Ping! Another e-mail pops up, seeking my attention. “I’m writing to enquire about trainee positions in Fiji.” Familiar mixed emotions wash over me. I’d worked hard to get the Fiji emergency medicine training rotation accredited by the Australasian College for Emergency Medicine. I’d spoken at conferences and written articles to attract applicants. Having staff from emergency care systems in high-income countries working alongside local staff brought new skills to the team, built understanding and mutual respect, and added credibility to the program. So why this ambivalence?
Was it the effort of managing the expectations of people used to having everything at their fingertips? Of challenging their ideas of “giving back” and “making a difference”? Or of trying but failing to impress on them that 3 months in a country would open their eyes but accomplish little more? There was no shortage of local, smart, motivated young doctors — but there was so little I could do about the daily frustrations with bureaucracy and dysfunctional systems that prevented them from fulfilling their potential and caused many to seek employment opportunities elsewhere.
By introducing trainees from the promised land, would I risk accelerating the brain drain and training doctors for export? Our first cohort of Fiji-trained, master’s level emergency specialists will graduate at the end of the year and will face enormous challenges in establishing the specialty in their home country. Fijian doctors can be found worldwide, but particularly in Australia and New Zealand, where they are attracted by better pay and conditions and where resources are plentiful.1
It is important to appropriately select and prepare visiting staff. Lack of cultural sensitivity and inappropriate ambitions and behaviors on the part of physicians trained elsewhere can cause substantial harm to patients, local staff, departments, and training programs. A new environment requires a significant period of adjustment and calibration. The first month should be spent watching and learning the demographics, epidemiology, illness behaviors, and “the way things are done around here.” Clinicians trained in countries with well-developed health systems often have little insight into how those systems facilitate their own clinical performance and protect their welfare. Actions taken without such insight can undermine patients’ respect for local doctors by reinforcing the common notion that Western physicians are superior.2
If you’re a trainee seeking an exotic medical adventure here, you need to consider the kinds of cases you may encounter — and the qualities you will need in order to handle them well. Say you respond to a request to provide medical assistance: a truck illegally transporting cyanide has run off an embankment and is resting next to a river upstream of several villages. It’s dark out. There is no HAZMAT expertise, no standard operating procedure. No personal protective equipment is provided. Bystanders mingle with fire service personnel, taking photos with their mobile phones. There is no designated hot zone and no cyanide antidote.
Or a 30-year-old man presents to the emergency department with chest pain. You diagnose an inferior ST-segment elevation myocardial infarction. He is given aspirin — streptokinase has been out of stock for 3 months now, and other thrombolytics have been deemed unaffordable for the public system. He develops complete heart block and cardiogenic shock, which don’t respond to an adrenaline infusion. Central catheters and pacing wires are available only in the private hospital.
Or a 20-year-old woman presents in extremis. She had rheumatic fever as a child and has had a mitral-valve replacement. You perform bedside echocardiography. Her mitral valve is barely moving. There is no cardiothoracic surgical service in the country.
Or a young woman in cardiac arrest with pulseless electrical activity does not survive. Postmortem examination reveals a ruptured ectopic pregnancy. She had been seen and sent home from the emergency department several nights earlier — pregnancy testing is unavailable in the emergency department.
Managing your emotions and understanding the emotions of others (so-called emotional intelligence) are of fundamental importance in these situations.3 Having spent the past 3 years establishing emergency medicine in Fiji and recruiting staff to assist, I have reflected extensively on the essential qualities for surviving and flourishing in such challenging environments. The upshot is encapsulated in what I have called the three Rs: realism, resilience, and resourcefulness.
Realism relates to expectation management. There is a gap between the care that overseas clinicians feel they should be able to provide and what can actually be delivered, given the realities of absent or dysfunctional systems and deficiencies in drugs, trained personnel, equipment, monitoring, diagnostics, or therapeutic procedures. Extreme effort (which may involve donated equipment, consumables, or point-of-care diagnostics) and new energy may help to narrow this gap for a short time for a small number of patients, but at what cost? Nonsustainable interventions introduce risk into the system by elevating expectations and creating additional burdens for the staff that remain when visiting clinicians leave. Indeed, alienation of local medical staff, administrators, and policymakers can result in major setbacks for a medical specialty that may be felt for years to come.
Resilience is the capacity to respond to stress in a healthy way so that goals are achieved at minimal psychological and physical cost. Resilient people “bounce back” after challenges while also growing stronger. Resilient clinicians see challenges as opportunities rather than threats. Focusing on strategies to increase individual and institutional resilience (such as building supportive communities) can lessen the impact of dysfunctional systems on clinicians’ welfare and performance.4
Resourcefulness allows clinicians to improvise when specific diagnostic tools, equipment, and drugs are unavailable — to engage in creative problem solving, taking the initiative, thinking outside the box, and going beyond conventional boundaries.
The three Rs can be applied to projects as well as people. In seeking to improve survival after cardiac arrest in Fiji, I identified a shortage of defibrillators, delayed identification of patients’ cardiac rhythm, and lack of confidence in rhythm recognition. These factors resulted in a failure to act. The problem was addressed by procuring automated external defibrillators (AEDs) for smaller health facilities (realism). The AEDs are stored in hard, waterproof cases and used for patient transport (resilience) and were donated in response to a social media campaign (resourcefulness).
Working in Fiji requires you to embody the three Rs. I now insist that the training supervisors of overseas applicants can attest to their realism, resilience, and resourcefulness. I interview them with these qualities in mind. No longer is it enough just to want to come. The three Rs can be applied when recruiting staff, to define the desired skill set and help in selecting participants for sustainable, long-term projects that are locally driven and meet local needs. They can also guide visiting workers’ preparation before their arrival and provide a focus for the supervisors who monitor their welfare and performance once they’re in country.