A third-year emergency medicine resident at The Johns Hopkins Hospital, Ruben Troncoso was in the midst of a residency rotation at Bermuda's King Edward VII Memorial Hospital when it struck him: "So many of the people I encountered had connections with Hopkins," he said. "I realized you can meet people around the world who have received our care in Baltimore."

It was the wide reach of Johns Hopkins, in fact, that brought Troncoso to Bermuda in May 2019. Johns Hopkins Medicine International, the global ambassador of Johns Hopkins Medicine in Baltimore, has a clinical affiliation agreement with Bermuda Hospitals Board (BHB), which runs King Edward VII Memorial Hospital. The collaboration initially focuses on clinical education and training, including a visiting residents program that brings physicians like Troncoso to Bermuda to learn from and share knowledge with BHB's providers.

"Bermuda is very special to us as we have a long-standing relationship with the island and its citizens that spans more than two decades," said Charles Wiener, president of Johns Hopkins Medicine International.

At the end of his third year, Troncoso, like all residents, was able to select a specialty to study and practice for four weeks at the location of his choice. He became the first resident to travel to Bermuda under the new visiting residents program. Johns Hopkins Medicine International arranged for his travel and accommodations and paired him with a mentor, Dr. Chikezie Dean Okereke, BHB chief of emergency and hyperbaric services. Troncoso focused on Bermuda's emergency department, its emergency medical service and hyperbaric medicine.

It was his first time practicing in a country other than the U.S., and he found Bermuda’s smaller-scale health care system – with just one medical acute care hospital – has unique advantages for both patients and providers.

"In our high-volume emergency department at Johns Hopkins, with so many patients, there are very few people I see over and over," he said. Not so in Bermuda – he saw the same patients repeatedly. Patients and providers had the opportunity to form relationships.

"Because there's one hospital, it's a centralized system," Troncoso said. "You're coordinating care for the entire island. That was new for me, because in the U.S., we have many different hospitals and health systems are very decentralized. In Bermuda, at King Edward VII Memorial Hospital, you're in the hub."

Identifying specialty providers for patients who needed follow up was an interesting experience as well, Troncoso said. "At Hopkins, we're spoiled – we have all the specialty services right here," he said. In Bermuda, some specialty care following an emergency department visit has to wait days or weeks until a specialist can visit the island.

With fewer specialists available, Troncoso observed, the physician faces unique challenges – and builds skills to overcome those challenges. "There is more independent care there," he said. "The physician has to do more with limited resources. That was the best part of my experience. Their physical exams were better, more thorough, than mine – very in-depth. I was learning from them, getting tips for exams."

That's a lesson Troncoso has shared with his colleagues and mentors at home since his return. He'd recommend the Bermudian visiting residents program to any physicians looking to improve and grow.

"Wherever you practice, whatever weaknesses you have are getting masked by whatever help you have in the hospital," he said. "When it's 2 a.m. and it's just you and several patients, you develop a whole new set of skills. It helps identify your weaknesses and turn those into strengths."