Background

Emergency medicine (EM) is one of the youngest medical specialties in the world and is rapidly growing all around the globe. Emerging in the late 1960s in USA and UK, EM is now a recognized medical specialty in more than 50 countries worldwide. EM is a mature, fully established medical specialty in only a handful of nations—USA, UK, Canada, Australia/New Zealand, Hong Kong, and Singapore. It is in the early or middle stages of development in about 45 countries, and many other countries have little or no EM or acute care systems development at all [1–4]. In the vast majority of the countries in the world, EM is not yet fully developed in the aspects listed in the following:

EM as a profession and specialty, with governmental recognition, board certification, national professional societies, and specialty journals;
EM residency programs and educational programs for physicians, medical students, nurses, and other health care professionals;
trauma system development;
emergency medical services (EMS) and prehospital services development;
administrative and management expertise in EM operations and development;
economic and financing aspects of EM and acute care services;
health legislation, policy, and public health agenda for EM and acute care [1–6].

Countries with EM systems under development look to nations with more fully developed EM systems, professional societies, and emergency physicians for expertise, education, advice, and collaboration. Over the past 20 years, emergency physicians from EM systems at all developmental stages have looked beyond their borders to learn how EM is practiced in other parts of the world and have become increasingly involved with their international colleagues. The emerging field of international emergency medicine (IEM) is concerned with the development of EM and acute care systems in countries and regions where such development is needed and with encouraging educational, research, and informational exchanges between EM systems around the world [7, 8]. The enormous and growing international community of emergency physicians has a tremendous amount of expertise and advice to share and is increasing its cooperation and collaboration through IEM activities, projects, and conferences.

Many emergency physicians have begun lecturing and teaching in settings outside their countries and outside the EM systems in which they were trained and have gained experience. This chapter addresses important considerations for teaching international audience, including common pitfalls and mistakes.

Technical Considerations for Teaching International Audience

Certain technical pitfalls should be anticipated when teaching abroad. Although many physicians around the world share and understand medical terminology (most physicians learn medicine in English, whether they are fluent in English or not), speakers should be aware of several important technical details when preparing educational materials, practicing lectures, and writing curricula. Senior EM educators can easily leave an audience confused, even in a normally first-rate lecture, if the following language considerations are ignored.

Avoid Idioms and Colloquialisms

An idiom is “an expression that means something other than the literal meanings of its individual words” [9]. Examples are

It’s raining cats and dogs
Something fishy is going on
The horse is already out of the barn
We can’t see the woods for all the trees
German: “Du hast einen Vogel,” which means “You’re crazy” but translates as “You have a bird”
Dutch: “Ik krijg altijd mijn zin,” which means “I always get what I want” but translates as “I always get my sin”

Although these colorful turns of phrase are meaningful to many native speakers of your own language, they often are misunderstood by people who have only a working knowledge of it. Furthermore, if your lecture is being translated, the intent of idioms becomes difficult to convey, causing delays in translation and further confusion.

Solution: Review your spoken and written educational materials for idioms and language that might be confusing.

Avoid Abbreviations

In your spoken language, lecture slides, and written educational materials, avoid using abbreviations, acronyms, and locally relevant terminology whenever possible. Following is a list of few examples.

Abbreviations on medical charts: HEENT, PERRLA, COR, EXT, DTR, SOB.
Laboratory and diagnostic data: CBC, H&H, CHEM-7, LFTs.
USA-specific or country-specific abbreviations: HIPPA, COBRA, EMTALA, ACEP, ABEM.

Solution: Whenever possible, write out terms and proper names to avoid confusion.

Remember Local Variations

Basic medical education and practice tend to be similar between countries, but many unforeseen differences emerge in the details of everyday medical practice. Examples include the following.

Medical documentation

SOAP note versus history and physical versus progress notes
- extent of documentation varies depending on location, culture, language, and use of technology;
- avoid common abbreviations;
- spell out medical notes used in your presentations when necessary.

Laboratory test names, laboratory values, and diagnostic results

Differences in laboratory values, units, and normal values
- a blood glucose of 75 may be high, low, or normal depending on what units are used;
- best to indicate HIGH, LOW, or NORMAL, as applicable.

Differences in use of panels and panel names
- CBC, Chem-7, BMP, LFTs, and so on.

Differences in availability of diagnostic tests and turnaround times related to cost, personnel, and training.

Medications

Differences in drug names
- trade names versus generic names;
- lack of access to certain medications because of cost, local formularies, and local sensitivities.

Different dosing practices
- amounts, duration, and so on.

Solution: Whenever possible, to avoid confusion, clarify and write out terminology used in documentation, the names of laboratory tests and values, and the names of pharmaceuticals.

Table 18.1 lists some common errors that are made in the presentation of written and verbal medical material and suggests strategies that can avoid confusion and miscommunication.

Table 18.1 Extracts from a hypothetical clinical case presentation that would have to be modified before delivering in spoken and/or written format to an international audience.

(i) CC: 50-yr F presents with rt facial droop and dysarthria × 90 minutes; describes RUE weakness & spasm, polyuria & polydipsia × 1 week		Chief Complaint: 50-year-old woman presents with right facial droop and dysarthria for 90 minutes; describes right upper extremity weakness and spasm, polyuria, and polydipsia for 1 week

PMH: HTN, hyperchol and hypothyroidism		MEDICAL HISTORY: hypertension, hypercholesterolemia, hypothyroidism

PSH: Left hand for CTS		SURGICAL HISTORY: Left hand for carpal tunnel syndrome

SOC: + ex tob, denies EtOH or IVDU	CHANGE TO	SOC: + ex tobacco, denies alcohol or intravenous drug use

CXR: neg		CHEST FILM: negative
CT Brain: old lacunar infarcts, no SAH/SDH		CT Brain: old lacunar infarcts, no subarachnoid or subdural hemorrhages

PE:		PHYSICAL EXAM:

GEN: A&Ox3; NAD, + droop		GENERAL: alert and oriented to person, place, and time; no acute distress, + facial droop
HEENT: perrla, eomi		Head/Eyes/Ears/Nose/Throat: pupils equal, round, reactive to light and accommodation, extra-ocular movements intact

COR: rrr		CORONARY: regular rate
PULM CTA b/l, -r/r/w, GAE		PULMONARY: clear bilaterally, no rales/rhonchi/wheezes, good air entry
ABD soft, NT, -r/r/r, -CVA		ABDOMEN: soft, nontender, no rebound/rigidity/referral, no costovertebral angle tenderness
EXT–c/c/e; pulses = b/l		EXTREMITIES: no cyanosis/clubbing or edema; pulses equal bilaterally
NEURO + 2/4 DTR, 5/5 STR; + Rt facial droop; + intention tremor		NEURO + 2/4 deep tendon reflexes, 5/5 strength; + right facial droop; + intention tremor
(ii) Rx: Lipitor, Synthroid, Zestril	CHANGE TO	MEDICATIONS: atorvistatin, levothyroxine, lisinopril
(iii) LABS:		LABS:
11.4		White blood cell count: 11.4
CBC: 8.4 > − − − − < 51		Hemoglobin: 11.4 (low normal)
32.7		Hematocrit: 32.7 (low normal)
		Platelets: 51 (very low)
136 I 91/185
CHEM-20: 3.3 I 40\		Sodium = 136 Potassium = 3.3 (low)
	CHANGE TO	Chloride = 91 CO₂ = 40
		Urea = 36 Creatinine = 0.8 Glucose = 185 (high)

PT/PTT: 12.1/21.3/1.0		Prothrombin time: 12.1 seconds
		Partial thromboplastin time: 21.3 seconds
		INR: 1.0

CK: 98		Creatinine kinase: 98 (high)
(iv) VS: HR 115 RR20 BP165/70 T99.4 Pox 96% on RA	CHANGE TO	VS: HR 115 RR20 BP165/70 T37 degrees C Pulse oximetry 96% on room air
ECG: inv T’S in III		ECG: inverted T-waves in III

Points to be considered: (i) spell out abbreviations; (ii) use generic or chemical names for pharmaceuticals; (iii) be careful with laboratory abbreviations, the names of panels, and local conventions of documentation—always indicate abnormal laboratory results; and (iv) some terms are nearly universal (e.g., ECG/EKG, BP); it is not necessary to write out every term.

Interpreter and Translator Considerations

In many international conferences and educational courses interpreters (for oral speech) or translation services (for written text) are used, who or that translate either simultaneously or sequentially. It is important to find out whether these services will be needed, if they will be available, and which kind will most likely be used.

For simultaneous translation, an interpreter listens to your words (perhaps sitting in sound booths), reads your slides and/or written materials, and then translates the lecture simultaneously to the audience via wireless headphones or other devices. The success or failure of this practice depends on the fluency of the interpreter (including his or her familiarity with medical terminology) and the ability of the lecturer to deliver understandable, cogent material. It can feel as though you are lecturing to the interpreter, who then lectures to the audience on your behalf. The use of idioms or unclear language can reduce the translator’s ability to interpret your message. Translators who become overwhelmed or confused tend to default to translating the words on the slides instead of the speaker’s words; for this reason, it is better in certain situations to write your spoken words on the slides and actually read your slides (something you would rarely do when lecturing to an audience of native speakers of your language). This technique enables the translator to translate your words verbatim and allows the audience to read the slide text along with the translator, if they are able to do so. This strategy can deliver and reinforce your message more effectively. It also allows the slides to be used as written and printed teaching and studying materials because they contain a more complete version of your material than your usual slides. In addition, when a simultaneous translator is reading the slides verbatim, it is necessary for you to pause for a few moments when you finish reading the text on your slide to allow the translator to “catch up” before you advance to the next slide—the translator is usually one or two sentences behind you and reads and translates less than your full text.

Sequential translation also involves a translator/interpreter but without simultaneous translation or wireless headphones. In this technique, the lecturer speaks a sentence or two and then pauses while the interpreter translates the information. The lecturer and translator trade sentences for the entirety of the lecture. This technique brings with it all the considerations and problems of simultaneous translation but introduces a few new ones: (i) the lecturer needs to speak slowly, in only a few sentences at a time, so that information is not lost, mistranslated, or forgotten by the translator and (ii) the audience is frequently several moments behind the speaker and the translator in terms of comprehension and understanding, causing a delay in their reactions, laughter, and responses to questions.

Translation services can double or triple the time it normally takes to deliver your lecture. Furthermore, the frequent pauses and trade-off between lecturer and translator can disturb the natural conversational rhythm of the talk, requiring additional time and possibly reducing the effectiveness of your presentation. This means that you cannot expect to deliver a 60-min lecture in the same time slot. Therefore, you must either shorten your talk or request more time for speaking.

Regardless of whether translators or interpreters are used, you should always allow more time for speaking or delivering your usual lecture when teaching to an international audience, given the unknowns in interpretation, fluency, and understanding. Do not forget that the use of translators and interpreters relies on the proper functioning of wireless or other broadcast technology, so having backup lectures and materials can be useful.

Solution: Always inquire whether translators or interpreters will be necessary and available and ask about the type of translation that will be used. Make corresponding allowances in time, content, and style.

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