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Cultural and Ethical Barriers

By: Ryan Joseph, DO, GEC Curriculum Director

Cultural disparities and reactions may seem confusing to many physicians and volunteers.

One evening, while practicing in a rural Ugandan emergency department (ED), I was called to see a young girl who had been struck by a vehicle just minutes prior. I rushed out to the front gates of the ED, and my eyes were immediately drawn to a small, lifeless body in the arms of an older gentleman. A thin trail of blood followed behind as she was taken to the ED and placed on a stretcher. There was an obvious large open skull fracture, an open ankle fracture with small abrasions, and lacerations scattered over her small, battered body. Upon primary assessment, she had a faint pulse with agonal respirations. We placed a nasal cannula, as this was the only supplemental oxygen available, and prepared to perform a FAST exam while the nurse began assessing vital signs. Seconds later, the young girl lost a pulse, and the emergency provider I was working with stated, “She just took her last breath.” I immediately asked the nurse to begin chest compressions, and I asked for some epinephrine to begin resuscitation. Instead of the compressions and medicine, I got a puzzled look from the nurse and the other provider. I asked them why we were not attempting to save her life, and they again stated, “She took her last breath. She’s gone.” I couldn’t comprehend: Why were we not doing everything we could to save this child’s life? The stoic look on the faces of the gentleman who brought her in, the nurse, and the other provider puzzled me.

International Emergency Medicine (IEM) has become a growing field of interest among recent medical school and residency graduates. A 1999 study showed that 62 of 113 (55%) EM residency programs reported participation in international projects.(1) By 2002, 86% of EM residents wanted to participate in an international rotation during residency training.(2) Although the interest has increased substantially, there is inadequate guidance and support from most accredited organizations and residency programs.(3) A survey of 102 EM residency programs looked at the preparation residents received prior to participating in an IEM elective and found that 40% did not receive any formal training.

The benefits of international clinical rotations for a physician’s development have long been recognized, including improved exam skills, broader medical knowledge, and improved procedural competency.(4) In addition to the individual physician’s development, the knowledge and skills acquired abroad can also help meet the current needs of the U.S. health system, which is seeing a continual rise in the number of immigrants.(5)


While acquiring and assimilating large amounts of information is inherent to a physician’s education, adequate ethical training may not be. A recent survey of family medicine residency programs showed that only 6 programs were found to have appropriately constructed, well-defined, comprehensive learning objectives in ethics education, and cultural competence was generally not included in any of the programs curricular aims.6 In contrast, trainees in the United Kingdom and Canada are required to demonstrate competence in ethics outcomes before becoming board certified as an emergency physician.(6) A paper by Iserson et al. asserts that we need to “prepare participants for the cultural and clinical situations they may face.”(7) In 2010 the Working Group on Ethics Guidelines for Global Health Training (WEIGHT) recommended that trainees “should demonstrate cultural competency and engage in appropriate discussions about different perspectives and approaches.”(8)

Unfortunately, our training during residency may not be adequate. Furthermore, as emergency physicians it is essential to our profession that at times we must “learn on the fly,” and this is how we commonly approach the ethical dilemmas we face. However, when approaching similar situations in an international setting, we must be able to recognize cultural uniqueness and be keenly aware of local customs.

About 10 minutes after our young patient died, her parents arrived. The gentleman who had brought the child in, the nurse, and the other provider informed them of what happened. Again, their expressionless faces puzzled me. Not one tear was shed. This young girl, who minutes before was playing outside of her school with friends, suddenly was dead — and there had no tears or questions, quite unlike most similar events in the U.S. This is just one example of cultural disparities and reactions that may seem confusing to many physicians and volunteers.

Unfortunately, scenes like this play out daily around the world, and tragedy is something many cultures become accustomed to. As physicians, nurses, pharmacists, or just volunteers wishing to lend a helping hand, we must be prepared for the ethical and cultural barriers we face when working abroad and learn not only how to cope, but to overcome these challenges.


  1. Alagappan K, Somoza C, Kahoun J, et al. Participation in international EM by U.S. EM residencies. Acad Emerg Med. 1999;6:411
  2. Dey CC, Grabowski JG, Gebreyes K, Hsu E, VanRooyen MJ. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med. 2002; 9(2):679-683.
  3. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med. 2009;84(3):320-325.
  4. Barry M, Bia FJ. Departments of Medicine and International Health. Am J Med. 1986;80(6):1019-1021.
  5. Zong J, Batalova J. Migration Policy Institute: Frequently Requested Statistics on Immigrants and Immigration in the United States. Published March 8, 2017. Accessed October 2, 2017.
  6. Manson HM, Satin D, Nelson V, Vadiveloo T. Ethics Education in Family Medicine Training in the United States: A National Survey. Fam Med. 2013;46(1):28-35.
  7. Iserson KV, Biros MH, Holliman CC. Challenges in international medicine: ethical dilemmas, unanticipated consequences, and accepting limitations. Acad Emerg Med. 2012;19:683-692.
  8. Crump JA, Sugarman J, WEIGHT. Global Health Training: Ethics and Best Practice Guidelines for Training Experiences in Global Health. Am J Trop Med Hyg. 2010;83(6):1178–1182.
  9. Havryliuk T, Bentley S, Hahn S. Global Health Education in Emergency Medicine Residency Programs. J Emerg Med. 2014;46:6:847-852.

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