Initiative for the implementation of planetary health in postgraduate medical training and continuing medical education in Switzerland.

The Swiss Medical Association FMH drew up the strategy "Planetary health - Strategy on the courses of action on climate change for the medical profession in Switzerland" in collaboration with the Swiss Institute for Medical Education SIME, the umbrella organisations and students. On 7 October 2021, the strategy was approved by the Swiss Medical Chamber with a budget of over CHF 380,000 (approx € 365,000). The first step in implementation involved setting up an advisory group which will tackle the concrete implementation of the strategy. This article provides an insight into the current state of work on the project with a focus on the measures in the areas of postgraduate medical training and continuing medical education. It is a work in progress.

[La formation médicale continue en Suisse - un récit]. / Ärztliche Weiterbildung in der Schweiz ­ ein Narrativ.

Postgraduate Medical Education in Switzerland - A Narrative Abstract: Medical education has to respond to new challenges such as digitalisation, increase of chronic and complex diseases, economisation. The concept of Competency-Based Medical Education (CBME) has been implemented in undergraduate education in Switzerland. Postgraduate medical education has undergone a fundamental reformation, among other things with the development of Entrustable Professional Activities (EPAs), the adaptation of training programmes or "Teach the Teachers" classes. For the associated cultural change to be successful, the commitment of the professional societies, the training institutions, the hospitals is needed, but also the support of the health and education policy is of utmost importance.

BASE Jumping in the Lauterbrunnen Valley: A Retrospective Cohort Study from 2007 to 2016.

BACKGROUND: BASE jumping, and especially BASE jumping with the help of wingsuits, is considered one of the most dangerous airborne sports. The valley of Lauterbrunnen in Switzerland has become infamous for the large number of BASE jumps and the high rate of accidents and fatalities. The aim of this study was to evaluate the morbidity and mortality of BASE jumping, to determine the severity of injuries and injury patterns of BASE jumping accidents and to compare preclinical assessment with clinical diagnoses to detect under- or overtriage. METHODS: This retrospective, descriptive cohort study covers a period of 10 years (2007-2016). The evaluation covered all BASE jumping incidents in the valley of Lauterbrunnen that required either a helicopter mission by the local HEMS (Helicopter Emergency Medical Service) company of Lauterbrunnen, Air Glaciers, or medical care in the regional hospital, the level I trauma centre or the medical practice of the local general practitioner. Besides demographic data, experience in BASE jumping and skydiving as well as BASE jumping technique(s) and details about the rescue missions were collected. The medical data focused on the severity of injuries, as expressed by the National Advisory Committee of Aeronautics (NACA) score in the prehospital assessment as well as the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) retrieved from the clinical records in the hospital or medical practice setting. RESULTS: The patients were predominantly young, experienced male BASE jumpers. Morbidity (injury risk) ranged from 0.05% to 0.2%, and fatality risk from 0.02% to 0.08%. Undertriage was low, with only two cases. Overtriage was significant, with 73.2% of all NACA 4-6 cases not qualifying for major trauma. CONCLUSIONS: BASE jumping remains a high-risk sport and is associated with significant rates of injuries and fatalities. Comparison with previous studies indicated that the injury rate may have decreased, but the fatality rate had not. In this known BASE jumping environment, prehospital assessment appears to be good, as we found a low undertriage rate. The high overtriage rate might be an expression of physicians' awareness of high-velocity trauma mechanisms and possible deceleration injuries.

A questionnaire for quality control in postgraduate medical education in Switzerland.

BACKGROUND: To ensure high qualification standards in medical institutions, a questionnaire has been developed to evaluate the postgraduate medical education in Switzerland. AIM: This article describes the development and longitudinal analysis of a questionnaire using eight scales to assess the quality of postgraduate medical education. METHOD: The questionnaire has been administered to all residents every year since 2003. In 2020, 8,745 residents returned the questionnaire, resulting in a response rate of 70%. In addition, a survey is conducted annually among the directors of medical institutions. RESULTS: We present results of the directors' survey and the resident evaluation from 2020, as well as longitudinal data over 16 years. The mean values of the eight scales remained stable or increased slightly over the years. The decision-making culture scale is generally rated best by the residents, while the evidence-based medicine scale is rated as the least good. The most important drivers of residents' satisfaction with a training site are the work environment and leadership culture scales. The directors perceive the evaluation to be fair and useful. CONCLUSIONS: The questionnaire represents a reliable and useful tool for the quality control in postgraduate medical training. It provides yearly feedback to the directors regarding how the residents perceive their training giving insights for improvments.

Accidental Hypothermia in a Swiss Alpine Trauma Centre-Not an Alpine Problem.

BACKGROUND: Research in accidental hypothermia focuses on trauma patients, patients exposed to cold environments or patients after drowning but rarely on hypothermia in combination with intoxications or on medical or neurological issues. The aim of this retrospective single-centre cohort study was to define the aetiologies, severity and relative incidences of accidental hypothermia, methods of measuring temperature and in-hospital mortality. METHODS: The study included patients ≥18 years with a documented body temperature ≤35 °C who were admitted to the emergency department (ED) of the University Hospital in Bern between 2000 and 2019. RESULTS: 439 cases were included, corresponding to 0.32 per 1000 ED visits. Median age was 55 years (IQR 39-70). A total of 167 patients (38.0%) were female. Furthermore, 63.3% of the patients suffered from mild, 24.8% from moderate and 11.9% from severe hypothermia. Exposure as a single cause for accidental hypothermia accounted for 12 cases. The majority were combinations of hypothermia with trauma (32.6%), medical conditions (34.2%), neurological conditions (5.2%), intoxications (20.3%) or drowning (12.0%). Overall mortality was 22.3% and depended on the underlying causes, severity of hypothermia, age and sex.

Association of Pre-existing Mental Health Conditions with Acute Mountain Sickness at Everest Base Camp.

Hüfner, Katharina, Fabio Caramazza, Evelyn R. Pircher Nöckler, Agnieszka E. Stawinoga, Paolo Fusar-Poli, Sanjeeb S. Bhandari, Buddha Basnyat, Monika Brodmann Maeder, Giacomo Strapazzon, Iztok Tomazin, Ken Zafren, Hermann Brugger, and Barbara Sperner-Unterweger. Association of pre-existing mental health conditions with acute mountain sickness at Everest Base Camp. High Alt Med Biol. 23:338-344, 2022. Background: Mental health disorders are common, but limited data are available regarding the number of people with a past medical history of psychiatric diagnoses going to high altitude (HA). It is also unknown whether mental health conditions are associated with an increased risk of acute mountain sickness (AMS). Methods: We analyzed data from a previous study at Everest Base Camp. Participants self-reported their past medical history and history of substance use and had a brief history taken by a physician. AMS was assessed using the self-reported 2018 Lake Louise AMS Score. Results: Eighty-five participants (66 men and 19 women, age 38 ± 9 years) were included. When questioned by a physician, 28 participants reported prior diagnoses or symptoms compatible with depression (23%), anxiety disorder (6%), post-traumatic stress disorder (1%), and psychosis/psychotic experiences (9%). The prevalence of psychiatric diagnoses in the past medical history was much lower in the self-reported data (2/85) compared to data obtained via physician assessment (28/85). Increased risks of AMS were associated with a past medical history of anxiety disorder (odds ratio [OR] 22.7; confidence interval [95% CI] 2.3-220.6; p < 0.001), depression (OR 3.6; 95% CI 1.2-11.2; p = 0.022), and recreational drug use ever (OR 7.3; 95% CI 1.5-35.5; p = 0.006). Conclusions: Many people who travel to HA have a past medical history of mental health conditions. These individuals have an increased risk of scoring positive for AMS on the Lake Louise Score compared with people without a history of mental health conditions.

Injuries in outdoor climbing: a retrospective single-centre cohort study at a level 1 emergency department in Switzerland.

Objectives: Outdoor rock climbing has become popular in recent years. However, few data have been published on climbing accidents in Switzerland, even though the Swiss Alps are a major climbing resort.To analyse data on accidents related to outdoor climbing treated in the Emergency Department (ED) of University Hospital Bern, Switzerland. Methods: A retrospective database search for accidents related to outdoor climbing was conducted in the clinical reporting system E.care of the ED of University Hospital Bern for the period April 2012-December 2018. Results: 78 patients were treated after an accident related to outdoor climbing, which accounted for 1 per 3571 (0.028%) of all ED visits during this period. Mean age was 35.8±10.4 years. 76% of patients were male. Falls were the most common mechanism of injury (64%), followed by rock or ice falling on the climber (21%). Injuries affected multiple body regions (38%) or only the lower limbs (22%). Most injuries were fractures (68%). Mean ISS was 7.5 (1-38), and grade 3 UIAA MedCom injuries were most common (45%). 11 cases of polytrauma occurred and one fatality. 44 patients needed inpatient admission. Mean duration of inpatient stay was 7 days. Mean costs per patient were 12 283 CHF. Conclusions: Accidents related to outdoor climbing accounted for a small number of patients seen in the University ED Bern. Further research should be on a nationwide basis, with collection of specific climbing data like use of a helmet and experience of climbing to inform injury prevention strategies. This should shed further light on this topic, as would a prospective study using the International Alpine Trauma Register.

Mindfulness predicts less depression, anxiety, and social impairment in emergency care personnel: A longitudinal study.

Medical personnel working in emergency rooms (ER) are at increased risk of mental health problems and suicidality. There is increasing evidence that mindfulness-based interventions can improve burnout and other mental health outcomes in health care providers. In contrast, few longitudinal prospective studies have examined protective functions of dispositional mindfulness in this population. The objective of this study was to examine whether mindfulness prospectively predicts anxiety, depression, and social impairment in a sample of emergency care professionals. The authors administered online surveys to ER personnel prior to work in ER, and at 3 and 6 months follow up. Participants were 190 ER personnel (73% residents, 16% medical students, 11% nurses). Linear mixed effects regression was used to model longitudinal 3-month and 6-month follow up of depression, anxiety, and social impairment. Predictors included time-varying contemporaneous work stressors, perceived social support at work and life events, and baseline dispositional mindfulness, demographics, and workplace characteristics. Mindfulness indexed when starting ER work predicted less depression, anxiety, and social impairment 6 months later. Mindfulness remained a strong predictor of mental health outcomes after controlling for time-varying stressful events in emergency care, negative life events, and social support at work. Mindfulness moderated the adverse impact of poor social support at work on depression. To our knowledge, this is the first longitudinal study to show that mindfulness prospectively and robustly predicts anxiety, depression, and social impairment. Results support the role of mindfulness as a potential resilience factor in at-risk health care providers.

[Lessons Learned - Observational Study After One Year of 'Domestic Violence Consultation' at the University Emergency Department Bern]. / Lessons Learned ­ Beobachtungsstudie nach einem Jahr Sprechstunde «Häusliche Gewalt¼ am Universitären Notfallzentrum Bern.

Lessons Learned - Observational Study After One Year of 'Domestic Violence Consultation' at the University Emergency Department Bern Abstract. The number of violent crimes in domestic violence has been steadily increasing in Switzerland since 2011. In November 2018, the University Emergency Department Bern established standardized care for victims of domestic violence with an integrated follow-up. In this retrospective study, the results one year after the establishment of the special consultation hour as well as the challenges are presented. Of the 53 individuals primarily treated at the emergency department for domestic violence, 69.8 % (n = 37) were offered a follow-up appointment. Specific subgroups were less likely to be offered follow-up appointments. It became apparent that despite instructions for action and training, not all affected groups were perceived in the same way.

Hypothermia in Trauma.

Hypothermia in trauma patients is a common condition. It is aggravated by traumatic hemorrhage, which leads to hypovolemic shock. This hypovolemic shock results in a lethal triad of hypothermia, coagulopathy, and acidosis, leading to ongoing bleeding. Additionally, hypothermia in trauma patients can deepen through environmental exposure on the scene or during transport and medical procedures such as infusions and airway management. This vicious circle has a detrimental effect on the outcome of major trauma patients. This narrative review describes the main factors to consider in the co-existing condition of trauma and hypothermia from a prehospital and emergency medical perspective. Early prehospital recognition and staging of hypothermia are crucial to triage to proper care to improve survival. Treatment of hypothermia should start in an early stage, especially the prevention of further cooling in the prehospital setting and during the primary assessment. On the one hand, active rewarming is the treatment of choice of hypothermia-induced coagulation disorder in trauma patients; on the other hand, accidental or clinically induced hypothermia might improve outcomes by protecting against the effects of hypoperfusion and hypoxic injury in selected cases such as patients suffering from traumatic brain injury (TBI) or traumatic cardiac arrest.

Assessment of Psychotic Symptoms in Individuals Exposed to Very High or Extreme Altitude: A Field Study.

Hüfner, Katharina, Fabio Caramazza, Agnieszka E. Stawinoga, Evelyn R. Pircher Nöckler, Paolo Fusar-Poli, Sanjeeb S. Bhandari, Buddha Basnyat, Monika Brodmann Maeder, Giacomo Strapazzon, Iztok Tomazin, Barbara Sperner-Unterweger, and Hermann Brugger. Assessment of psychotic symptoms in individuals exposed to very high or extreme altitude: A field study. High Alt Med Biol. 22:369-378, 2021. Background: Symptoms of psychosis such as hallucinations can occur at high or extreme altitude and have been linked to accidents on the mountain. No data are available on how to assess such symptoms in the field and what their prevalence or predisposing factors might be. Methods: In this field study at Everest Base Camp (5,365 m) in Nepal, 99 participants of organized expeditions underwent 279 assessments: The High Altitude Psychosis Questionnaire (HAPSY-Q), the Prodromal Questionnaire, 16-items (PQ-16), and the Mini International Neuropsychiatric Interview (M.I.N.I., psychosis section) were collected together with further clinical data. Statistical analysis was done for each phase, that is, altitude range of the climb, and overall data. Results: One of 97 climbers fulfilled the M.I.N.I. diagnostic criteria for psychosis during one acclimatization climb. At least one endorsed item on the HAPSY-Q and the PQ-16, indicating the presence of symptoms of psychosis in the absence of a psychotic disorders, were identified in 10/97 (10.3%) and 18/87 (20.7%) participants respectively. The scores of the HAPSY-Q and the PQ-16 were correlated (r = 0.268, p < 0.001). Odds ratio analysis identified an increased risk for accidents in individuals with endorsed items on the HAPSY-Q. Conclusions: The diagnosis of high altitude psychosis is rare in climbers during organized expeditions. Nevertheless, subdiagnostic symptoms of psychosis occurred in a significant proportion of climbers. Future research is needed to validate these pilot findings.

Real-world stress resilience is associated with the responsivity of the locus coeruleus.

Individuals may show different responses to stressful events. Here, we investigate the neurobiological basis of stress resilience, by showing that neural responsitivity of the noradrenergic locus coeruleus (LC-NE) and associated pupil responses are related to the subsequent change in measures of anxiety and depression in response to prolonged real-life stress. We acquired fMRI and pupillometry data during an emotional-conflict task in medical residents before they underwent stressful emergency-room internships known to be a risk factor for anxiety and depression. The LC-NE conflict response and its functional coupling with the amygdala was associated with stress-related symptom changes in response to the internship. A similar relationship was found for pupil-dilation, a potential marker of LC-NE firing. Our results provide insights into the noradrenergic basis of conflict generation, adaptation and stress resilience.

Effects of Climate Change on Avalanche Accidents and Survival.

Avalanches are major natural hazards in snow-covered mountains, threatening people and infrastructure. With ongoing climate change, the frequency and types of snow avalanches may change, affecting the rates of avalanche burial and survival. With a wetter and warmer snow climate, consequences of burial may become more severe. In this review, we assess the potential effects of climate change on the frequency and characteristics of avalanches. We then discuss how these changes might affect the survival rates of subjects buried by avalanches and might influence the responses of search and rescue (SAR) teams and health care providers. While climate change is inevitable, the effects on avalanches remain elusive. The frequency of human triggered avalanches may not change, because this depends largely on the number and behavior of winter recreationists. Blunt trauma and secondary injuries will likely become more frequent as terrain roughness is expected to rise and snow cover to become thinner. Higher snow densities in avalanche debris will likely interfere with the respiration of completely buried victims. Asphyxia and trauma, as causes of avalanche death, may increase. It is unlikely that SAR and health care providers involved in avalanche rescue will have to change their strategies in areas where they are already established. The effects of climate change might foster the expansion of mitigation strategies and the establishment of mountain rescue services in areas subject to increased avalanche hazards caused by changes in snow cover and land use.

Point-of-Care Ultrasound Diagnosis of Community-Acquired Pneumonia in a High-Altitude, Resource-Poor Setting.

Objective: Point-of-care ultrasound (POCUS) for the evaluation of patients with suspected high-altitude pulmonary edema can be a useful tool in remote, high-altitude areas. The same technique can also yield high differential diagnostic accuracy for other relevant causes of acute respiratory distress at high altitude. With the recent development of high-quality, hand-held ultrasound devices, POCUS can be used with increasing reliability in such environments. We present a case of severe respiratory disease in a young, otherwise healthy patient during a trek at high altitude in the Khumbu valley of Nepal. Methods: By using POCUS, we were able to exclude several important differential diagnoses and diagnose the patient with community-acquired pneumonia. Results: Our findings allowed us to start early on-site treatment and positively influenced shared decision-making with the patient, which led to a helicopter evacuation. Conclusions: This case illustrates that POCUS can be a valuable tool in remote, high-altitude regions and could allow healthcare providers to diagnose and follow-up with patients exhibiting acute respiratory symptoms when other radiological imaging modalities are not available.

Aviation Sports Crashes in the Austrian Mountains: A 10-Year Retrospective Study.

INTRODUCTION: We aimed to describe the epidemiology and injury patterns of aviation sports crashes in the Austrian mountains and identify risk factors. METHODS: In this retrospective cohort study, out-of-hospital data on patients who sustained crashes when participating in aviation sports from January 1, 2006 through December 31, 2015 were assessed. The out-of-hospital data were merged with in-hospital data obtained from Innsbruck Medical University Hospital. RESULTS: A total of 2037 persons were involved in 1856 aviation sports crashes. Data on 126 in-hospital patients were available. Wind and pilot error were the most common causes. Most injuries occurred in paragliders (n=111, 88%). Most commonly, paragliders sustained injuries to the lumbar spine and hang gliders to the thoracic spine. Rescue operations were undertaken mainly by helicopter emergency medical services (n=87, 69%) or combined rescue forces (ground and helicopter, n=100, 79%.). The Injury Severity Score was 15±15, with a peak in patients with isolated injuries of the lower extremities (n=38, 32%) and a second peak in patients with multiple trauma (n=44, 35%). CONCLUSIONS: In the Austrian mountains, wind and pilot errors are the most common causes of aviation crashes. Aviation sports crashes frequently resulted in severe injuries and multiple trauma. The lumbar spine is particularly at risk in paragliders, whereas the thoracic spine is commonly affected in hang gliders. Injuries frequently caused long-term paralysis and limitations in quality of life. To minimize long-term consequences and save lives, skilled and well-equipped teams may be beneficial to provide effective on-site care and safe transportation to a trauma center.

Data and methods to calculate cut-off values for serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest.

The data and estimation methods presented in this article are associated with the research article, "Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: a retrospective multi-centre study" [1]. In this article we estimate recommended cut-off values for in-hospital triage with respect to extracorporeal rewarming. With only 6 survivors of 103 patients collected over a period of 20 years the ability to estimate reliable threshold values is limited. In addition, because the number of avalanche victims is also limited, a significantly larger dataset is unlikely to be obtained. We have therefore adapted two non-parametric estimation methods (bootstrapping and exact binomial distribution) to our specific needs and performed a simulations to confirm validity and reliability.

Development of a Self-Administered Questionnaire to Detect Psychosis at High Altitude: The HAPSY Questionnaire.

Aims: Psychotic symptoms during exposure to high altitude (HA) have been linked to accidents or near accidents on the mountains. It is thus of great importance to directly identify psychotic symptoms in individuals who are exposed to HA quickly and reliably on the mountain, even in the absence of experienced medical personnel. Psychotic features at HA frequently include positive psychotic symptoms such as hallucinations, delusions, or disorganized thinking/speech. The aim of the current study was to develop the first self-administered questionnaire (High Altitude Psychosis [HAPSY] Questionnaire), which individuals may use in the future to self-assess altitude-related psychotic symptoms on the mountain. Methods: We utilized two existing self-rating questionnaires for psychotic symptoms (the Psychotomimetic States Inventory, PSI and the Cardiff Anomalous Perception Scale, CAPS) as the basis for a two-round Delphi process. As part of this process, additional statements were suggested by the 40 Delphi participants. Results: Eleven self-administered statements-all of them related to positive psychotic symptoms-were identified to be most useful for the self-detection of HA-related psychotic symptoms on the mountain. Conclusion: This is the first self-administered questionnaire that allows the identification of HA-related psychotic symptoms on the mountain. A subsequent validation study is needed to address the psychometric properties of this questionnaire. Clinical validation will have to be performed in a field study.

Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: A retrospective multi-centre study.

AIM: Evidence of existing guidelines for the on-site triage of avalanche victims is limited and adherence suboptimal. This study attempted to find reliable cut-off values for the identification of hypothermic avalanche victims with reversible out-of-hospital cardiac arrest (OHCA) at hospital admission. This may enable hospitals to allocate extracorporeal life support (ECLS) resources more appropriately while increasing the proportion of survivors among rewarmed victims. METHODS: All avalanche victims with OHCA admitted to seven centres in Europe capable of ECLS from 1995 to 2016 were included. Optimal cut-off values, for parameters identified by logistic regression, were determined by means of bootstrapping and exact binomial distribution and served to calculate sensitivity, rate of overtriage, positive and negative predictive values, and receiver operating curves. RESULTS: In total, 103 avalanche victims with OHCA were included. Of the 103 patients 61 (58%) were rewarmed by ECLS. Six (10%) of the rewarmed patients survived whilst 55 (90%) died. We obtained optimal cut-off values of 7 mmol/L for serum potassium and 30 °C for core temperature. CONCLUSION: For in-hospital triage of avalanche victims admitted with OHCA, serum potassium accurately predicts survival. The combination of the cut-offs 7 mmol/L for serum potassium and 30 °C for core temperature achieved the lowest overtriage rate (47%) and the highest positive predictive value (19%), with a sensitivity of 100% for survivors. The presence of vital signs at extrication is strongly associated with survival. For further optimisation of in-hospital triage, larger datasets are needed to include additional parameters.

Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: An external validation of the HOPE score.

AIMS: The HOPE score, based on covariates available at hospital admission, predicts the probability of in-hospital survival after extracorporeal life support (ECLS) rewarming of a given hypothermic cardiac arrest patient with accidental hypothermia. Our goal was to externally validate the HOPE score. METHODS: We included consecutive hypothermic arrested patients who underwent rewarming with ECLS. The sample comprised 122 patients. The six independent predictors of survival included in the HOPE score were collected for each patient: age, sex, mechanism of hypothermia, core temperature at admission, serum potassium level at admission and duration of CPR. The primary outcome parameter was survival to hospital discharge. RESULTS: Overall, 51 of the 122 included patients survived, resulting in an empirical (global) probability of survival of 42% (95% CI = [33-51%]). This was close to the average HOPE survival probability of 38% calculated for patients from the validation cohort, while the Hosmer-Lemeshow test comparing empirical and HOPE (i.e. estimated) probabilities of survival was not significant (p = 0.08), suggesting good calibration. The corresponding area under the receiver operating characteristic curve was 0.825 (95% CI = [0.753-0.897]), confirming the excellent discrimination of the model. The negative predictive value of a HOPE score cut-off of <0.10 was excellent (97%). CONCLUSIONS: This study provides the first external validation of the HOPE score reaching good calibration and excellent discrimination. Clinically, the prediction of the HOPE score remains accurate in the validation sample. The HOPE score may replace serum potassium in the future as the triage tool when considering ECLS rewarming of a hypothermic cardiac arrest victim.

Intercultural Competence of Western Teachers for Nepalese Rescuers.

INTRODUCTION: Educational projects in mountain rescue in Nepal have a long tradition. They are usually led by Western experts who train their Nepalese colleagues using teams of people with diverse cultural background. To better understand the challenges of these encounters, we conducted a prospective cohort study during the first mountain rescue instructor course in Nepal. METHODS: Western instructors (WIs) and Nepalese instructor candidates (NICs) were asked to self-assess their intercultural competence with the help of questionnaires. The responses were compared and analyzed for differences between WIs and NICs and differences in a pre-post assessment of the WIs. In addition, semistructured interviews were conducted with randomly selected NICs. RESULTS: We found significant differences in communication styles between NICs and WIs: NICs showed a preference to establish relationships before discussing business and not to speak openly in conflict situations. WIs were much more direct and preferred dispassionate exchanges. In an assessment after the course, WIs had changed their attitude toward the host culture. CONCLUSIONS: We found differences in communication styles between WIs and NICs that are relevant to globalized medical education. Faculty members should be prepared before implementing medical training abroad and should have time to experience the host culture.