Global Health Opportunities in Obstetrics and Gynecology Training: Examining Engagement Through an Ethical Lens

Abstract

Abstract. This study aims to describe global health training (GHT) programs through the ethical lens suggested by the Working Group on Ethics Guidelines for Global Health Training (WEIGHT). A total of 35 GHT programs were identified, and general information was obtained online. Semi-structured telephone interviews of key members of 19 programs were then conducted and transcribed. The interview guide was constructed using WEIGHT recommendations. Transcript data were grouped according to domains: reciprocity, trainee selection and preparedness, needs assessments, and ethical questions. Many programs expressed difficulty in building reciprocal relationships due to imbalanced power structures. Eleven programs reported no formal application process for selecting trainees. Twelve (63%) programs reported only a single day of preparation. Nine (47%) programs did not conduct a formalized needs assessment of partner sites. Ethical considerations varied from concerns for safety to inadequate training for residents. This study reveals the limited preparedness curricula and lack of formalized needs assessments among several programs. Although many programs make an effort to build reciprocal exchanges with host partners, experiences for foreign trainees within the United States are limited, and U.S. residents are often tasked with duties above their training level abroad. This study demonstrates the need to restructure how GHT programs are formed and operated.

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

“…Both described having felt like a medical tourist because of their relatively minimal contributions within the host community.” [23]Negative view of short-term trips[23, 38]“...the majority of participants described the IHE in negative terms.” [23]Awareness of sustainability[22, 23, 31–35, 40]“One student noted, “I believe it is unethical to perform a procedure or provide treatment, then leave without ensuring that adequate medical expertise remains to deal with any complications that arise.” [33]Concerns that short-term trips are neo-colonialist or exploitiveSub-codes• Fear of imposing Western values• Concerns about exploitation• Concerns with vulnerable populations[1, 22, 23]“[W]hen you’re really looking out for your own interests and there’s a huge power and economic differential … there’s a potential for exploitation, and … if you’re not really able to know the local interests, there’s a potential for doing harm.” [1]“They were also anxious not to adopt ‘a paternalistic view of “I know better than you because I come from this more developed country”’. One respondent reported that he ‘really did not want to be remembered as one of these people that come in and impose their values and their experiences’.” [22]Lack of ethical issues[35, 37]“A total of 32% of the programs interviewed reported having no ethical questions or situations.” [35]Theme 2: Struggling to Identify and Balance the Benefits and Harms of STINTTsPerceived benefit (or lack thereof) to community[1, 22, 23, 30, 32, 34, 35, 38, 39]“...seven students also perceived that they had a positive effect on the communities they served, by providing clinical care for patients…” [1]“For some reason we thought that we could go over there and [help] these people from a medical point of view but we only had classroom learning…So when people ask about my experience I always try to discourage [medical students] from doing observerships because you can’t really contribute.” [38]Perceived harms to community[1, 22, 23, 32, 35–38]“Although some host supervisors denied the occurrence of any harm, others expressed concern that international elective students may negatively impact the local community in terms of resource use and pat...…”

“…In some instances, trainees who had a “Western education” were perceived as possessing superior knowledge regarding clinical issues. Occasionally, even local professionals who were more experienced than the participants themselves would defer to their opinions.” [31]Insufficient Attention to Local Priorities and Partners• Sub-code: Competition of interests[1, 23, 33, 35]“…students also questioned the value and effects of the service they provided and realized the necessity of engaging in a partnership with the community to ensure that all parties’ interests are represented and met.” [1]Discriminatory treatment for/against a trainee on the basis of their Western origin[22, 30, 31, 37]“Several respondents recounted situations in which patients had requested the student perform a procedure even though there was a more competent local health care worker available (R23). R31 described his discomfort at finding that patients seemed to expect him to be able to help them because he was a Westerner:‘Every time I walked through a hospital… people would beg me to save their lives.…”

“…R31 described his discomfort at finding that patients seemed to expect him to be able to help them because he was a Westerner:‘Every time I walked through a hospital… people would beg me to save their lives. …it was like if they think you’re White or you seem to actually know some things...’” [22] Sub-theme 1B: Challenges of navigating different culture Navigating different cultures[22, 31, 33–35, 37, 39, 40]“One resident described gaining respect for families and their contribution to patient care; at the same time he believed that encouraging Ethiopian peers to adopt a “Western style of respecting patients’ privacy” was important, as patients typically attend hospital visits with many family members. Participants struggled to synthesize their sensitivity and respect for Ethiopian culture with their own deeply held cultural values.” [40]Communication difficulties[22, 23, 32–34, 37, 38]“However, this issue was compounded by language barriers that made it more difficult for respondents to explain their roles to patients and others.…”

“…For example, one student stated that his concern for the health of people in the Third World or developing countries did not appear to be an educational priority for most of his classmates on the trips.” [1]Perceptions of team members[34]Watzak et al, included questions asking survey-respondents about other team members’ behavior, including whether team members were honest or demonstrated respect to patients. [34]Sub-theme 2: Trainees’ experiences related to the learner roleTrainee preparedness[23, 32–35, 37, 38]“Medical schools have a responsibility to ensure ethical and safe global health experiences. However, our findings suggest that medical students are often poorly prepared for the ethical and safety dilemmas they encounter during these electives.” [38]Lack of objectives[23]“Our study participants consistently described the lack of educational objectives as a negative aspect of IHEs.” [23]Mistreatment of trainees [by mentors/advisors][37, 38]“Eventually ethically challenging situations occurred where trainees felt ridiculed for their limited skill even when asked to do a procedure clearly beyond their skill level: “Residents would ask: ‘why don’t you do that thoracotomy?’ ‘Well I am a first year med student.…”

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