ETHICS/RESIDENTS’ PERSPECTIVE
Ethical Challenges and Considerations of Short-Term
International Medical Initiatives: An Excursion to Ghana as a
Case Study
John E. Jesus, MD
From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
0196-0644/$-see front matter
Copyright © 2009 by the American College of Emergency Physicians.
doi:10.1016/j.annemergmed.2009.07.014
[Ann Emerg Med. 2010;55:17-22.]
Medical students, physicians, nongovernmental
organizations, and military personnel have participated in shortterm international medical initiatives to the developing world
for decades. Interest in international medical endeavors,
particularly in the field of emergency medicine, has only
increased with time and ease of transport. Despite our good
intentions, ethical challenges frequently pervade the provision of
care in these settings. Through the example of a 2-week medical
initiative to Ghana, this article explores the ethical subtleties
that underlie those challenges and proposes potential avenues by
which to address them.
INTRODUCTION
Medical students, physicians, nongovernmental
organizations, and military personnel have participated in shortterm international medical initiatives for decades. The increased
ease of transport and interest in international endeavors have
only served to increase the numbers of people traveling and
locations visited. In fact, by 2004, 22.3% of US medical
students had completed an international educational
experience,1 and by 2008, 47% of accredited MD-granting
medical schools had established initiatives, centers, institutes, or
offices of global health.2 Furthermore, the field of emergency
medicine has also seen a recent burgeoning of international
interest, research, and collaborations accompanying the
development and recognition of the specialty in more than 30
nations.3-7 Ethical quandaries frequently pervade the practice of
medicine in the developing world by visiting medical personnel
and are exacerbated by factors inherent in what are frequently
brief stays. Efforts to discuss the ethical challenges of short-term
international medical assistance thus far have been relatively
sparse. This article will focus on the ethical subtleties that
underlie our well-intentioned actions abroad, through the lens
of a recent excursion to the eastern region of Ghana. Examples
of ethical challenges that will be explored in the following pages
include the difficulties of obtaining consent and administering
appropriate medical interventions in the setting of language and
cultural differences, the challenges of using limited or
Volume , .  : January 
“substandard” medication or equipment in austere resourcepoor environments, the possibility for harm when treatments
are provided without opportunity for follow-up, the normative
importance of pursuing sustainable projects, and the risks of
allowing amateurs or trainees to practice medicine without the
same oversight they would have within the United States.
Suchdev et al8 put forth a model for sustainable short-term
international medical trips that identifies the following 7 areas
of focus: developing a clear mission, collaborating with the local
community, educating travelers and the local community,
making the commitment to serve the needs of the community,
engaging in teamwork, having sustained capacity building, and
developing a mechanism of periodic evaluation. Building on the
model by Suchdev et al,8 this article provides further detail and
additional guidelines that should be considered before each
international medical initiative, including effective
communication and cultural sensitivity, contextually relevant
use of resources and triage, the avoidance of chronic care
medicine and elective surgery without appropriate follow-up, a
focus on sustainability, and the importance of humility and
oversight.
PRINCIPLES OF BIOMEDICAL ETHICS
In any conversation concerning biomedical ethics, it is
important to recognize 4 major principles: respect for persons,
beneficence, nonmaleficence, and justice. These principles
derive from “a set of moral norms that bind all [morally serious]
persons in all places.”9 They serve as the basis for US federal
regulations governing the treatment of human subjects, as well
as for internationally recognized documents, including the
Belmont Report, the Declaration of Helsinki, and the Council
for International Organizations of Medical Sciences
International Ethical Guidelines for Biomedical Research
Involving Human Subjects.10 Principlism provides a practical
framework with which to evaluate moral problems. They are
not absolute rules, but rather act as prima facie obligations.
Accordingly, each of these obligations must be fulfilled unless an
equally important competing obligation outweighs it in the
pursuit of the “ ‘greatest possible balance’ of right over wrong.”9
It is important to acknowledge that reasonable and
Annals of Emergency Medicine 17
Residents’ Perspective
conscientious people may disagree on how best to interpret
these principles. Equally important during such disagreements is
a serious attempt at respectful resolution through reasoned
argument. I will attempt to critically assess the ethical challenges
of short-term medical initiatives in developing countries by
examining the challenges of providing care during a recent
medical initiative to Ghana.
CHALLENGES TO ETHICAL CARE
Culture and Language
Communication breakdowns and cultural differences are
ubiquitous. Indeed, there are more than 46 million people in
the United States who do not speak English as their primary
language; this population is less likely to receive the care they
need, is less likely to be compliant with treatment regimens, is at
greater risk of experiencing medical errors, and has been the
subject of recent calls for research to more rigorously understand
how language affects care.11 Similarly, participants in short-term
medical initiatives have a responsibility to become as familiar as
possible with local cultural norms and traditional
understandings and practices of healing and to establish an
effective method of communication before traveling and
treating patients. Without an emphasis on cultural competence,
medical providers may place the ethical principle of
nonmaleficence in jeopardy because miscommunication and
misunderstanding may lead to patient harm. In addition,
respect for persons calls on providers to acknowledge and honor
a patient’s ability to consent for treatment, which may be
impossible without an interpreter.12 Furthermore, awareness of
a culture’s beliefs and practices is important to the concept of
beneficence because it fosters an environment of trust and
mutual respect, which may translate to better compliance and
greater effectiveness of medical treatment.13-15 It is impossible
to eliminate all potential miscommunication and
misunderstanding, regardless of geographic location, patient
population, and linguistic skill. The goal, rather, is to allay those
challenges to the greatest extent possible.
In 2008, 5 other medical students and I spent 2 weeks on
a hospital ship staffed by Ghanaian medical personnel from
the Volta River Authority Hospital in Akosombo. The
services provided by this boat are part of an ongoing
commitment by the Volta River Authority, started in 1990,
to provide acute primary care and education free to relatively
isolated communities around the Volta Lake without ready
access to hospitals or clinics (the Volta River Authority is a
hydroelectric power utility company that has engaged in
social and health endeavors aimed at mitigating the effects of
the company’s presence on the surrounding environment and
inhabitants).
Although English is the “official” language of Ghana,
there are 79 spoken languages in a country that is
approximately the size of Oregon.16 Around the Volta Lake,
the most common languages we encountered were Ewe, Twi,
and Ga, whereas very few people spoke English. Because the
18 Annals of Emergency Medicine
Jesus
hospital ship had been operational since 1990, the local staff
was familiar with the language and cultural practices of the
local communities we visited. Meetings with the village chief
on arrival to each village were cultural interfaces critical to
obtaining consent to hold the clinic and treat willing patients
the next morning.
The ability to communicate is essential to any international
medical initiative and served as a significant barrier in our
interaction with the local population. Despite significant efforts
to mitigate communication barriers, the situation posed an
ethical challenge. Although we were able to navigate certain
cultural norms and rituals, our lack of knowledge of local
traditional practices of healing could have been problematic and
harmful. Prunus africana, yohimbine, and various hepatotoxic
alkaloid herbal remedies are known biologically active
substances present in Africa that could be a potential cause of a
patient’s symptoms or could interact or otherwise interfere with
the medications they receive.17 Moreover, the language and
translation difficulties encountered may have easily led to
inappropriate use of medication or misinterpretation of
symptoms and concerns.18
Recommendation: Before departure, establish an effective
method of communication and become familiar with cultural
norms and practices of healing.
Lack of Adequate Time and Resources
Short-term international medical initiatives are often
conducted in austere, resource-poor settings in which it is
impossible to devote the full extent of available resources to
every individual. Though generally considered in the context of
disaster response and the emergency department, triage is also
an important tool during short-term medical initiatives. Because
the principle of justice obligates medical personnel to consider
medical utility and prospect of success as important factors in
their decisions about how to allocate scarce resources, it is
necessary to develop a system that identifies patients by their
medical needs and likelihood of benefit.9 There are many
proposed approaches to triage, but common among them all is
the utilitarian notion of doing the most good for the most
people. This ethic satisfies the formal principle of justice: to
“treat similar cases similarly and equals equally.”19
Additionally, this concept of justice also validates the actions
of providers who offer the best possible care with available
medications and equipment, though existing resources may
be considered substandard to what is available in the more
developed world.
The realities of practicing medicine in rural, isolated
communities with limited resources and capabilities were
strikingly evident during our time in Ghana. One clear truth
quickly emerged: the medical ship could only deliver care with
the materials and medications that were stocked before
departure. Because the stock was limited, the pharmacist
divided it by the number of villages on the itinerary. In
addition, the staff would pack up the clinic, leaving some
patients untreated, because it was important to have adequate
Volume , .  : January 
Jesus
time for travel and obtaining consent from the chief of the next
village. Because there exists just 1 medical ship that is able to
visit the same village only twice in 5 years, its arrival draws a
large crowd of people and potential patients at every
destination. There was no formal system of triage on the ship.
Although those who were in greater need tended to present
early, the mere fact the ship had to leave certain villages with
patients yet untreated was problematic. The “first come, first
served” rule by which the clinic operated had the potential for
injustice because it implied that those who were already
receiving treatment had priority over those who arrived later but
who had more urgent medical needs.9 As a result, it was
ethically dubious to evaluate throngs of patients with exerciseinduced musculoskeletal pain, only to have left later-arriving
patients with more dangerous and treatable conditions such as
malaria and intestinal parasitic infections without appropriate
treatment.
Recommendation: Resources ought to be contextually
relevant to the medical conditions of the local population and
delivered to those with the greatest medical need and likelihood
of benefit.
Chronic Care and Elective Surgery
Good intentions alone do not ensure success, nor do they
provide sufficient ethical justification for international medical
efforts. For example, it is not clear whether the benefits
outweigh the potential harms of chronic disease management in
the acute setting without long-term continuity. Tuberculosis
and HIV are conditions that require complex care and a high
degree of patient compliance with therapy during long periods,
without which efforts to treat individuals threatens to produce
resistant organisms that endanger not only the individual
patient but also the local community exposed to the individual’s
infection. Although community-based treatment of tuberculosis
in resource-poor settings has been successful, it involves direct
observational therapy for a period of several months.20,21
Furthermore, nonemergency surgery without the possibility of
continued follow-up presents a similar ethical concern.
Referencing international ventures for fistula repair, Wall et al22
wrote the following: “You have a moral obligation as a surgeon
to insure that your patients receive appropriate post-operative
care. . .It is unethical to perform complicated reconstructive
operations only to have them fall apart because patients do not
receive appropriate ongoing attention after you have gone.”
The principle of nonmaleficence, often phrased as the
obligation to “do no harm,” is clearly applicable in the
preceding examples. Many medical initiatives regularly focus on
what sorts of care they will provide and how they will provide it.
Equally imperative, however, is the care physicians should not
offer their patients.
The medical ship on the Volta Lake appropriately addressed
acute primary care needs and largely avoided the provision of
care for chronic medical conditions and nonemergency surgical
procedures. No patients were tested or treated for tuberculosis
or HIV, and no surgeries were performed. There were, on
Volume , .  : January 
Residents’ Perspective
occasion, patients with obvious disease that could not be treated
with the resources and personnel on the ship. Jaundice,
cataracts, and inguinal hernias are examples of conditions
relatively common in the communities we visited. Without the
ability to conduct diagnostic tests or provide necessary followup care, these patients were told to proceed directly to the
nearest hospital. The nearest hospital, unfortunately, was many
hours or days of travel away from those villages.
Recommendation: Without the ability to provide long-term
follow-up care, avoid chronic care medicine and elective surgery.
Sustainability
Historically, the success of international short-term
initiatives has been measured by the “body count,” or number
of people treated during a visit.23 The communities served,
however, will require the health services provided long after
their visitors leave the country. The principle of beneficence is
understood as an obligation of medical providers to maximize
possible benefits and minimize harms.10 Consequently, a more
rational and beneficent approach to serving communities in the
developing world should involve teaching and training
community members and local health care workers the skills
required to provide necessary services in the absence of foreign
medical assistance. If, in fact, the focus of international medical
initiatives is the assistance of local communities, rather than the
experience of those who visit those communities, then every
initiative should devote some effort toward sustainability.24 The
Ghana Postgraduate Obstetrics/Gynecology program is a
tremendously successful example of a collaboration between 2
Ghanaian medical schools, the Ghana government, and the
American College of Obstetricians and Gynecologists and Royal
College of Obstetricians and Gynaecologists (among others), to
address the dearth of trained obstetrics/gynecology physicians in
Ghana.25 As of November 2006, 37 of 38 specialists who
completed the program continue to serve Ghanaian
communities.26
Although the postgraduate program in Ghana is an
example of an internationally supported and sustainable
effort, small-scale efforts during short-term medical
initiatives are also possible. For instance, academic
institutions will often have ongoing relationships with
particular international sites, to which teams of medical
students, residents, and faculty are sent annually. Within this
context, local community members may be trained in specific
skills required to address relevant and prevalent community
health concerns in the absence of outside assistance, with
follow-up and reinforcement on each successive visit.
Additional examples are provided by the Ghanaian personnel
on the medical ship, who provide an educational session at
every village to instruct local populations on methods to
improve hygiene, on how to avoid aquatic parasites and
malaria infection, and about birth control and condom use.
Recommendation: Every initiative should include a focus on
sustainability, such as the transfer of relevant skills or education,
Annals of Emergency Medicine 19
Residents’ Perspective
Jesus
to extend benefits beyond the presence of foreign medical
assistance.
Delivery of Care by Nonlicensed Personnel and the Need for
Oversight
Medical licensure grants a person the authority to practice
medicine within a geographic area; it also attempts to protect
patients by ensuring that all medical personnel are qualified,
competent practitioners.27 Recent discussion has highlighted the
difficulties and concerns with using untrained volunteers to
deliver care and medications in the international setting.28
International humanitarian volunteers may have various levels
of medical education or none at all. Medical students,
depending on the number of years of education, will also vary in
their knowledge and level of competence, and although medical
students have various roles within hospitals in the United States,
they act with the guidance and oversight of licensed residents
and attending physicians. Even licensed physicians are not
trained to deliver all types of medical care. A physician who
completes a residency in internal medicine, for example, is not
trained to perform vascular surgery. Licensure by itself does not
guarantee competence or patient protection.
Medical personnel in resource-poor locations are subject to
the same ethical principles that they would be in more
developed affluent countries. In addition to treating individuals
as autonomous agents, the principle of respect for persons
requires the protection of populations with diminished
autonomy.29 A corollary to the idea of diminished autonomy in
medical decisionmaking is the infringement on autonomy
presented by a lack of choice. Many communities in the
developing world are confronted with the lack of alternative
health care and a high prevalence of dangerous infections, which
each contributes to the absence of reasonable choice. Licensure
and oversight are important because they serve as protections
against unethical conduct. Although not always practical, to the
extent possible, short-term medical initiatives to the developing
world should incorporate personnel that are both licensed and
trained in the particular skills necessary to deliver the care that is
relevant to a community.
On the Volta Lake, an experienced nurse practitioner
provided guidance and oversight for all medical personnel. With
the assistance of an interpreter, medical students treated patients
with relative independence when staffing one of the 3 general
medicine tables. The nurse practitioner served as a sounding
board for questions concerning conditions about which the
medical students had concerns or did not know how to treat. In
addition, she reviewed our diagnoses and treatment plans each
evening to ensure appropriate clinical rationale and submitted
an evaluative report to the director of Health Services of the
Volta River Authority, who was responsible for all visiting
health service providers. Nurse practitioners have been used
with increasing frequency in the United States and Ghana in a
variety of settings to address primary care needs of underserved
populations, including children, women, migrant workers, the
homeless, and the elderly.30-32 Given the scope of the primary
20 Annals of Emergency Medicine
Tents, tables, and chairs served as a clinic for a village
along the Volta Lake in Ghana.
care services delivered by the medical ship on the Volta Lake,
the presence of a nurse practitioner as lead health care provider
was appropriate and may, in fact, be important to the long-term
success and sustainability of the ship’s monthly excursions.
Recommendation: When faced with an emergency or austere
situation in which medical demand outstrips available resources,
physicians, medical students, and volunteers alike must have the
humility to recognize their limitations and tailor their actions
accordingly.33
CONCLUSION
Increasing numbers of people are participating in short-term
international medical initiatives. These efforts have been
successful in providing much-needed medical services to
populations with little to no access to health care. These wellintentioned participants face significant ethical challenges and
are still without a systematic and practical ethics framework to
address these issues.34 This article seeks to contribute to the
discourse through examining 5 major ethical considerations and
then proposing several avenues through which to conduct
ethical global medical outreach, using a recent excursion to
Ghana as a case study.
Regardless of the difficulties that face short-term
international medical initiatives, the need for such services is
enormous. To face this challenge, we should strive to nurture
and encourage interest in international health, including its
implementation through ethically appropriate short-term
international medical initiatives. Not only does the potential for
direct benefit exist for populations in resource-poor areas but
also international health experiences positively affect
participants’ knowledge, skills, and attitudes and may have a
role in recruiting and influencing residents to choose careers in
primary care and underserved settings.35-38 With appropriate
ethical consideration, international medical initiatives may
contribute to the development of self-sustaining, long-term
Volume , .  : January 
Jesus
improvements in health care access and the reduction of
growing health disparities concentrated in the developing world.
The author would like to thank John Nkrumah Mills, MD,
Medical Director, Volta River Hospital in Ghana and James
Childress, PhD, for their thoughtful comments on an earlier draft of
this article, and the University of Virginia Medical Alumni
Association for its support and assistance.
section editor: Debra E. Houry, MD, MPH
Supervisng editors: Suzanne L. Lippert, MD, MS; Donald M.
Yealy, MD
Funding and support: By Annals policy, all authors are required
to disclose any and all commercial, financial, and other
relationships in any way related to the subject of this article
that might create any potential conflict of interest. See the
Manuscript Submission Agreement in this issue for examples
of specific conflicts covered by this statement. Supported in
part by a grant from the University of Virginia Medical Alumni
Association; funding also received from the University of
Virginia School of Medicine.
Publication date: Available online August 21, 2009.
Reprints not available from the author.
Address for correspondence: John E. Jesus, MD, Beth Israel
Deaconess Medical Center, Department of Emergency
Medicine, 1 Deaconess Road, Boston, MA 02215; 617-7542351; Fax 617-754-2350; Email: jjesus@bidmc.harvard.edu.
REFERENCES
1. Drain P, Primack A, Hunt D, et al. Global health in medical
education: a call for more training and opportunities. Acad Med.
2007;82:226-230.
2. Crump J, Sugarman J. Ethical considerations of short-term
experiences by trainees in global health. JAMA. 2008;300:14561458.
3. Levine C, Becker J, Lippert S, et al. International emergency
medicine: a review of the literature from 2007. Acad Emerg Med.
2008;15:860-865.
4. Walker D, Tolentino V, Teach S. Trends and challenges in
international pediatric emergency medicine. Curr Opin Pediatr.
2007;19:247-252.
5. Ban K, Pini R, Sanchez L, et al. The Tuscan Emergency Medicine
Initiative. Ann Emerg Med. 2007;50:726-732.
6. Alagappan K, Schafermeyer R, Holliman J, et al. International
emergency medicine and the role for academic emergency
medicine. Acad Emerg Med. 2007;14:451-456.
7. Smith J, Shokoohi H, Holliman J. The search for common ground:
developing emergency medicine in Iran. Acad Emerg Med. 2007;
14:457-462.
8. Suchdev P, Ahrens K, Click E, et al. A model for sustainable shortterm international medical trips. Ambul Pediatr. 2007;7:317-320.
9. Beauchamp T, Childress J. Principles of Biomedical Ethics. 6th ed.
Oxford University Press; 2009.
10. US National Commission for the Protection of Human Subjects of
Biomedical and Behavioral Research. The Belmont Report: Ethical
Guidelines for the Protection of Human Subjects of Research.
Washington, DC: US Government Printing Office; 1979.
Publication No. (OS) 78-0012.
Volume , .  : January 
Residents’ Perspective
11. Jacobs E, Chen A, Karliner L, et al. The need for more research
on language barriers in health care: a proposed research agenda.
Milbank Q. 2006;84:111-133.
12. Padela A, Imran R, Punekar B. Emergency medical practice:
advancing cultural competence and reducing health care
disparities. Acad Emerg Med. 2009;16:69-75.
13. Arras J. Noncompliance in AIDS research. Hastings Cent Rep.
1990;20:24-32.
14. Nguyen G, LaVeist TA, Harris ML, et al. Patient trust-in-physician and
race are predictors of adherence to medical management in
inflammatory bowel disease. Inflamm Bowel Dis. 2009;15:1233-1239.
15. Rentmeester CA. Case study. Trust, translation and HAART.
Commentary. Hastings Cent Rep. 2008;38:13-14.
16. Gordon R. Languages of Ghana. In: Paul LM, Languages of the
World. 15th ed. Dallas, TX: SIL International; 2005. Available at:
http://www.ethnologue.com. Accessed September 10, 2008.
17. Schiano T. Hepatotoxicity and complementary alternative
medicines. Clin Liver Dis. 2003;7:453-473.
18. Ritchie E, Robert M. Military humanitarian assistance: the pitfalls
and promise of good intentions. In: Beam T, Military Medical
Ethics Vol 2. Washington, DC: The Surgeon General At TMM
Publications. Borden Institute. Walter Reed Army Medical Center;
2004:805-830.
19. Childress J. Triage in response to bioterrorist attack. In: Moreno
J, ed. In the Wake of Terror: Medicine and Morality in a Time of
Crisis. Cambridge, MA: MIT Press; 2003:72-93.
20. Blumberg H, Burman W, Chaisson R, et al. American Thoracic
Society/Centers for Disease Control and Prevention/Infectious
Diseases Society of America: treatment of tuberculosis. Am J
Respir Crit Care Med. 2003;167:603-662.
21. Shin S, Furin J, Bayona J, et al. Community-based treatment of
multidrug-resistant tuberculosis in Lima, Peru: 7 years of
experience. Soc Sci Med. 2004;59:1529-1539.
22. Wall L, Arrowsmith S, Lassey A, et al. Humanitarian ventures of “fistula
tourism?”: the ethical perils of pelvic surgery in the developing world. Int
Urogynecol J Pelvic Floor Dysfunct. 2006;17:559-562.
23. Dupuis C. Humanitarian missions in the Third World: a polite
dissent. Plast Reconstr Surg. 2004;113:433-435.
24. Bishop R, James L. Medical tourism can do harm. BMJ. 2000;
320:1017.
25. Klufio C, Kwawukume E, Danso K, et al. Ghana postgraduate
obstetrics/gynecology collaborative residency training program:
success story and model for Africa. Am J Obstet Gynecol. 2003;
189:692-696.
26. Anderson F, Mutchnick I, Kwawukume E, et al. Who will be there
when women deliver? assuring retention of obstetric providers.
Obstet Gynecol. 2007;110:1012-1016.
27. Federation of State Medical Boards. State of the states:
physician regulation 2008. Available at: http://www.fsmb.org/
pdf/States_2008.pdf. Accessed April 21, 2008.
28. Roberts M. Duffle bag medicine. JAMA. 2006;295:1491-1492.
29. Council for International Organizations of Medical Sciences.
International Ethical Guidelines for Biomedical Research Involving
Human Subjects. Geneva, Switzerland: Council for International
Organizations of Medical Sciences; 2002. Available at: http://
www.cioms.ch/frame_guidelines_nov_2002.htm. Accessed
September 10, 2008.
30. Sherwood G, Brown M, Fay V, et al. Defining nurse practitioner
scope of practice: expanding primary care services. Internet J Adv
Nurs Pract. 1997;1.
31. American Academy of Nurse Practitioners. Scope of Practice for
Nurse Practitioners. Washington, DC: American Academy of Nurse
Practitioners; 1993. Revised in 2007. Available at: http://www.
aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB
0D/0/Scope_of_Practice.pdf. Accessed April 25, 2008.
Annals of Emergency Medicine 21
Residents’ Perspective
Jesus
32. Nyonator F, Awoonor-Williams J, Phillips J, et al. The Ghana
Community-based Health Planning and Services Initiative for
scaling up service delivery innovation. Health Policy Plan.
2005;20:25-34.
33. Pinto A, Upshur R. Global health ethics for students. Dev World
Bioeth. 2009;9:1-10.
34. Decamp M. Scrutinizing global short-term medical outreach.
Hastings Cent Rep. 2007;37:21-23.
35. Thompson M, Huntington M, Hunt D, et al. Educational effects
of international health electives on US and Canadian medical
students and residents: a literature review. Acad Med.
2003;78:342-347.
36. Smith J, Weaver D. Capturing medical students’ idealism. Ann
Fam Med. 2006;4(suppl 1):S32-37.
37. Gupta A, Wells C, Horwitz R, et al. The International Health Program:
the fifteen-year experience with Yale University’s internal medicine
residency program. Am J Trop Med Hyg. 1999;61:1019-1023.
38. Miller W, Corey R, Lallinger G. International health and internal
medicine residency training: the Duke University experience. Am J
Med. 1995;99:291-297.
CORRECTION
In the November 2009 issue, in the article by Vaillancourt et al (“The Out-of-Hospital Validation of the Canadian
C-Spine Rule by Paramedics,”; pages 663-671), the first section of the Editor’s Capsule Summary is incorrect. It
should have said, “What is already known on this topic: Previous out-of-hospital studies indicate that selective
spinal immobilization may miss patients with cervical injury.” We apologize for the error.
22 Annals of Emergency Medicine
Volume , .  : January 