this nature, it is important to understand the societal context involved. What happened in the society or institution that encouraged the assistance of a foreign group? There are several possibilities, including political agendas, medical errors, or a desire to replicate a program because it was implemented successfully in another region or country. Regardless of the reason, this factor is often not stated or obvious but is of fundamental importance for the consultants to determine.
In our program, we had the support of leaders who had visions of creating a strong EM delivery and training program as a way to showcase their health and educational system. Along with these political agendas, increased ED visits, well-publicized medical errors, and the recent acceptance of EM in several European countries contributed to a perceived need for EM.
Learning about another country’s culture is fundamental to success in such an intervention. Without this understanding, there is room for miscommunication and failure. One of our early experiences involved a meeting where the director of a hospital was discussing how best to implement our proposed training project with the leadership of various departments. We watched, in amazement, while everyone yelled loudly at each other, gesticulating and passionately defending their points of view. After a moment of chaos, the director of the hospital suggested that everyone take a break for espresso. When we returned 15 minutes later, we learned that everything had been resolved during the coffee break.
We attempted to overcome potential cultural barriers by involving as many Italians as possible in the program. We had Italian assistants accompany us to meetings. We involved Italian instructors as much as possible, and when Americans taught, we removed unfamiliar abbreviations and terminology from their lectures. We also discovered that language and subtleties of language were extremely important. When non–Italian-speaking instructors came, we provided translation. We found that it is unrealistic to expect foreign physicians—even those who speak English well—to experience high-level medical learning in a nonnative language.
Most importantly, we learned that the health care environment as a whole shapes the culture of a physician. Whereas in the United States we are generally stimulated by financial fee-for-service incentives for seeing more patients, performance of procedures, and good documentation, this is not directly the case in a socialized system like Italy’s. We discovered that recognition from leadership, getting credit for continuing medical education, and gaining “points” on one’s curriculum vitae (helpful when looking for another position) were the important motivators in the current structure of the Italian system.
The credibility of the consulting group is essential to having initial participation from involved parties. Each country has its own culture, style, vanity, and sense of adequacy. While recognizing the need to change, not only will no one automatically accept a program from outsiders, but there is a natural defensiveness to describe one’s own system as superior, without need for change or improvement. To increase the acceptability of training recommendations, the physicians undergoing the change need to respect the teaching skills, knowledge, and expertise of the consultants. This is likewise the case for those providing the funding of the program.
A key component of our early credibility was supplied by the reputation of our institution and the up-front involvement of many of our senior faculty. Early in the process, we invited key leadership personnel from Tuscany to visit Boston, including both physicians and administrators. They met with our leadership and attended a series of conferences and lectures designed to illustrate the care model we provide and the curriculum we proposed to help them implement. They also observed care in our ED, and we discussed which aspects were applicable for translation to their system.
Our group brought extensive experience with international programs. Nevertheless, we were not hesitant to seek outside help when necessary, to ensure credibility. For example, passing the qualification course in Tuscany means that the physician is competent to safely practice EM. To make that judgment, we brought American emergency physicians not affiliated with our institution, but who had extensive testing experience with the American Board of Emergency Medicine, to conduct the final examination. We also had many visiting experts (from nonaffiliated institutions) in international EM, emergency ultrasound, medical simulation, and pediatric EM, all with the goal of making the highest quality, most credible program possible.
While understanding and respecting another culture is important, being outsiders does provide some advantage. The principal benefit is that it enables the consultants to stay outside the quarrels and advocacies of existing politics and to avoid choosing sides. By truly being consultants (i.e., experts who comment on and suggest improvement in a system in a nonbiased fashion), we were able to make valid changes to the system without threatening the existing political structures. This position allowed us to greatly help the emergency physicians who were long ignored by other specialties.
A key lesson learned is that it is often tempting to solve problems using the resources from one’s home institution. However, it is imperative for the local institutions to solve their own problems in ways that work best within their system. Ultimately, if the structure is totally dependent upon the consultants, there cannot be any permanent change or improvement to the system. For example, we had great difficulty finding mannequins to use for instructing resuscitation techniques. Many times we were tempted to simply bring them from the United States for use in the course. By instead insisting that they procure their own mannequins, and helping to find the resources to do so, they now have the equipment to continue simulation training after we leave. As consultants, it is of utmost importance to work towards the hosts’ self-sufficiency by creating a lasting framework that will exist after the consulting presence is gone.
As the backgrounds of the participants were diverse, it is difficult to know the individual experience of each student. It is therefore prudent and efficient to provide the same curriculum to all students, even if some of it is redundant to prior education. EM offers a unique approach to the patient and knowledge base, and that should be the blueprint for the entire curriculum. We chose to use a hybrid curriculum based on the residency program of our home institution and the American and European core curricula.12–14 This structure was carried through in all of our programs.
Furthermore, when dealing with so much variability in approach to the patient, we discovered that the structure imposed by courses such as Advanced Cardiac Life Support (ACLS), Pediatric Advance Life Support (PALS), and Advanced Trauma Life Support (ATLS) was useful to encourage a unified approach to care of critical patients. To this end, we created our own 1-day courses for both adult cardiac and pediatric critical care based on the most recent American and European resuscitation guidelines, and all participants were provided the opportunity to take the formal ATLS course.15,16 Getting everybody on the “same page” by encouraging an airway–breathing–circulation approach to all patients, we were able to instill the EM approach in all course participants.
Constant evaluation of the program by course participants is essential to determine if the intervention is appropriate. We administered survey evaluations for every didactic activity performed, including all lectures and workshops starting from the first day. This action has created a culture of evaluation and critique. Our participants expect that we will ask their opinion of the didactic activities, which was not done before our arrival. Our lecture evaluation form asks participants to judge the didactic ability of the instructor, the importance of the lecture to EM, if the lecture content is up to date, and if the lecture was clear and effective. We constantly monitor this information and have used it frequently to modify which topics are covered and which instructors teach.17 Once a critique is received, it is important to be willing to change. Flexibility with a constant goal of maximizing the experience, either by fine-tuning or by effecting more drastic changes, is essential to success.
The ultimate responsibility of such a program is to help create a stable infrastructure from which the consultants can and will withdraw. The exact structure will vary from country to country and region to region and will likely not be a reproduction of EM in the consultant’s country, as its evolution and societal needs will differ. Regardless of what it becomes, the infrastructure should be enduring and be able to continue to support the goal of EM as a specialty even after the consultants leave.
In our project, we used local resources, including office staff that will be present after our departure. We began the project with a train-the-trainers program to ensure that there was a capable cadre of instructors to train the next generation of emergency physicians. We enacted our qualification track to bring the physicians already working in EDs to an appropriate level of knowledge. We encouraged the masters program in EM to begin training the next generation of emergency physicians, and we advocated for the institution of a residency training program that could take students as they graduate medical school, allowing them to train as specialists in EM. Most importantly, we have been strong proponents for the national recognition of EM as an autonomous specialty, which we believe is the key to the enduring presence of EM in a country.
Emergency medicine is an important specialty for countries to develop, not only for the improvement in the management of acute medical and traumatic diseases it offers, but also for its public health impact through both primary and secondary disease prevention and its essential role in response to natural and man-made disasters.1,18 Awareness of this fact has led to the recognition and development of the specialty of EM in more than 30 countries.14 Still, there is much more work to be done internationally. Sharing the vast experience of EM in countries with developed systems like the United States with countries attempting to develop EM can decrease development time and minimize duplication of efforts and heterogeneity of the scope, content, and conduct of EM in each country.8
Kirsch et al.8 addressed the methodology of developing EM in other regions. These authors listed four methods of developing local expertise in EM: 1) Local interested physicians complete an EM residency in a country where the specialty is recognized and return home to start the specialty; 2) physicians with EM clinical experience become mentors for new trainees and develop the specialty, sometimes including visiting faculty from other countries with developed EM to assist; 3) Local physicians visit other countries for short training programs and courses; and 4) short training courses run by experienced EM faculty are held in the target country.
Although it is noted that the second technique is difficult due to its expense and the need for faculty from developed countries to relocate to the target country for extended periods, we are believers in this methodology. In fact, many successful interventions that have been published use this technique.2–4 We believe that, for a large-scale program to be successful, it is absolutely essential that there be constant consultant presence.
Other specific projects have also established guidelines for developing EM internationally. A program in Ethiopia lists essential steps to develop an EM system, including addressing facilities, staffing, and organizational needs.5 Thomas10 describes essential “pieces of the puzzle” necessary for program development: reliable and identified partners (the physician group interested in developing EM), support (governmental and from other physician specialties), and infrastructure components. A curriculum development project in China6 used the six steps defined by Kern et al.:19 problem identification, needs assessment, goals and objectives, educational strategies, implementation, and evaluation and feedback. Lessons learned from a project in another part of China are that American ethnocentricity must be constrained, that cultural sensitivity and patience are essential for long-turn changes, and that the consultant must be content with changes seen in small increments rather than massive transformation.4 Finally, a guideline by Holliman et al.20 lists a number of planning recommendations for development of EM systems. This article remains a definitive reference for those involved in EM development projects, and we propose The Eight Cs as complementary information.
While we found many of the existing recommendations helpful, we were surprised at how much the success (or failure) of a collaborative, cross-cultural, educational venture actually hinged on real-life, everyday considerations. Understanding and addressing factors such as local politics, personality conflicts, and subtle cultural differences or language nuances were no less important than understanding some of the larger (and more well-described in the literature) factors. Therefore, we emphasize real-life examples and factors such as politics, credibility, and consulting tips, which are underestimated or not stated in other guidelines, but that we found are fundamental to success.
We recognize that Italy is a country with significant resources and a project of this scale will not be possible in every case. However, the core lessons learned can be applicable to any development project. We offer these criteria as a checklist to consider when implementing any international EM collaboration. Just as every country has a unique culture and history, there is no “one-size-fits-all” recommendation that will work for all projects. Likewise, the challenges we faced and overcame will undoubtedly be different than in other projects. Still, if The Eight Cs are considered and addressed, we predict a higher probability of success in such endeavors.