Eyes wide open: an essay on developing an engaged awareness in global medicine and public health

Global surgery for medical students - is it meaningful? A mixed-method study

Introduction

There has been an increase in global health courses at medical universities in high-income countries. Their effect on students, however, is poorly understood. In 2016 an elective global surgery course was introduced for medical students at Karolinska Institutet in Sweden. The course includes a theoretical module in Sweden and a two-week clinical rotation in Uganda. The present study aimed to assess the format and determine its effect on students’ knowledge of global surgery and approach towards patients of non-Swedish origin.

Method

A mixed-methods design was used. Semi-structured case-based interviews were conducted individually with 18 students and analysed using qualitative content analysis. Examination scores and the course evaluation were analysed with Kruskal Wallis one-way analysis of variance, Pearson’s Chi-square and a Wilcoxon signed-rank test as appropriate.

Results

The course was appreciated and students reported gained insights and interest in global surgery. Students’ ability to reason about global surgery issues was improved after the course. Students considered complicating aspects in the meeting with patients of non-Swedish origin. Students with abroad clinical experience felt less compelled to act on preconceptions.

Discussion

The global surgery course at Karolinska Institutet is appreciated and students gained valuable knowledge. The case-based interviews acted as a catalyst for reflection and showed that students felt insecure as they lacked knowledge about globally common surgical conditions and struggled with generalized preconceptions of patients of non-Swedish origin. To further support students to integrate theoretical knowledge and professional development, we suggest the introduction of problem-based learning.

Conclusion

The ability of the course to inspire students’ commitment to global surgery is promising as this engagement is the key to reaching the goal of equitable health globally. Offering such courses is a step towards inspiring and recruiting the future clinicians and researchers needed for expanding the field of global surgery.

Rethinking Goals: Transforming Short-Term Global Health Experiences Into Engagements

The authors challenge the conventional wisdom guiding what participants in short-term experiences in global health (STEGHs) should be learning. Medical students and residents from the United States have been told to focus on standardized competencies and ethical principles, in addition to the biomedical knowledge, skills, and attitudes highlighted by working internationally. The authors suggest that although these training goals are important, they may divert learners from developing their professional identities in ways that contribute to the health of all persons, especially those who are economically poor and socially marginalized. The authors postulate that such a professional transformation will occur only if STEGH participants attend to 5 key learning goals: develop contextual inquisitiveness, grow in insightful understanding, nurture global humility, cultivate structural awareness, and critically engage in the pursuit of creating equitable and just societies. Further, the authors argue that only by attending to these goals will any genuine change in the root causes of inequities in health outcomes occur. The authors review these goals and encourage their use for professional and pedagogical purposes over the duration of any STEGH-before departure, while in host communities, and upon return home.

Time for action: key considerations for implementing social accountability in the education of health professionals

Within health professional education around the world, there exists a growing awareness of the professional duty to be socially responsible, being attentive to the needs of all members of communities, regions, and nations, especially those who disproportionately suffer from the adverse influence of social determinants. However, much work still remains to progress beyond such good intentions. Moving from contemplation to action means embracing social accountability as a key guiding principle for change. Social accountability means that health institutions attend to improving the performance of individual practitioners and health systems by directing educational and practice interventions to promote the health of all the public and assessing the systemic effects of these interventions. In this Reflection, the authors (1) review the reasons why health professional schools and their governing bodies should codify, in both curricular and accreditation standards, norms of excellence in social accountability, (2) present four considerations crucial to successfully implementing this codification, and (3) discuss the challenges such changes might entail. The authors conclude by noting that in adopting socially accountable criteria, schools will need to expand their philosophical scope to recognize social accountability as a vitally important part of their institutional professional identity.

Beyond Visas and Vaccines: Preparing Students for Domestic and Global Health Engagement

At campuses across the United States, scores of students are embarking on global health experiences in low- and middle-income countries. The desire to improve the health of poor communities while preparing for future health careers is often the main driver. The spotlight on domestic health issues also has fueled a resurgence of interest in underserved communities in the United States. Regardless of the destination, rigorous preparation is needed to ensure that the students' presence benefits the communities they aim to serve. Development of mutually beneficial programs with host communities coupled with thoughtful preparation of students is essential to the future of these university programs but, more importantly, to achieve the goal of shared learning and capacity building across borders. US program leaders may not fully consider the potential risks that can occur to their programs from involving poorly prepared students, or these risks may appear largely theoretical. However, many experienced practitioners and their international collaborators can relate examples of damaged partnerships, adverse consequences on community structures, dangers to patient safety, and harmed professional reputations and credibility. Domestic health experiences do not require a visa or vaccines but bring students in contact with many of the same ethical, professional, and cross-cultural challenges as overseas endeavors. Fortunately, best practices for preparing students to confront these challenges have emerged from years of experience in domestic and global contexts alike. It all begins with establishing institutional partnerships built on principles of reciprocity and respect. Through careful program design, universities can align missions, goals, and expectations to best serve all invested parties: local partners, students, faculty, staff, and the communities where they will be working. A second critical component is appropriate student selection. Matching student skills with partner needs can optimize benefits for both the host organization and student. Finally, universities can prepare students to navigate in cross-cultural settings in a professional and ethical manner through careful training. Just as negative experiences can have lasting negative consequences, the best ones can lead to strengthened partnerships; durable benefits for local and global communities; and optimal learning for students, their supervisors, and hosts.

Enhanced skills in global health and health equity: Guidelines for curriculum development

INTRODUCTION

Global health addresses health inequities in the care of underserved populations, both domestic and international. Given that health systems with a strong primary care foundation are the most equitable, effective and efficient, family medicine is uniquely positioned to engage in global health. However, there are no nationally recognized standards in Canada for postgraduate family medicine training in global health.

OBJECTIVE

To generate consensus on the essential components of a Global Health/Health Equity Enhanced Skills Program in family medicine.

METHODS

A panel comprised of 34 experts in global health education and practice completed three rounds of a Delphi small group process.

RESULTS

Consensus (defined as ≥ 75% agreement) was achieved on program length (12 months), inclusion of both domestic and international components, importance of mentorship, methods of learner assessment (in-training evaluation report, portfolio), four program objectives (advocacy, sustainability, social justice, and an inclusive view of global health), importance of core content, and six specific core topics (social determinants of health, principles and ethics of health equity/global health, cultural humility and competency, pre and post-departure training, health systems, policy, and advocacy for change, and community engagement).

CONCLUSION

Panellists agreed on a number of program components forming the initial foundation for an evidence-informed, competency-based Global Health/Health Equity Enhanced Skills Program in family medicine.

Building Power Between Polarities: On the Space-in-Between

In this article, I introduce the concept of the space-in-between. This space-in-between is born of the realization that, between the expression of any two polarities (across dimensions such as emotion, thought, geography, and ideology), there exists a philosophical construct useful for framing thinking about practice, research, and managerial relationships in the health professions. Out of this construct emerge practical considerations useful for structuring the conduct of meaningful interpersonal and intercultural interactions. I describe how the idea of a space-in-between developed out of my medical practice, grew as a result of my experiences in international environments. and has found fulfillment in my ongoing work. I explore the application of a space-in-between in public health, medical anthropology, medical ethics, and global health. I review how, as a result of incorporating this space in their daily work, clinicians, educators, researchers, and managers can grow as leaders by sharing the presence that arises from the space-in-between them and the people in the communities they serve.

Beyond ethical and curricular guidelines in global health: attitudinal development on international service-learning trips

BACKGROUND

Health professionals from high-income countries are increasingly becoming involved in international service-learning trips in low and low/middle-income countries. While much has been written about the ethics and curricular guidelines related to such endeavors, scant attention has been paid to the attitudes with which trainees and clinicians enter into or return from them. In this essay the authors explore how attitudes contribute to the success or failure of international service-learning trips.

DISCUSSION

The authors submit that the attitudes with which visiting health professionals approach international service-learning trips are much more critical to the success of these experiences than their demonstrated knowledge base or specialized skill sets. They list five attitudes that can aid those participating in international service-learning trips. They list five troubling attitudes that, while common, those participating in international service-learning trips can learn to recognize and avoid. They suggest five strategies key to learning respectful attitudes that can foster success in such cross-cultural activities. Lastly, the authors review several concepts related to attitude development in short or long-term global health work.

SUMMARY

The attitudes with which visiting health professionals approach international service-learning activities can be important components of the success or failure of the experiences. Through thoughtful consideration of attitudes and approaches, participants on such trips can build a framework for rich and rewarding experiences in global medicine and global health.