Ethical Obligations Regarding Short-Term Global Health Clinical Experiences: An American College of Physicians Position Paper

Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery

BACKGROUND

There are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact.

METHODS

Key concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries.

RESULTS

The guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas.

CONCLUSION

The article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

A scoping review of the ethical impacts of international medical electives on local students and patient care

BACKGROUND

International electives are often considered a valuable learning opportunity for medical students. Yet, as travelling to lower and middle income countries (LMICs) becomes more common, ethical considerations of such practices emerge. We conducted a scoping review to assess the extent to which five ethical themes were addressed in existing literature about electives, with the aim of investigating the ethical impacts of medical student electives on local resources, patients and clinicians in LMICs.

METHODS

We systematically searched PubMed, Global Health and Embase databases using the search terms "(ethics) AND (medical electives)". Thematic content analysis was undertaken using a combination of deductive and inductive themes. The deductive themes included: exceeding clinical competence, use of limited local resources, respect for patients and local culture, collaboration with local community/colleagues, and one-sided benefits in partnership. In addition, we also allowed for emerging themes within the data, and conducted a narrative synthesis of the results.

RESULTS

A total of 37 papers discussed ethical issues relating to medical student international electives to LMICs. More publications were written from the medical student perspective (n = 14), than by the host-institution (n = 5), with nearly half written from third-party perspectives (n = 18). Negative impacts on local host students and impact upon patient care were identified as additional ethical considerations.

CONCLUSIONS

Our review demonstrated that while there is a degree of awareness in the existing literature of the potential negative impacts of medical electives to local LMIC students' access to medical education and patient care, continued work is needed to ensure equitable partnerships. We recommend that these ethical themes should be further explored in pre-departure elective teaching courses and post-elective debriefs to increase medical students' awareness of the impact of their presence on host communities.

An Exploratory Study of Physical Therapists From High-Income Countries Practising Outside of Their Scope in Low and Middle-Income Countries

PURPOSE

To quantify how often physical therapists from high-income countries (HIC) travelling to low- and middle-income countries (LMIC) practise outside their scope of practice, in what circumstances, and their likelihood of doing the same in the future.

METHODS

An exploratory descriptive study using a survey.

RESULTS

One hundred and twenty-six licensed physical therapists from around the world participated. Physical therapists typically spent less than a month (73.8 per cent) in LMIC; 67.5 per cent believed that physical therapists practise outside of their scope, and 31.7 per cent reported doing so. Reasons were believing that something is better than nothing (47.5 per cent ), a mismatch between the physical therapist's and host's expectations (40.0 per cent ), and preserving their relationship with the host (25.0 per cent ). It was deemed appropriate by 64.5 per cent to practise outside of their scope in some situations and 53.8% considered repeating the activity in the future. Half of the respondent's first experience in LMIC occurred as a student or in their first decade of practice.

CONCLUSIONS

Working in LMIC requires a keen understanding of the risks and challenges associated with such experiences. To ensure best practice, a skill set that consists of critical self-reflection, systems thinking, and structural competency combined with clinical competency and accountability is imperative.

Global Neurology: The Good, the Bad, and the Ugly

Global health programs engaging in isolated or short-term medical missions can and do cause harm, reinforce health care disparities, and impede medical care in the regions where it is so desperately needed. Related ethical, medical, and legal concerns are reviewed in this article. The authors recommend abandoning these ill-considered missions and focusing attention and resources on advancing neurology through ethically congruent, multisectoral, collaborative partnerships to establish sustainable, self-sufficient training programs within low- and middle-income countries.

The impact of global health outreach experiences on medical student burnout

BACKGROUND

Student burnout during medical education is a prevalent and critical problem. Burnout has reaching consequences, including negative health outcomes for students, financial loss for schools, and worsened patient care as students transition to practice. Global Health Outreach Experiences (GHOEs), known to enhance cultural awareness and clinical knowledge among medical students, are offered in most programs. Prior studies document that GHOEs benefit physicians suffering from burnout, with effects demonstrating improvement over 6 months. No study, to our knowledge, has assessed the influence GHOEs may have on medical student burnout with a comparable control group. This study examines whether participation in a GHOE, compared to a standard break from school, has a positive effect on burnout.

METHODS

A case control study utilizing the Copenhagen Burnout Inventory was conducted on medical students. 41 students participated in a one-week, spring break GHOE and 252 were randomly selected as non-participating students in a control group. Assessments were gathered 1 week prior, 1 week after, and 10 weeks after spring break. Response across the surveys in chronological order included 22, 20, 19 GHOE and 70, 66, 50 control participants.

RESULTS

A significant reduction in personal burnout (PB) (P = 0.0161), studies related burnout (SRB) (P = 0.0056), and colleagues related burnout (CRB) (P = 0.0357) was found among GHOE attendees compared to control participants at 10-weeks after spring break. When modeled with potential confounders, CRB and SRB reductions remained significant.

CONCLUSION

GHOEs may be a potential tool for institutions to combat burnout rates in their students. The benefits of GHOEs appear to enhance over time.

Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist

INTRODUCTION

While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent.

METHODS

We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. Guidelines were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain.

RESULTS

A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience.

CONCLUSION

As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.

Resilience of the medical mission model: assessment of the perceived impact of the COVID-19 pandemic on short-term medical missions to Latin America and the Caribbean

Background

COVID-19-related travel restrictions profoundly impacted short-term medical missions (STMMs) abroad. This study describes the effect of the pandemic as perceived by STMM organisations serving Latin America and the Caribbean (LAC).

Methods

Information was updated for 359 primary care STMM organisations previously active in 2015, which were contained within an existing online database. Organisations were contacted to complete an online survey that gathered quantitative and qualitative descriptions of pandemic-related adaptations and program changes.

Results

22.5% (73/324) of previously active organisations had no website activity since 2020 or earlier, no longer existed, or had unclear website activity. Eighty-seven organisations responded to the survey. Ninety-six percent indicated that they would definitely (72/86, 84%) or probably (10/86, 12%) return to sending STMMs in the next five years, and most (46/83, 55%) of these intended to send an STMM within the next six months. Seventy-two respondents (93%) reported new adaptations, including direct funding for local healthcare professionals, sending equipment to host communities, focusing on training and teaching, and incorporating virtual care and electronic medical records.

Conclusions

The results demonstrate resilience, flexibility and optimism among STMM organisations and an intent to return to pre-pandemic programming rapidly.

An Online Ethics Curriculum for Short-Term Global Health Experiences: Evaluating a Decade of Use

Background:

Medical students and early career healthcare professionals commonly participate in short-term experiences in global health (STEGH).

Objective:

The authors evaluate the use of a free-to-access, case-based online curriculum addressing ethical issues trainees should consider prior to engaging in STEGH.

Methods:

Demographic data and feedback on specific cases were collected from 5,226 respondents accessing the online curriculum between November 1, 2011 and October 31, 2021. Feedback on the curriculum included 5-point Likert scale and open-ended responses. Quantitative data were analyzed using standard descriptive statistics. Qualitative data were independently dual coded and analyzed thematically in NVivo.

Findings:

The curriculum reached respondents from 106 countries. Undergraduate (36%) and graduate (38%) respondents included those from several different professional specialties. Less than a quarter of all of respondents, less than half with previous global health experience, and one-third with planned future global health experiences had received prior global health ethics training. Overall, the curriculum was highly rated; respondents felt it provided necessary tools to improve their thought processes, confidence, and behavior when encountering ethical issues during STEGH. Areas for curriculum improvement include balancing case specificity with generalizability.

Conclusion:

This curriculum has met a need for accessible introductory global health ethics education and demonstrates successful use of an online platform in case-based ethics learning.

Guidelines for short-term medical missions: perspectives from host countries

Background

In the past decade, there has been increasing guideline development for short-term medical missions (STMMs) traveling from high-income to low- and middle-income countries for the purpose of supporting health care services. The ethics of STMMs is criticized in the literature and there is frequently a lack of host country collaboration. This typically results in guidelines which are developed through the lens of the sending (high-income) countries’ staff and organizations. The aim of this paper is to evaluate an existing best practice guideline document from the perspective of host country participants with knowledge of STMMs from Honduras, Malawi, and the Philippines.

Methods

The guideline used for the evaluation consisted of nine best practice elements that were discerned based on literature and the experience of those working within the field. Semi-structured interviews were conducted in a cross-sectional study with participants (n = 118) from the host countries. Thematic analysis was conducted by two researchers and the results were assessed by working group members to confirm interpretations of the data.

Results

Overall, participants expressed a strong interest in having more structured guidance surrounding STMM practices. There was a positive response to and general acceptance of the proposed STMM guidelines, although participants found the 24-page document onerous to use; a companion checklist was developed. The key themes that emerged from the interviews included collaboration and coordination, care for hard-to-reach communities, capacity building, critical products and essential medical supplies, and opportunity and feasibility.

Conclusions

Host input suggests that the guidelines provide structured regulation and coordination of the medical mission process and have the potential to improve the way STMMs are carried out. The guidelines have also proven to be a useful tool for the actual implementation of STMMs and can be a tool to strengthen links and trust between mission teams and local health staff. However, local contexts vary considerably, and guidelines must be adapted for local use. It is recommended that STMM teams work in conjunction with host partners to ensure they meet local needs, increase capacity development of local health workers, and provide continuity of care for patients into the local system.

Taking Pause: A COVID-19 Student Reflection on Global Health Research Opportunities, Training, and Institutional Reform

Restrictions to research due to COVID-19 have required global health researchers to factor public health measures into their work and discuss the most ethical means to pursue research under safety concerns and resource constraints. In parallel, global health research opportunities for students have also adapted to safety concerns and resource constraints. Some projects have been canceled or made remote, but inventively, domestic research opportunities have been created as alternatives for students to continue gaining global health learning competencies. Knowing the ethical challenges inherent in short-term student global health research and research in strained health systems, it is intriguing why these safer alternatives were not previously pervasive in global health education. This paper provides perspectives from students training at academic institutions in the US on how COVID-19 disrupted student research and what can be learned from the associated shifts in global health research. Additionally, the authors take this opportunity to advocate for academic institutions from high-income countries to reflect on long-standing global health research conventions that have been perpetuated and bolster training for students conducting global health research. The authors draw on their experiences, existing literature, and qualitative interviews with students who pursued global health research during COVID-19.

Reliability of the Service Trip Audit Tool to assess the quality of short-term medical missions

Background

We aimed to assess the adherence of short-term medical missions (STMMs) operating in Latin America and the Caribbean (LAC) to key best practices using the Service Trip Audit Tool (STAT) and to calculate the inter-rater reliability of the data points. This tool was based on a previously published inventory of 18 STMM best practices.

Methods

Programme administrators and recent volunteers from 335 North American organizations offering STMMs in LAC were invited to complete the STAT anonymously online. Adherence to each of 18 best practices was reported as either ‘yes’, ‘no’ or ‘not sure’. Fleiss’ κ was used to assess inter-rater agreement of the responses.

Results

A total of 194 individuals from 102 organizations completed the STAT (response rate 30.4%; 102/335 organizations) between 12 July and 7 August 2017. Reported adherence was >80% for 9 of 18 best practices. For 37 non-governmental organizations (NGOs) with multiple raters, inter-rater agreement was moderate to substantial (κ>0.4) for 12 of 18 best practices.

Conclusions

This is the first study to evaluate adherence to STMM best practices. Such an objective evaluation will be valuable to governments, volunteers and NGO donors who have an interest in identifying high-quality partners. Assessment and monitoring of STMMs through self-audit may be foundational steps towards quality improvement.

Long-Term Impact of Interprofessional Medical Mission Service Trips in Sierra Leone

Objective: The purpose of this study was to evaluate the impact of capacity-building short-term mission service trips to Sierra Leone on local health education and perspectives. Methods: This was a prospective, mixed-methods study. During three mission trips between June 2017 and December 2019, health professional students taught multiple locally selected patient care-related topics. Local staff completed knowledge questionnaires and were surveyed or interviewed on mission service impact along with the cultural competence of missionaries. Mission team members completed the Intercultural Effectiveness Scale (IES) and surveys to determine their cultural competence. Results: After initial education, 90% passed the knowledge questionnaire with at least a 50% and the correct response rate was 57.9 vs. 66.7% after 6 months and 2.5 years, respectively (p = 0.40). Local staff ranked education/training as most valuable (84%) and highly desired (53%). Mean IES score and survey responses of both missionaries and local staff rated mission team cultural competence as average. Conclusions: Education-focused mission trips in Sierra Leone seem to have long-lasting benefits and a positive impact on local staff, though improved intercultural competence is needed.

Ethical Considerations Regarding Global Surgery Experiences in Canadian General Surgery Residencies: A Preliminary Discussion

OBJECTIVE

Recently, there has been an explosion of interest in global surgery (GS) among students, residents and surgeons. However, little information exists regarding the ethical landscape of GS in general surgery residencies. Using an American College of Physicians position paper on the ethical obligations of global health experiences as a reference, this study provides a preliminary discussion of how GS experiences in Canadian residencies compare to the American College of Physicians-proposed ethical standards.

DESIGN

The Program Director (PD) at each Canadian general surgery residency program was invited to a complete an online survey.

RESULTS

All 17 PDs participated. Relative to the position paper, very few PDs included underserved settings in high income countries in their definitions of GS. Only 7 of 15 programs offer predeparture training for residents. Similarly, funding was available at less than half of all institutions. There is a need for the development of frameworks to assess the ethics of GS programs. Similarly, mechanisms on how to build relationships that are maximally beneficial for the stakeholders in resource-limited environments are not yet well established.

CONCLUSIONS

This is the first study to look at the ethical GS landscape in general surgery residencies across Canada. This study may assist other residencies in the development and tailoring of ethical GS programs. These results show the need for further characterization of the training, development and monitoring of GS programs.

U.S. trainees' experiences of ethical challenges during research in low- and middle-income countries: A mixed methods study

High-income country (HIC) trainees are participating in research in low- and middle-income countries (LMIC) in increasing numbers, yet the ethical challenges they face have not been well described. We conducted a mixed methods study of U.S. graduate and undergraduate students who conducted research in LMIC, including an online survey and semi-structured interviews. Among 123 online survey respondents, 31% reported ethical challenges and nearly two-thirds of respondents did not feel well prepared to deal with ethical challenges. Qualitative analysis of the 17 semi-structure interviews and narrative survey responses revealed many themes of 'ethics in practice': challenges in setting research priorities, navigating relationships with host country partners, scope of research practice, and human subject protections. Respondents reported that pre-departure trainings were not reflective of ethical frameworks or research contexts in LMIC, and few described seeking host mentor help in addressing ethical challenges. These results suggest a need for improvements in training, oversight and mentorship of trainee researchers, and to further engage both HIC and LMIC institutions, educators and researchers in addressing ethical issues.

Low- and Middle-Income Country Host Perceptions of Short-Term Experiences in Global Health: A Systematic Review

PURPOSE

Stakeholders have expressed concerns regarding the impact of visiting trainees and physicians from high-income countries (HICs) providing education and/or short-term clinical care in low- and middle-income countries (LMICs). This systematic review aimed to summarize LMIC host perceptions of visiting trainees and physicians from HICs during short-term experiences in global health (STEGH).

METHOD

In September 2018 then again in August 2020, the authors searched 7 databases (PubMed, Embase, Scopus, Web of Science, ERIC, Cochrane Library, Global Index Medicus) for peer-reviewed studies that described LMIC host perceptions of STEGH. They extracted information pertaining to study design, participant demographics, participant perceptions, representation of LMICs and HICs, and HIC visitors' roles and used thematic synthesis to code the text, develop descriptive themes, and generate analytical themes.

RESULTS

Of the 4,020 studies identified, 17 met the inclusion criteria. In total, the studies included 448 participants, of which 395 (88%) represented LMICs. The authors identified and organized 42 codes under 8 descriptive themes. They further organized these descriptive themes into 4 analytical themes related to STEGH: (1) sociocultural and contextual differences, (2) institutional and programmatic components, (3) impact on host institutions and individuals, and (4) visitor characteristics and conduct.

CONCLUSIONS

STEGH can have both beneficial and detrimental effects on LMIC host institutions and individuals. The authors translated these findings into a set of evidence-based best practices for STEGH that provide specific guidance for LMIC and HIC stakeholders. Moving forward, LMIC and HIC institutions must work together to focus on the quality of their relationships and create conditions in which all stakeholders feel empowered to openly communicate to ensure equity and mutual benefit for all parties.

Ethical Considerations for Short-Term Global Health Projects

Various types of health professional volunteers from high-income nations are increasingly engaged in short-term global health projects in low- and middle-income countries. The goal of global health projects is to improve health for all people and address health inequities. Short-term projects lasting days to months can create challenges for volunteers and hosts. Despite attempting to do good, volunteer efforts may unwittingly cause harm to host organizations by planning projects without consideration for the local infrastructure, the community, and the health care staff. Although well-intentioned and often beneficial, volunteer efforts can fail to provide adequate follow-up or may disrupt or override local health efforts. In some low-resource settings, dire health needs and lack of supervision may result in volunteers practicing beyond their professional scope. Recently published guidelines, competencies, and position statements have addressed ethical behaviors for short-term global health experiences. Partnerships that are founded on principles of justice and autonomy provide an avenue for mutual collaboration. Short-term global health projects that focus on host needs are likely to strengthen local capacity to improve health outcomes. This article reviews guidelines for short-term global health experiences and addresses the ethical principles for planning effective projects.

Beyond the Tip of the Blade: An Investigation of Upper Extremity Machete Injuries in Honduras

BACKGROUND

 Machete injuries constitute a major cause of morbidity in Honduras. In this study, we aimed to determine the incidence, initial management, surgical treatment, and follow-up patterns for machete injuries at the national public hospital in Honduras. Microsurgery in Honduras is currently in transition with limitations at multiple levels. This study aims to provide critical information to better prepare visiting surgeons and establishes a blueprint to improve microsurgical reconstruction.

METHODS

 A retrospective chart review was performed to identify patients with machete injuries to the upper extremity (UE) who presented to the Hospital Escuela Universitario (HEU) for treatment from 2015 to 2017. Additional microsurgical data was obtained by personal communication with members of the plastic surgery department at the HEU.

RESULTS

 Complete data was retrieved for 100 patients who presented to the HEU with a UE machete wound. The cohort was male dominated (93%), employed as farmers (47%), and had a mean age of 32.1 years. Violence was the most common mechanism of injury (p < 0.001). The majority of UE machete injuries involved tendon (70%), nerve (28%), and an open fracture (55%). Of the 76% of patients who were scheduled for a follow-up visit, only 25% attended. Within the last calendar year, one replantation, 10 revascularizations at the wrist and forearm level, three microvascular free tissue transfers, and 175 nerve repairs were performed.

CONCLUSION

 Management of UE machete injuries in Honduras is challenging and requires early recognition of possible injuries to multiple anatomical systems. The majority of injuries required operative intervention. Only a small percentage of patients presented for follow up. A program to streamline care starting at injury recognition up to final follow-up is currently unavailable and needs to be developed to optimize microsurgical care.

Evaluating Medication Habits in Medical Mission Patients: A Cross-Sectional Study

Background

Short-term medical missions (STMMs) are a highly debated and largely understudied form of international volunteer work. With growing dedication to health care abroad, research evaluating their impact is crucial to ensure continued interventions are effective in improving medical care. STMM care varies in length, frequency, size, location, services offered, and country of origin and destination. This makes systematic evaluation of STMMs difficult. In addition, the transient nature of patient visits makes trending STMM’s impact on long-term health outcomes complex.

Despite intermittent availability, primary care missions offering pharmaceutical supplies have the unique opportunity to provide continued care to the community via free prescription supplies each visit. Given the challenges with measuring long-term outcomes in this population, it is unknown if these donated medications have any impact on patient health outcomes. As medication noncompliance is known to hinder health outcomes, our study chose to evaluate patient medication habits to see if these prescription supplies were being utilized appropriately. To our knowledge, no study has surveyed medical mission patients to explore their access and utilization of medication.

Methods

A cross-sectional study was conducted using a patient survey to identify risks and/or factors associated with medication noncompliance in patients visiting the medical mission, Waves of Health (WOH). For over 10 years, WOH has organized biannual seven-day trips to the Dominican Republic. The multi-question survey was translated into the native language, Spanish with Dominican dialect. Noncompliance was defined through the survey question “Did you run out of your prescription medication at all during the past year?” Spanish speaking participants, of both sexes and age ≥18 years old, who visited the mission clinic in November 2019 met inclusion for this study. Patients from Haiti or age <18 years old were excluded. Participation was voluntary.

Survey items were dichotomized for univariate analysis to identify factors associated with running out of medication. To explore predictors of running out of medicine, we performed multivariate logistic regression analysis by ENTER method. 

Results

Of 127 patients, over half (58.3% [74]) reported running out of medication. Inadequate access to healthcare, daily medication use, and rationing personal medications were all significantly associated with running out of medicine. Frequency of WOH visits was not associated with running out of medication. Multivariate regression showed that being on daily medication and rationing personal medications were statistically significant predictors of running out of medicines. Access to healthcare, frequency of WOH visits, and WOH medication supply were not predictors of running out of medication.

Conclusion 

Mission interventions to improve medication practices should be explored due to the high number of patients who reported improper utilization of medication. In order to improve health outcomes in primary care settings, patients must play an active role in their care and understand the importance of taking their medication as prescribed for optimal disease management. Primary care STMMs may relieve short-term health concerns, but without proper utilization of chronic disease medications, it is unclear if STMMs role is impactful in long-term health outcomes.

Occupational Therapy in Haiti: A Pilot Study to Identify Intervention Methods Used during Short-Term Medical Missions

Due to the shortage of occupational therapists (OTs) in Haiti and over 800,000 individuals with disabilities, most occupational therapy assessments and interventions are provided by OTs on short-term medical missions (STMMs). Learning which methods OT use to provide assessments and interventions during these STMMs is the first step to understanding how to facilitate follow-up and carry-over for clients and ensure longevity for STMMs in Haiti. This study used a cross-sectional, descriptive design to gather data on methods used by OTs. Thirty-three OTs, who travelled to Haiti on STMMs, completed a 16-question, online survey. The most common method provided by OTs was education to patients, caregivers, and local providers. Training of Haitian rehabilitation technicians was also prevalent. There was an association between the years of the OTs' clinical experience and the effort of OTs to train local providers, but this result was not statistically significant. Further research should be implemented on specific methods that can be used in the absence or shortage of Haitian OTs to ensure follow-up for Haitian clients. The sharing of data regarding OT methods on STMMs will promote evidence-based, client-centered, and cost-effective therapy to enhance effective client outcomes.

Assessment of Local Health Worker Attitudes toward International Medical Volunteers in Low- and Middle-income Countries: A Global Survey

BACKGROUND

International Medical Volunteers (IMVs) positively and negatively impact host countries, and the goals of their trips may not always align with the interests of the hosts in Low- and Middle-Income Countries (LMICs). We sought to better understand local physicians' interest of hosting IMVs and what type of support they desired.

METHODS

This study was a convenience sample survey-based needs assessment. The surveys were distributed to local physicians by 28 professional society groups in LMICs.

FINDINGS

A total of 102 physicians from 51 countries completed the survey. Despite 61.8% participants having no experience with IMVs, 75% were interested in hosting them. Host physicians most desired clinical education (39%), research collaboration (18%), and Systems Development (11%). The most requested specialties were obstetrics and gynecology (25%) and emergency medicine (11%). Respondents considered public hospitals (62%) to be the most helpful clinical setting in which IMVs could work, and 3 months (47%) as the ideal length of stay.

Respondents expressed interest in advertising the specific needs of the host country to potential IMVs (80%). Qualitative analyses suggested hosts wanted more training opportunities, inclusion of all stakeholders, culturally competent volunteers, and aid focused on subspecialty education, health policy, public health, and research.

CONCLUSION

Hosts desire more bidirectional clinical education and research capacity building than just direct clinical care. Importantly, cultural competence is key to a successful host partnership, potentially improved through IMV preparation. Finally, respondents want IMVs to ensure that they stay within their scope of practice and training.

Global Surgery Opportunities in Canadian General Surgery Residencies: A Cross-Sectional Study

OBJECTIVE

In recent years, there has been an explosion of interest in global surgery (GS) among students, residents, and surgeons. However, little information regarding the landscape of GS in general surgery residencies exists. This study was therefore designed to explore the opportunities and the framework for global surgery in Canadian general surgery training programs.

DESIGN

The Program Director (PD) at each Canadian general surgery residency program was invited to complete an online survey.

RESULTS

All 17 PDs participated. Only 3 institutions have a formal curriculum in GS, while 9 have an Office of GS. Seven residencies mention GS on their department website. Ten of 17 residencies have had trainees participate in GS experiences in the last academic year. Funding or pre-experience training is available at less than half of all institutions. Only one residency ranked GS exposure as being "very important" to their program. Across all programs, the average ranking of GS experiences was 2.3 out of 5, which translates descriptively to being of "little importance". Despite this, 10 PDs identified GS as attractive to applicants, and 5 stated their plans to expand GS opportunities at their institution.

CONCLUSIONS

This is the first study to look at the GS landscape in general surgery residencies across Canada. These results may inform graduating medical students and residents about the current status of GS in Canadian residencies. This study may also assist other residencies in the development and tailoring of GS programs.

A global health capstone: an innovative educational approach in a competency-based curriculum for medical students

BACKGROUND

Global health educational programs for medical and public health professionals have grown substantially in recent years. The University of Illinois Chicago College of Medicine (UICOM) began a global medicine (GMED) program for selected students in 2012 and has since graduated four classes. As part of the four-year curriculum, students complete a longitudinal global health capstone project. This paper describes the global health capstone project as an innovative educational tool within a competency-based curriculum.

METHODS

The authors define and describe the longitudinal global health capstone including specific requirements, student deliverables, and examples of how the global health capstone may be used as part of a larger curriculum to teach the competency domains identified by the Consortium of Universities for Global Health. The authors also reviewed the final capstone projects for 35 graduates to describe characteristics of capstone projects completed.

RESULTS

The global health capstone was developed as one educational tool within a broader global health curriculum for medical students. Of the 35 capstones, 26 projects involved original research (74%), and 25 involved international travel (71%). Nine projects led to a conference abstract/presentation (26%) while five led to a publication (14%). Twenty-one projects (60%) had subject matter-focused faculty mentorship.

CONCLUSIONS

A longitudinal global health capstone is a feasible tool to teach targeted global health competencies and can provide meaningful opportunities for research and career mentorship. Further refinement of the capstone process is needed to strengthen mentorship, and additional assessment methods are needed.

Mentorship and Ethics in Global Health: Fostering Scientific Integrity and Responsible Conduct of Research

Addressing ethical issues through mentorship is key to encouraging scientific integrity and increasing research capacity. Across the global health arena, mentorship requires helping mentees understand and negotiate the regulatory aspects of research—which can substantially differ even between countries with similar resources. Mentorship support spans across the research framework from obtaining ethical approval and ensuring scientific integrity, to determining authorship and disseminating study results—providing multiple opportunities to model ethical behavior for mentees. The power imbalances between the global north and south in accessing funding resources produce further challenges in setting the research agenda and for ensuring equity in the dissemination of research findings. Gender further complicates the aspiration for equity; the proportion of women in high administrative or research positions remains low. This study explores four specific mentoring case scenarios commonly encountered in the global health research field in low- and middle-income institutions.

Extent, nature and consequences of performing outside scope of training in global health

BACKGROUND

Globalization has made it possible for global health professionals and trainees to participate in short-term training and professional experiences in a variety of clinical- and non-clinical activities across borders. Consequently, greater numbers of healthcare professionals and trainees from high-income countries (HICs) are working or volunteering abroad and participating in short-term experiences in low- and middle-income countries (LMICs). How effective these activities are in advancing global health and in addressing the crisis of human resources for health remains controversial. What is known, however, is that during these short-term experiences in global health (STEGH), health professionals and those in training often face substantive ethical challenges. A common dilemma described is that of acting outside of one's scope of training. However, the frequency, nature, circumstances, and consequences of performing outside scope of training (POST) have not been well-explored or quantified.

METHODS

The authors conducted an online survey of HIC health professionals and trainees working or volunteering in LMICs about their experiences with POST, within the last 5 years.

RESULTS

A total of 223 survey responses were included in the final analysis. Half (49%) of respondents reported having been asked to perform outside their scope of training; of these, 61% reported POST. Trainees were nearly twice as likely as licensed professionals to report POST. Common reasons cited for POST were a mismatch of skills with host expectations, suboptimal supervision at host sites, inadequate preparation to decline POST, a perceived lack of alternative options and emergency situations. Many of the respondents who reported POST expressed moral distress that persisted over time.

CONCLUSIONS

Given that POST is ethically problematic and legally impermissible, the high rates of being asked, and deciding to do so, were notable. Based on these findings, the authors suggest that additional efforts are needed to reduce the incidence of POST during STEGH, including pre-departure training to navigate dilemmas concerning POST, clear communication regarding expectations, and greater attention to the moral distress experienced by those contending with POST.

Health Volunteers Overseas: A Model for Ethical and Effective Short-Term Global Health Training in Low-Resource Countries

Three core attributes enable short-term volunteers to make incremental contributions to long-term outcomes at host institutions: (1) focusing on teaching rather than service delivery, (2) engaging in mutually beneficial and equitable partnerships with host institutions, and (3) operating within a structured management system.

Are you ready? A systematic review of pre-departure resources for global health electives

BACKGROUND

There has been an exponential increase in the offering of short-term international field experiences in recent years in response to student demands for global health opportunities. Pre-departure preparation is an essential component to equip trainees with the adequate safety, wellness, and cultural competence needed to engage in a meaningful and mutually beneficial elective. This review seeks to quantify the plethora of pre-departure preparation training available to public health, clinical, and undergraduate trainees across the continuum of education for short-term experiences in low-and middle-income countries (LMICs).

METHODS

We performed a systematic review of Pubmed, Embase, Web of Science, Scopus, and Ovid Global Health in February, 2018. A three-concept search was employed and included "global or international health"; "education or preparation of personnel/students"; and "field programs or travel." The study teamed used PRISMA reporting guidelines to conduct title and full-text reviews and conduct data extraction and analysis.

RESULTS

The search returned 2506 unique articles. Of these, 55 met inclusion criteria and were included in the final review. Ninety one percent (91%) of articles focused on pre-departure trainings for medical students and residents. Nine thematic domains for short-term international field experiences emerged; culture, safety, and project-specific knowledge were the most frequently covered domains while mentorship, professionalism, and emotional wellness and culture shock were least common. Approximately half (53.3%) of studies specifically evaluated the pre-departure component of the international experience using a survey or evaluation form. Recommendations emerged from these evaluations including early engagement with international partners, inclusion of self-reflection exercises and site-specific content, and utilization of interactive approaches in learning. Some institutions face barriers to conducting pre-departure preparation such as lack of dedicated faculty, finances, and institutional support.

CONCLUSIONS

Interest in pre-departure training for international experiences is growing but few programs conduct and publish evaluations of these trainings. Pre-departure trainings should be developed in partnership with receiving institutions and faculty and incorporate critical self- reflection throughout the experience. In addition to the experience itself, institutions need to evaluate these curricula to better understand how they influence trainees' capacity to effectively engage in LMIC settings.

American College of Physicians Ethics Manual: Seventh Edition

Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The seventh edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.

The ethical experiences of trainees on short-term international trips: a systematic qualitative synthesis

BACKGROUND

Medical student and resident participation in short-term international trips for trainees (STINTTs) has increased in the past few decades. However, there has been no systematic review of trainees' actual ethical experiences. The authors sought to identify what ethical issues medical trainees encounter during STINTTs, as elicited by and reported in peer-reviewed, quantitative and qualitative research papers.

METHODS

The authors systematically searched five academic databases finding 659 unique titles and abstracts. The authors applied inclusion and exclusion criteria to these titles and abstracts resulting in fourteen papers, which were analyzed using qualitative thematic synthesis.

RESULTS

The qualitative analysis of the papers generated four themes: (1) Trainees' Concerns Over Perpetuating Medical Tourism; (2) Struggling to Identify and Balance the Benefits and Harms of STINTTs; (3) The Complicated Trainee Mens (mind); and (4) Ethical Situations Encountered by Trainees. The fourth theme, which was the largest, was further divided into (a) Navigating social and cultural dynamics, (b) Trainees' experiences related to the learner role, and (c) Ethical situations not qualifying for other catagories. Some of these issues reported in the empirical research papers are well represented in the broader literature on STINTTs, while others were less so-such as mistreatment of trainees. All included papers were published after 2010, and comprised a total of less than 170 medical trainees.

CONCLUSIONS

Medical trainees report experiencing a wide range of ethical challenges during short-term international trips in which they engage in clinical or research activities. The authors call educators' attention to specific challenges that trainees face. The relevant literature covering US and Canadian STINTTs is relatively young and largely qualitative. The authors briefly sketch a program for expanding the research on this increasingly common educational experience.