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Global Health Program Director's Guide: Chapter 5

Chapter Author: Nicole St Clair, MD

Key Points

enlightenedThere are many considerations for trainee preparation for GH electives, including logistics, personal motivations, safety, health, emergencies, ethics, sustainability, resources, culture, culture shock, language, and professionalism. This chapter offers a “top ten” list to help structure pre-departure training and mentorship.

enlightenedCulture shock is frequently experienced by trainees during GH electives, and the phenomenon is summarized here in an effort to optimize pre-departure training and on-site mentorship.

 

The purpose of this chapter is to outline important trainee considerations for GH elective preparation. Chapter 4 provided a summary of the minimum infrastructure necessary for training programs to offer GH electives, whereas this chapter highlights trainee-specific considerations. It should be noted that there is a great deal of overlap, and much of the content of this chapter can be incorporated into pre-departure, on-site, and post-return training and mentorship programs.

Preparation for short-term GH electives is an evolving field within GH, as the ethical, sustainability, and cultural implications of short-term engagement can be profound. To best prepare trainees for participating in GH electives, the authors suggest developing a mentorship program and curriculum that at minimum address the “top ten” considerations for GH elective preparation (Figure 5).44

A more thorough list of best practices that have been proposed in the literature for preparation is included in Appendix O.

Programs that do not have the infrastructure to prepare trainees for GH electives through a combined mentorship and curriculum model may consider publicly available preparation resources, including but not limited to:

Additional details pertinent to trainee preparation are highlighted in the following sections and can be paired with the institutional considerations outlined in Chapter 4 if a program develops an infrastructure for preparation training.

Trainee Prerequisites for Participation in a GH Elective

Prerequisites are determined by the individual training program and vary depending on the GH elective patient population and preferences of the training institution and the host site. For GH electives where patient volume and acuity are high, the authors suggest that institutions restrict participation to trainees who have completed at least 18 months of training, including experience in the pediatric and neonatal intensive care units prior to participation.31 The host institution should also have the opportunity to restrict participation based on level of training.

Pre-Travel Trainee Motivations, Goals, and Objectives

Part of the vetting process prior to enrolling a trainee in a GH elective should include an exploration of his or her motivations. A known phenomenon is that of “medical voluntourism,” loosely defined as health professionals seeking experiential or altruistic alternatives to traditional vacations for a variety of personal motivations. Understandably, critics argue that the short-term, often voyeuristic nature of medical voluntourism carries with it significant ethical, sustainability, professional, cultural, and patient safety concerns. An additional common motivation for trainees is to have an opportunity to “make a positive difference” during their GH elective, which is almost universally misaligned with reality, as the short-term nature of their elective, in addition to the burden that they place on the local infrastructure, will rarely have a true positive impact on the hosts and host patient population and more often has a positive impact on the trainee. A third, and more dangerous motivation, involves trainees seeking to “practice” procedures that they cannot normally do at their home institution. Those trainees should be discouraged from participation, as the ethical, medicolegal, and patient safety implications of extending their clinical practice outside of their scope of expertise, and with suboptimal supervision, are profound.

It is critical for pre-departure motivations to be explored, examined, and aligned with the realistic constraints of a short-term training experience in an unfamiliar setting. In addition to direct discussions with the trainee about motivations, a helpful resource is to view the 45-minute documentary “First Do No Harm”. Additionally, it is important to have the trainee develop a personal list of goals and objectives for a GH elective that they cannot otherwise achieve with a stateside elective; these goals and objectives should be reviewed with the trainee’s stateside faculty mentor and the in-country host supervisor(s).

Application for a GH Elective

Application processes vary based on institutional requirements. At minimum, the authors recommend having trainees submit a signed program letter of agreement that specifies a supervisory agreement with a host supervisor for the entirety of the trainee’s elective and outlines the trainee’s expected roles during the elective. It is also strongly encouraged for training programs to require a formal application that solicits motivations for participation, goals and objectives, and emergency contact information. Through the application process, trainees can also be educated on policies and expectations at the host institution. Trainees should start their planning process at least a year prior to the elective, and a timeline-based checklist is offered in Appendix Q. Programs are encouraged to share trainee application materials with the host institution so that they have access to their goals and objectives and important personal information (eg, training level/allowed scope of practice, emergency contact information, emergency medical insurance, health-related information, etc).

Costs of a GH Elective

Expenses for GH electives can vary widely, usually from $1,000 to $6,000, depending on the location and the associated fees (airfare, housing, visa, medical licensure, in-country transportation, food, immunizations, medications, evacuation insurance, gifts, donations, elective fees, etc). Few national funding opportunities are available, the most notable being the American Academy of Pediatrics International Travel Grant. Some institutions have the resources to offer stipends to offset the cost of GH electives, but in the majority of cases careful trainee budgetary planning is required.

Safety, Health, and Emergency Considerations

These considerations were thoroughly outlined in Chapter 4, both from an institutional and trainee perspective, and are core components of preparation training.

Special Considerations for Non-U.S. Residents

Non-U.S. residents who are enrolled in training programs on J-1 or other visas may encounter logistical problems associated with their travel plans, and potential issues will vary based on the GH elective destination. This topic is beyond the scope of this guide, but best practices for foreign medical graduates include the following:

  • Refer to travel regulations through the State Department and elective site country
  • Review any pertinent information in the Exchange Visitor Sponsorship Program travel webpage
  • Trainees should carry both their passport and their current DS-2019 during all travel. The DS-2019 must be validated by the Responsible Officer at the Educational Commission for Foreign Medical Graduates (ECFMG) no more than 1 year prior to travel. Only the original DS-2019 is accepted upon re-entry into the United States.
  • Trainees should communicate closely with their Graduate Medical Education Office regarding any travel plans.
Culture Shock and its Impact on Trainee Experience and Professionalism

The intensity of the immersive experience of GH electives can result in highly charged emotional responses from trainees, including but not limited to: critical judgments about local practice methodologies; frustration about resource limitations or perceived slower pace of clinical care; anger about higher levels of acuity and mortality; frustration about different professional standards; and feelings of helplessness in difficult clinical situations. Many of these emotions are closely linked with the phenomenon of culture shock, which entails a fairly predictable, stage-like process of adapting to a new environment (Figure 6). The “frustration” stage of culture shock is associated with the greatest risk of visiting trainees displaying unprofessional behavior, which can be manifested in judgment, criticism, and negative behaviors. In addition to the professionalism concerns surrounding the on-site behavior of trainees during this difficult transition period, there are also concerns pertaining to their communication methods with friends and family, particularly with regard to the use of social media and photography.

  • Social media: Trainees frequently document their experiences through the use of a blog, email, Instagram, Facebook, and other outlets. During the frustration stage of culture shock, it is not uncommon for them to utilize judgment terms such as “primitive” when referencing medical care with resource limitations — likely without recognizing the impact of such statements on the host institution, host government/Ministry of Health, providers, and patient population.
  • Photography: Trainees frequently forget about patient privacy guidelines surrounding patient photos and fail to inquire with the host institution about photo policies.

Some institutions approach these issues with pre-departure training pertaining to culture shock, communication, professionalism, and wellness while abroad (Appendix I) and also have their trainees review and sign a Professionalism Agreement (or Code of Conduct). An example can be found in Appendix J; these agreements can be developed in collaboration with host partners. Whenever possible, it is also helpful to discuss general communication and behavior styles at the host country (typical approaches to conflict management, dress code, communication dynamics in a hierarchical structure, etc).

Ethics

Specific ethical concerns pertinent to GH electives were highlighted in Chapter 4, particularly related to donations, sustainability, and scope of expertise. In addition to the suggestions for institutions to offer pre-departure ethics training, trainees should seek input from peers, mentors, global partners, and other training resources to best prepare for some of the scenarios that they may encounter in resource-limited, high-acuity settings that likely have markedly different health systems.36,45 Online modules offered by Johns Hopkins Berman Institute of Bioethics provide case examples for trainees to navigate through various ethical scenarios pertinent to short-term GH electives.

“In three days, I coded three children, and all of them died. I know the meaning of futility, and loss. I know how it feels to hold a dead child in my arms and present her to her mother. I know what it’s like to go home at night and predict which children will probably die… It is so unlike home...Strange, I thought that with such futility I would become violently angry over the circumstances. But you adjust so quickly to a new ‘norm,’ one of knowing your resources, and recognizing when you can do no further. It is an entirely new experience for me.”

- Anonymous trainee

enlightenedFor those seeking to employ a GH track director and/or a GH track program coordinator, sample position descriptions are included in Appendices B and C.

Citation: St Clair N, Abdul-Mumin A, Banker S, Condurache T, Crouse H, Helphinstine J, Kazembe P, Lukolyo H, Marton S, McQuilkin P, Pitt M, Rus M, Russ C, Schubert C, Schutze G, Steenhoff A, Uwemedimo O, Watts J, Butteris S. Global health in pediatric education: an implementation guide for program directors. American Board of Pediatrics Global Health Task Force Publication, in collaboration with the American Academy of Pediatrics Section on International Child Health and the Association of Pediatric Program Directors Global Health Learning Community. September, 2018. abp.org/ghpdguidehome