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