Ethical dilemmas during international clinical rotations in global health settings: Findings from a training and debriefing program

International short-term placements in health professions education-A meta-narrative review

INTRODUCTION

In order to be prepared for professional practice in a globalised world, health professions students need to be equipped with a new set of knowledge, skills and attitudes. Experiential learning gained during an international placement has been considered as a powerful strategy for facilitating the acquisition of global health competencies. The aim of this review was to synthesise the diverse body of empirical research examining the process and outcomes of international short-term placements in health professions education.

METHODS

A systematic review was conducted using a meta-narrative methodology. Six electronic databases were searched between September 2016 and June 2022: Medline, Embase, CINAHL, PsycINFO, Education Research Complete and Web of Knowledge. Studies were included if they reported on international placements undertaken by undergraduate health professions students in socio-economically contrasting settings. Included studies were first considered within their research tradition before comparing and contrasting findings between different research traditions.

RESULTS

This review included 243 papers from 12 research traditions, which were distinguished by health profession and paradigmatic approach. Empirical findings were considered in four broad themes: learner, educational intervention, institutional context and wider context. Most studies provided evidence on the learner, with findings indicating a positive impact of international placements on personal and professional development. The development of cultural competency has been more focus in research in nursing and allied health than in medicine. Whereas earlier research has focussed on the experience and outcomes for the learner, more recent studies have become more concerned with relationships between various stakeholder groups. Only few studies have looked at strategies to enhance the educational process.

CONCLUSION

The consideration of empirical work from different perspectives provides novel understandings of what research has achieved and what needs further investigation. Future studies should pay more attention to the complex nature of the educational process in international placements.

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 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.

Analysis in the ethical decision-making of dental, nurse and physiotherapist students, through case-based learning

INTRODUCTION

Training in ethical competencies is perceived with special interest among the objectives of health education. The dimensions of the person such as integrity, autonomy and dignity influence the choice of interventions, but the different specialties of the health sciences conceive these dimensions with different perspectives depending on the clinical setting. These divergences can be detected during the first years of undergraduate studies, and it is important to know the professional bias and its possible causes.

MATERIALS AND METHODS

A procedure was developed through case-based learning (CBL) to assess various characteristics of decision-making during the early stages of student training. A semi-quantitative method was designed based on the narrative responses of a case with ethical implications in the field of gender violence. The method was applied to 294 undergraduate students in nursing (95), physiotherapy (109) and dentistry (90) from the Faculty of Health Sciences of a Spanish university. A frequency analysis of the narrative responses of the students to the proposed case was carried out, using the chi-square test to determine any association between the variables studied: gender, specialty and ethical knowledge.

RESULTS

Four types of response categories were detected, as a result of combining the personal conversation, report to legal authority or require assistance of other teams. The most common option in dentists is conversation only, while physical therapists include the assistance of other teams. In nursing, a balance is observed between both possibilities. The results show that student responses differ significantly among specialties and also differ significantly according to test scores on ethical knowledge. However, no significant differences were found between the responses provided by men and women.

CONCLUSION

Most of the health sciences students highly valued their own capacity for dialogue and reflection to approach situations with complex ethical dimensions. We consider that case-based learning (CBL), in combination with narrative analysis is a valid means of evaluating the professional ethical competencies of students in health sciences careers applied to a common goal.

A Systematic Review of Global Health Assessment for Education in Healthcare Professions

Objective:

Methods:

Results:

Conclusions:

Global Health Crisis, Global Health Response: How Global Health Experiences Prepared North American Physicians for the COVID-19 Pandemic

The COVID-19 pandemic plunged hospital systems into resource-deprived conditions unprecedented since the 1918 flu pandemic. It brought forward concerns around ethical management of scarcity, racism and distributive justice, cross-disciplinary collaboration, provider wellness, and other difficult themes. We, a group of medical educators and global health educators and clinicians, use the education literature to argue that experience gained through global health activities has greatly contributed to the effectiveness of the COVID-19 pandemic response in North American institutions. Support for global health educational activities is a valuable component of medical training, as they build skills and perspectives that are critical to responding to a pandemic or other health system cataclysm. We frame our argument as consideration of three questions that required rapid, effective responses in our home institutions during the pandemic: How can our health system function with new limitations on essential resources? How do we work at high intensity and volume, on a new disease, within new and evolving systems, while still providing high-quality, patient-centered care? And, how do we help personnel manage an unprecedented level of morbidity and mortality, disproportionately affecting the poor and marginalized, including moral difficulties of perceived care rationing?

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.

Medical professionalism in ophthalmology: design and testing of a scenario based survey

BACKGROUND

Professionalism is hard to quantify but essential in medical practice. We present a survey tool for ophthalmologists that assessed professionalism using case-based scenarios in central Saudi Arabia.

METHODS

Ophthalmologists (resident, fellows and consultants) participated in a web-based survey in 2015. Out of 44 attributes related to professionalism, experts selected 32 attributes with validity indices of ≥0.80. To evaluate these attributes, 51 scenario-based questions were developed and included in the survey. For each attribute, participants were given choices of close ended responses: unacceptable (1), probably unacceptable (2), acceptable (3), probably acceptable (4). The attribute score was compared to the gold standard (responses of an expert group). An attribute score was generated and compared among subgroups.

RESULTS

Of the 155 ophthalmologists, responses of 147 ophthalmologists who completed more than 50% of questions were reviewed. Their mean attribute score was 84.1 ± 10.1 (Median 87.1; 25% quartile 78.1; minimum 50; and maximum 100). The variation in attribute score among consultants, fellows and resident ophthalmologists was significant (P = 0.008). The variation of attribute score by groups of attributes was also significant (P < 0.05). The score for 'Personal characteristics' was on a lower scale compared to that of other attribute groups. The variation in the scores for attribute groups; 'Personal characteristics attribute' group (p < 0.01) and 'Workplace practices & relationship' group (P = 0.03) for consultants, fellows and residents were significant.

CONCLUSIONS

Professionalism among ophthalmologists and those in training was high and influenced by years of experience. The survey tool appeared to show differences in responses to specific professional attribute groups between trainees and consultants. Additional studies with a larger sample size might be helpful in validating the survey as a tool to be used to assess professionalism in graduate medical education in ophthalmology.

Perspectives and Solutions from Clinical Trainees and Mentors Regarding Ethical Challenges During Global Health Experiences

Background

Clinical trainees face challenges throughout short-term experiences in global health (STEGH) that are not routinely addressed.

Objectives

Describe common professional and ethical dilemmas faced by clinical trainees and identify gaps and solutions for pre, during, and post-STEGH training and mentoring.

Methods

We conducted a mixed-methods study among trainees and mentors involved in global health. The study utilized focus groups with trainees (November-December 2015) and online surveys of trainees, in-country and stateside faculty mentors (October 2016-April 2017).

Results

85% (17/20) of students reported feeling prepared for their STEGH; however, 59% (23/39) of faculty felt students were unprepared. A majority of both students (90%) and faculty (77%) stated students would likely experience an ethical dilemma during STEGH. Major themes relating to meaningful global health work were elucidated: personal and inter-professional skills; interpersonal networks and collaboration; and awareness of power dynamics and bias.

Conclusions

The most common challenges faced by trainees during STEGH related to leadership, bias, ethics and interprofessional collaboration. Redirecting trainee energies from a focus on 'doing' and deliverables to attitudes (e.g., humility, professionalism) that cultivate personal and professional growth will help create lifelong global health learners and leaders.

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.

Healthy, safe and effective international medical student electives: a systematic review and recommendations for program coordinators

Background

Thousands of medical students undertake international medical electives each year. These students face potentially substantial health and safety risks as well as educational and ethical challenges and therefore should undertake their electives within well-structured and coordinated programs.

Methods

We conducted a qualitative systematic review based on a pre-determined protocol. Relevant publications and guidelines relating to international medical electives were identified through a review of the literature using on-line search engines, principally PubMed. We then conducted a systematic qualitative synthesis to extract relevant publications. Finally, the literature was organized according to themes, with the aim of developing a structured set of Recommendations for Implementation for program coordinators.

Results

A wide range of important issues were identified which were categorized into seven themes upon which recommendations were made principally for the benefit of program coordinators: Responsibilities; General policies; Travel advisories; Occupational risk assessment; Funding & finances, Pre-departure training programs; and Post-return debriefing and screening.

Conclusions

Recommendations for program coordinators on the health and safety of medical students while on international medical electives have been sourced from existing guidelines and relevant publications. There was considerable consensus from the literature and as such these synthesised recommendations could form the basis for internationally accepted standards for elective placement program coordinators.

Electronic supplementary material

The online version of this article (10.1186/s40794-019-0081-0) contains supplementary material, which is available to authorized users.

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.

The Practitioner's Guide to Global Health: an interactive, online, open-access curriculum preparing medical learners for global health experiences

BACKGROUND

Short-term experiences in global health (STEGH) are increasingly common in medical education, as they can provide learners with opportunities for service, learning, and sharing perspectives. Academic institutions need high-quality preparatory curricula and mentorship to prepare learners for potential challenges in ethics, cultural sensitivity, and personal safety; however, availability and quality of these are variable.

OBJECTIVE

The objective of this study is to create and evaluate an open-access, interactive massive open online course (MOOC) that prepares learners to safely and effectively participate in STEGH, permits flexible and asynchronous learning, is free of charge, and provides a certificate upon successful completion.

METHODS

Global health experts from 8 countries, 42 institutions, and 7 specialties collaborated to create The Practitioner's Guide to Global Health (PGGH): the first course of this kind on the edX platform. Demographic data, pre- and posttests, and course evaluations were collected and analyzed.

RESULTS

Within its first year, PGGH enrolled 5935 learners from 163 countries. In a limited sample of 109 learners, mean posttest scores were significantly improved (p < 0.01). In the course's second year, 213 sampled learners had significant improvement (p < 0.001).

CONCLUSION

We created and evaluated the first interactive, asynchronous, free-of-charge global health preparation MOOC. The course has had significant interest from US-based and international learners, and posttest scores have shown significant improvement.

Working in global health: A planning and implementation framework for international electives

Purpose: Propose a framework for planning and undertaking an international elective. Methods: On returning from conducting maternal health and well-being research in several remote communities in India, two undergraduate medical students have reflected on and documented their experiences with the view to assisting other students (and their supervisors) considering undertaking an international elective. Results: A framework for undertaking clinical or research electives in remote or rural communities is presented. The framework comprises three distinct phases: Pre-departure planning and briefing, in-country experiences and returning from the elective and considers a range of factors to ensure that, as a minimum, visiting students "do no harm" and are themselves not harmed. Conclusions: Students' home institutions have a duty of care for preparing them for their international electives by providing pre-departure training, support during the elective and comprehensive de-briefing on their return. These electives should be evaluated (including by host communities) to ensure that exchanges are socially accountable, with no harm to the often-vulnerable communities in which students gain considerable experience. Also important is that future students build on the positive experiences of their predecessors to ensure sustainability of any interventions in host communities.