Resident Rotations in Low- and Middle-Income Countries

Abstract

Introduction: Interest in clinical rotations in low- and middle-income countries (LMICs) has grown among high-income country (HIC) orthopaedic residents. This study addresses the following questions: (1) What motivates HIC surgical residents to rotate in LMICs? (2) What is the impact of rotations on HIC residents? (3) What are the LMIC partner perceptions of HIC collaboration? Materials and Methods: A search strategy of multiple databases returned 3,740 unique articles pertaining to HIC surgical resident motivations for participating in rotations in LMICs or the LMIC host perspective. Data extraction was dually performed using meta-ethnography, the qualitative equivalent of meta-analysis. Results: Twenty-one studies were included in the final analysis. HIC residents were primarily motivated to rotate in LMICs by altruistic intent, with greatest impact on professional development. LMIC partners mostly valued HIC sustained investment and educational opportunities for LMIC partners. From LMIC's perspective, potential harm from collaboration arose from system-level and individual-level discordance between HIC and LMIC expectations and priorities. HIC priorities included the following: (1) adequate operative time, (2) exposure to varied pathology, and (3) mentorship. LMIC priorities included the following: (1) avoiding competition with HIC residents for surgical cases, (2) that HIC groups not undermine LMIC internal authority, (3) that HIC initiatives address local LMIC needs, and (4) that LMIC partners be included as authors on HIC research initiatives. Both HIC and LMIC partners raised ethical concerns regarding collaboration and perceived HIC residents to be underprepared for their LMIC rotation. Discussion: This study synthesizes the available literature on HIC surgical resident motivations for and impact of rotating in LMICs and the LMIC host perception of collaboration. Three improvement categories emerged: that residents (1) receive site-specific preparation before departure, (2) remain in country long enough to develop site-specific skills, and (3) cultivate flexibility and cultural humility . Specific suggestions based on synthesized data are offered for each concept and can serve as a foundation for mutually beneficial international electives in LMICs for HIC orthopaedic trainees.

Host Perspectives of High-Income Country Orthopaedic Resident Rotations in Low and Middle-Income Countries

“…I nstitutional review board approval for the study was obtained. A previous survey (see Appendix B) evaluating the impact of visiting orthopaedic residents as perceived by the LMIC hosting orthopaedic surgeons and trainees 9 and relevant peer-reviewed literature 5,[10][11][12][13] were used to design a semistructured interview guide (see Appendix C). A portion of the guide was focused on exploring the perceived impact of visiting residents, including the impact on patient care, orthopaedic education, and interpersonal experiences, and the remainder was focused on seeking recommendations for improving these rotations.…”

“…Most studies on visiting resident rotations have been limited to the high-income country (HIC) perspective, and the impact of such rotations on surgeons and trainees in LMICs has not been well studied 5 . While potential benefits for LMIC hosts include academic exchange and addressing a gap in care, reported downsides include cross-cultural conflict, unintended interference with established systems, and care vacuums that are unintentionally created after rotations end 3,[6][7][8] .…”

International medical electives in Sub-Saharan Africa: experiences from a 19-year NGO-driven initiative

“…They also emphasise that, ‘the continuity of student presence provided by a partnership allows more comprehensive student preparation’, and that the preparation of students for electives, ‘is easier to organise and of more direct relevance for groups of students who are going to the same place as part of an institutional partnership’ [ 24 ]. In short, a stable relationship with the host institution helps prepare residents for the elective experience and can lessen the potential concerns relating to host institutions in LMICs [ 26 , 27 ]. We reviewed over two-hundred articles on international medical electives, and to the best of our knowledge, there has been no systematic analysis of how institutions that provide residents begin their involvement with international medical electives.…”

Qualitative Analysis of the Host‐Perceived Impact of Unidirectional Global Surgery Training in Kijabe, Kenya: Benefits, Challenges, and a Desire for Bidirectional Exchange

“…Even fewer have assessed host trainee perspectives or host perspectives related to global surgery experiences [35][36][37]. A recent qualitative meta-ethnography assessing resident rotations in LMIC identified only 4 studies assessing host perspectives of HIC collaboration with a combined total of 25 LMIC surgeons and 20 LMIC surgical trainees represented in these studies [38][39][40][41][42].…”