Cross-cultural perspectives on the patient-provider relationship: a qualitative study exploring reflections from Ghanaian medical students following a clinical rotation in the United States

Gynecologic Oncology Sub-Specialty Training in Ghana: A Model for Sustainable Impact on Gynecologic Cancer Care in Sub-Saharan Africa

African women have double the risk of dying from cancer than women in high-income countries. In Ghana, most women with gynecological malignancies present with advanced-stage disease when treatment is less effective. Barriers to improved cancer outcomes include the availability of cancer screening, affordability of treatment, and access to gynecologic oncology specialists. In response to a paucity of gynecologic oncology providers, an in-country fellowship training program was established at Komfo Anokye Teaching Hospital (KATH) in 2013. Historically, Ghanaian resident physicians were sent to other countries for fellowship training and were unlikely to repatriate. The establishment of an in-country training program not only addresses the challenge of "brain drain," but also builds local capacity in gynecologic oncology education and emphasizes culturally relevant and accessible healthcare. The four-years gynecologic oncology fellowship program at KATH was developed as part of a longitudinal multi-decade partnership between the University of Michigan and academic medical centers in Ghana. The fellowship trains obstetricians and gynecologists to provide subspecialist clinical and surgical care to patients with gynecologic malignancies. Fellows collaborate with the radiation, oncology and pathology departments, participate in monthly inter-institutional tumor board meetings, conduct research, advise on health policy issues, and train subsequent cohorts. This fellowship is representative of emerging twenty-first-century trends in which subspecialty training programs in low-income countries are strengthened by international collaborations. Providing specialized training in gynecologic oncology can help develop and maintain resources that will improve clinical outcomes for women in low-resources settings.

Embedding international medical student electives within a 30-year partnership: the Ghana-Michigan collaboration

BACKGROUND

Global health experiences are an increasingly popular component of medical student curricula. There is little research on the impact of international medical electives embedded within long-standing, sustainable partnerships. Our research explores the University of Michigan medical student elective experience in Ghana within the context of the Ghana-Michigan collaborative.

METHODS

Study participants are University of Michigan medical students who completed an international elective in Ghana between March 2006 and June 2017. Post-elective reports were completed by students, including a description of the experience, highlights, disappointments, and the impact of the experience on interest in future international work and future practice of medicine. A retrospective thematic analysis of reports was carried out using NVivo 12 (QSR International, Melbourne, Australia).

RESULTS

A total of 57 reports were analyzed. Benefits of the elective experience included building cross-cultural relationships, exposure to different healthcare environments, hands-on clinical and surgical experience, and exposure to different patient populations. Ninety-five percent of students planned to engage in additional international work in the future. Students felt that the long-standing bidirectional exchange allowed them to build cross-cultural relationships and be incorporated as a trusted part of the local clinical team. The partnership modeled collaboration, and many students found inspiration for the direction of their own careers.

CONCLUSIONS

Embedding clinical rotations within a well-established, sustained partnerships provides valuable experiences for trainees by modeling reciprocity, program management by local physicians, and cultural humility-all of which can help prepare learners to ethically engage in balanced, long-term partnerships in the future.

"They Will Come to Understand": Supervisor Reflections on International Medical Electives

Phenomenon: Increasing numbers of medical students from high-income countries are undertaking international medical electives (IMEs) during their training. Much has been written about the benefits of these experiences for the student, and concerns have been raised regarding the burden of IMEs on host communities. The voices of physicians from low- and middle-income countries who supervise IMEs have not been explored in depth. The current study sought to investigate host-physician perspectives on IMEs. Approach: Host supervisors were recruited by convenience sampling through students travelling abroad for IMEs during the summer of 2012. From 2012 through 2014, 11 semistructured interviews were conducted by telephone with host supervisors from Nepal, Uganda, Ghana, Guyana, and Kenya. Participants were invited to describe their motivations for hosting IMEs and their experiences of the benefits and harms of IMEs. Interviews were transcribed verbatim and checked for accuracy. An initial coding framework was developed and underwent multiple revisions, after which analytic categories were derived using conventional qualitative content analysis. Findings: For host supervisors, visits from international medical students provided a window into the resource-rich medical practice of high-income countries, and supervisors positioned themselves, their education, and clinical expertise against perceived standards of the international students' context. Hosting IMEs also contributed to supervisors' identities as educators connected to a global community. Supervisors described the challenge of helping students navigate their distress when confronting global health inequity. Finally, the desire for increasingly reciprocal relationships was expressed as a hope for the future. Insights: IMEs can be formative for host supervisors' identities and are used to benchmark host institutions compared with international medical standards. Reciprocity was articulated as essential for IMEs moving forward.

A Comparison of the Expectations and Experiences of Medical Students From High-, Middle-, and Low-Income Countries Participating in Global Health Clinical Electives

Phenomenon: Global health education (GHE) is expanding to include socioculturally and resource-different settings, with the goal of developing a workforce with members who can promote health equity locally and globally. GHE is also no longer limited to students from high-income countries (HICs). However, it is unknown whether the motivations and experiences of medical students from HICs and from low- and middle-income countries (LMICs) participating in GHE clinical electives through institutional partnerships are similar or different. Such an understanding is needed to design programs that meet the needs of participants and effectively train them in the principles and practice of global health.

APPROACH

This was a cross-sectional, mixed-methods survey of LMIC students from partner sites rotating at one U.S. medical school, and U.S. students from one medical school rotating at partner sites, between 2010 and 2015. Variables included demographic characteristics of participants, components of the curriculum at the home institution, and components of the away rotation, including perceptions of its content and impact. Content analysis was used to identify themes in the responses provided to open-ended questions.

FINDINGS

In all, 63 of 84 (75%) LMIC and 61 of 152 (40%) U.S. students participated. Recall of predeparture training was low for both LMIC and U.S. students (44% and 55%, respectively). Opportunities to experience different healthcare systems, resource-different settings, and cultural exposure emerged as motivators for both groups. Both groups noted differences in doctor-patient relationships, interactions between colleagues, and use of diagnostic testing. U.S. respondents were more likely to perceive differences in the impact of social determinants of health and ethical issues. Both groups felt that their experience affected their interactions with patients and perspectives on education, but U.S. students were more likely to mention perspectives on healthcare delivery and social determinants of health, whereas LMIC respondents noted impacts on career goals. Insights: These results argue that GHE is not restricted to resource-constrained settings and that students from LMICs have similar reasons for participation as those from HICs. LMIC students also identified a lack of emphasis on GHE topics like social determinants of health during GH electives, which could diminish the effectiveness of these experiences. Both U.S. and LMIC students emphasized the cultural component of their GHE experience but had different perceptions regarding core tenets of GHE, such as the social determinants of health and health equity, during these experiences.

Current Practices in Hosting Non-US Pharmacy Students at US Pharmacy Schools in Experiential Clerkships

Objective: To provide specific considerations for hosting non-U.S. pharmacy students at U.S.-based colleges/schools of pharmacy (C/SOP) for experiential clerkships and training. Findings: A literature review (2000-2016) in PubMed, Google Scholar and IPA databases was conducted using specific keywords. Recommendations and future directions for development of experiential rotations for non-U.S. students in U.S. experiential rotations are presented for both the home and host country. Summary articles and best practices across the disciplines, as well as expert opinion, were found across U.S. models for hosting non-U.S. students in advanced practice rotations in the medical disciplines. Consistent themes regarding legal agreements, acculturation, standardized calendars and social and safety considerations were considered for inclusion in the final document. Conclusion: Development of a successful experiential rotation/training for non-U.S. students requires consideration for well-developed objectives, qualified preceptors, multitude of legal and cultural considerations and recommendations for longevity and sustainability.