The Nuts and Bolts of Global Emergency Medicine

Ch 6. Ethics

Introduction

The benefits for medical students and residents participating in global health work are numerous, including reinforcement of physical exam skills, exposure to new disease processes, greater appreciation for public health interventions, and increased intent to work with underserved populations upon return.¹ This experience, however, can also be problematic and raise ethical dilemmas.^2,3 Global health educational opportunities often place students and residents in situations where the cultural and professional norms are significantly different than those to which they are accustomed. Although increasing numbers of residents participate in international clinical rotations and 30% of U.S.-trained medical students embark on global health experiences,⁴ global health curricula remain limited and poorly standardized. Some educational institutions provide formal global health education with close faculty supervision, while others offer virtually nothing.⁵ Many residents, particularly those with prior global health experience, even choose a residency program based on the availability of global health training opportunities.⁶ This does not mean, however, that those residents have been or will be given a formal education on ethics and professionalism while working in low-resource settings.

Critics of global health experiences argue that trainees going abroad may have the perception that those who live in poverty will benefit from any medical care, whether delivered by an experienced provider or not.⁷ Good intentions of helping during disaster situations or rotating through low-income countries, though, cannot excuse substandard medical care. One major problem is that trainees are frequently less supervised when working abroad than they are in their home institutions. With the tremendous need for healthcare in many low-resource settings, trainees may be allowed or even expected to provide care beyond their level of experience. These elements can result in serious medical errors and endanger patients.⁸ Students and residents may also be placed in situations where they are asked to perform tasks that make them uncomfortable. For example, a trainee may be asked to draw blood from a patient in a region with high rates of HIV infection without the availability of sterile gloves, or to assist with a surgery that is not utilizing sterile technique due to unavailability of antiseptic and sterile supplies. In other instances, a patient may undergo a procedure without informed consent, or receive treatment that the trainee considers to have an unacceptable risk-benefit ratio.⁹

As the examples above demonstrate, working overseas can present the trainee with a tremendous number of ethical dilemmas, both personal and patient-centered. The paradigm of medical ethics in a host institution may be entirely different than what the trainee has learned to abide by and pay credence to at his/her home institution. With that in mind, we will discuss common pitfalls in ethics and tips to combat these pitfalls.

Pitfalls to Avoid

Improper ethics preparation

There are some ethical dilemmas that can be avoided by preparation, and some that can be prepared for. Learn how to address both.

Importance of Establishing Learning Objectives

As you will see in the next section, ethical dilemmas can arise when expectations are not clear. Your expectations, those of your home institution, and those of your host institution must all be brought into alignment with each other in order to avoid misunderstandings and misunderstandings. Learning objectives should be discussed between these three, before your trip begins, with clear criteria for a successful experience.

Departure Ethics Training

As you will again see later in this chapter, there are certain ethical dilemmas that arise as a result of different cultures interacting. Although these conflicts sometimes cannot be avoided, they can be prepared for with proper global health and pre-departure training. A global health curriculum is a program within that trains residents, students, and faculty for unavoidable obstacles that arise in all global health work. All global health curricula should include training in ethics. Pre-departure training is geared specifically towards a specific region or program and addresses local issues or obstacles. Exposing trainees to a basic ethical framework based on best practice guidelines¹⁶ and practicing clinical scenarios they may encounter will help the learner to make appropriate decisions when he or she is working independently. It is encouraged for institutions to have a global health curriculum with country-specific pre-departure training prior to a global health rotation, as this is an effective way to mitigate these situations.¹⁵

Unrealistic expectations

It is vital for you as a visiting resident or student to have appropriate expectations of yourself and your host institution/nation. However, there are common situations where a trainee’s expectations of an international experience can lead to problems.

Cultural Expectations

Although one of the main goals of international clinical experiences is to go outside of your comfort zone and broaden your horizons, there is significant stress that is inherent to living
outside of your routine and customs. Understand that the culture and way of life in a foreign country may be very different than it is at home, and expecting people to behave and operate the same way that you do at home can lead to frustration and conflict, and detract from your learning experience. Understand that no matter how experienced of a traveler you are, “culture shock” is a very real and common phenomenon that most people experience at some point while abroad. Maintaining a cultural curiosity, learning appropriate language skills, and educating yourself on the socio-cultural, political, and historical context can go a long way in protecting yourself from this. In addition, regularly take time out to reflect upon the experience, be patient with differences in practice, and maintain your own wellness to foster your resilience to this common occurrence. This being said, expecting to become completely comfortable with the local culture in your short time there can also lead to frustration, so be realistic with yourself.

Clinical Expectations

It is important not to assume that the practices and approaches learned at home are superior to those practiced in your host country. Local medical protocols may be dictated by cultural norms with which you are not familiar or cannot comprehend within the time constraints of a brief rotation. While you may be able to teach healthcare workers in the host nation about aspects of your practice at home, they are the experts in their local diseases and are well-versed in making the most of limited resources. Learn from and honor their experience. Always remember that your primary purpose of being there is to learn.

Professionalism Expectations

Remember that the standards of professionalism in other countries will almost certainly differ from your standards, and you may witness behaviors and practices that run counter to your home expectations. Attempt to learn as much as you can about the reasons for certain behaviors and understand why local practitioners operate the way that they do. Although you are expected to behave within the constraints of locally appropriate behavior, remember that you are also expected to adhere to the same standards of behavior, timeliness, engagement and professionalism that would be expected at home.

Impact Expectations

As good as your intentions may be, you are unlikely to make lasting effects on host nation systems during a two-week or even a two-month rotation. Some aid workers suggest that those who are overly optimistic about the results of their efforts are more prone to depression and burnout.10 Remember you are a guest in the institution, and that host-nation students and faculty will be there long after you return home. In addition, any interventions or studies planned during the rotation should be sustainable and help increase capacity in the host nation. As an example, bringing donated equipment or medications can be helpful if they integrate with host’s setting, but bringing poorly functioning/incompatible equipment or unfamiliar, expired, or poorly labeled medications actually may be a disservice for the host institution.

Being a burden

Always remember that being able to participate in a global health rotation is a privilege, not a right. You are not only representing yourself and your home institution, but also medicine in your home country as well. You should aspire to learn as much as possible without becoming a burden on the host institution.

Information

As a trainee, you should be informed: learn about the history, political situation, social norms and health infrastructure of the country you will be visiting. In addition, becoming familiar with the local language and learning some local words goes a long way toward establishing a connection with your hosts and patients. This will help you to integrate more seamlessly into the local environment and decrease the obligation on your hosts. General travel guides can be a good source of information, along with updates on the political situation on the US State Department website. (Go to www.state.gov and search for your host country under the “Countries & Regions” tab.)

Duration

The duration of your experience should be tailored so that you are in-country long enough to derive true clinical benefit from it, but not so long that you becomes a burden to the host. Some papers suggest that 6-8 weeks is the optimal amount of time to invest in an overseas global health rotation.^11,12

Monopolization

Visiting students sometimes monopolize host nation faculty time, potentially decreasing mentorship for local students. Be cognizant and respectful of the other learners around you.

Communication

To minimize any negative impact on the host institution, it is important to maintain good communication with a local mentor regarding goals and expectations for the experience prior to arrival, and to maintain that communication throughout the experience. In addition, adequate communication between both your home and host institutions can ensure that everyone is benefitting.

Professionalism

It is also of the utmost importance to be respectful and professional at all times. Arrive at your overseas site prepared to work hard and learn as much as you can while contributing in any way you can. This will go a very long way toward being an asset and not a burden to your hosts. Of course, work within your set of qualifications and under appropriate supervision. 

Inadequate Supervision 

If well organized and executed, an overseas elective can be an extremely positive experience for both the host and the trainee. While some students and residents participate in established programs with extensive pre-trip preparation and close clinical supervision, others may find that supervision and guidance both leading up to and during the actual clinical experience are inadequate. This is particularly true for those seeking experiences independently or as part of open electives that are self-organized. A lack of persistent and quality supervision of a medical trainee can be frustrating for the learner as well as dangerous for patients. 

Level of Experience

Arguably, the optimal time to practice clinical medicine abroad is during residency, after you develop a clinical context of diseases and familiarity with common treatments and procedures. Whatever the stage of training, however, close, on-site supervision by an attending physician with experience working in your specific clinical context is paramount. If your supervisor is from your host institution, it is important to also have a close relationship with a faculty mentor at your home institution as well.13 This facilitates the exchange of experiences, emotional and logistical support, and resources while you are at home and while overseas, as well as keeping you accountable for your experience. He or she should be someone who is accustomed to working with residents and medical students and is familiar with clinical teaching and feedback practices. These are key for a positive learning experience and for ensuring patient safety. 

Scope of Practice

Even within the same specialty of medicine, there will be differences in the scopes of practice between different countries. When you visit a facility, you have an ethical mandate to practice within their scope of experience and not perform treatments or procedures beyond your competency level.14 While you may be asked to teach or oversee residents and students at a host institution, it is important to be honest about your limitations and inform your mentors if you are uncomfortable supervising specific procedures or in certain situations. 

Professionalism 

In addition to being informed, linguistically adept, culturally competent, and respectful of other learners, other factors contribute to professionalism while working abroad. Most medical curricula include formal professionalism training, but it is not uncommon to fail to apply these norms when working abroad. 

Remember your purpose

It is expected that new experiences in new places are part of your experience aboard. However, while it may be tempting to explore your new surroundings and spend your time in the country sightseeing, keep in mind the agreement you made with your host institution and the primary purpose of your trip. Timely arrival to shifts, active participation in discussions, and completion of your work are just as important abroad as they are at home. 

Privacy and Consent

Patients encountered abroad deserve the same high standards of respect and privacy as those at home. Although photos of rashes and other physical exam findings can be excellent teaching tools for those back home, you should make sure that they are obtained professionally and in accordance with both local standards and the standards of your home institution. 

Cultural Professionalism

Be sensitive to gender roles, cultural taboos and social norms in the country where you are working. In many countries, for example, it is inappropriate to come to work or to any professional meeting wearing anything but formal business attire. Observe what the people around you are doing, ask questions, and be aware of the things you are doing that may not be appropriate or professional in your role as a visiting provider or trainee.

Twinning Partnerships

Data on whether institutions benefit from hosting residents and medical students is scarce, but reciprocal institutional benefit should always be the goal.17 Twinning partnerships are one way to ensure this benefit. Twinning partnerships are mutual exchange programs between host institutions rather than unilateral exchanges, and they emphasize leadership development for host-nation physicians, context-specific educational content, and multidisciplinary collaboration18. Although these require a significant institutional commitment, they can allow for better understanding between both institutions and the students and residents that participate in them.

In Closing

Students and residents who participate in global health rotations have a responsibility to have a beneficial (or at least neutral) impact on the countries where they rotate. Proper preparation, anticipating ethical quandaries, and maintaining respect for the host institution’s structure will allow you to get the maximal benefit from your experience.

Additional Resources

Journal Articles To Read

• Gray BH. “World Blindness and the Medical Profession: Conflicting Medical Cultures and the Ethical Dilemmas of Helping” Millbank Q (1992) 70: 535-556
• Jayasinghe S. “Faith-based NGOs and healthcare in poor countries: a preliminary exploration of the ethical issues” J Med Ethics (2007) 33: 623-626.
• Lemery, J. “A Case for White Coat Diplomacy” JAMA 2010;303:1307-08
• Morton, M and Burnham, G. “Dilemmas and controversies within civilian and military organizations in the execution of humanitarian aid in Iraq: A review.” AJDM 2010; 5:385-391
• Wall LL, Arrowsmith SD et al. “Humanitarian ventures or “fistula tourism?: the ethical perils of pelvic surgery in the developing world” Int Urogynecol J 2006; 17: 559-562.
• Gray BH. “World Blindness and the Medical Profession: Conflicting Medical Cultures and the Ethical Dilemmas of Helping” Millbank Q (1992) 70: 535-556
• Jayasinghe S. “Faith-based NGOs and healthcare in poor countries: a preliminary exploration of the ethical issues” J Med Ethics (2007) 33: 623-626.
• Jesus, J. “Ethical Challenges and Considerations in Short-Term International Medical Initiatives: An Excursion to Ghana as a Case Study.” Ann Emerg Med (2010) 55:17-22. 
• Morton, M and Burnham, G. “Dilemmas and controversies within civilian and military organizations in the execution of humanitarian aid in Iraq: A review” AJDM (2010) 5:385-391 
• Wall LL, Arrowsmith SD et al. “Humanitarian ventures or “fistula tourism?: the ethical perils of pelvic surgery in the developing world” Int Urogynecol J (2006) 17: 559-562

Online Training

The Practitioner’s Guide to Global Health

First Do No Harm: A Qualitative Research Documentary

Johns Hopkins- Berman Institute of Bioethics. Ethical Challenges in Short-Term Global Health Training

Textbooks To Read

• Global Health and Global Health Ethics,  Solomon Benatar and Gillian Brock
• Reimagining Global Health: An Introduction, Paul Farmer and Arthur Kleinman

References

1. Jeffrey J, Dumont R, Kim G and Kuo T. Effects of International Health Electives on Medical Student Learning and Career Choice: Results of a Systematic Literature Review. Fam Med 2011; 43(1): 21-28.
2. Crump JA, Sugarman J. Ethical considerations for short-term experiences by trainees in global health. JAMA. 2008; 300: 1456-1458
3. Jesus J. Ethical Challenges and Considerations in Short-Term International Medical Initiatives: An Excursion to Ghana as a Case Study. Ann Emerg Med 2010; 55:17-22.
4. Association of American Medical Colleges. 2013 GQ Medical School Graduation Questionnaire: all schools summary report. Washington, DC. Association of American Medical Colleges; 2013.
5. Shah S, Wu T. The medical student global health experience: professionalism and ethical implications. J Med Ethics. 2008;34(5):375-378.
6. Drain PK, Holmes KK, Skeff KM, Hall, TL, Garder P. Global Health Training and International Clinical Rotations during Residency: Current Status, Needs, and Opportunities. Academic Medicine. 2009 March; 84(3): 320-325.
7. Shah S, Wu T. The medical student global health experience: professionalism and ethical implications. Journal of Medical Ethics. 2008;34:375-78.
8. Bhat SB. Ethical coherency when medical students work abroad. Lancet 2008;372:1133-34.
9. Bhat SB. Ethical coherency when medical students work abroad. Lancet 2008;372:1133-34.
10. Hunt M. Moral experience of Canadian healthcare professionals in humanitarian work. Prehosp Disaster Med 2009; 24(6):518-24.
11. Drain PK, Holmes KK, Skeff KM, Hall, TL, Garder P. Global Health Training and International Clinical Rotations during Residency: Current Status, Needs, and Opportunities. Academic Medicine. 2009 March; 84(3): 320-325.
12. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global Health in Medical Education: A Call for More Training and Opportunities. Academic Medicine. Mar 2007. 82(3):226-230
13. Crump JA, Sugarman J. Global Health Training: Ethics and Best Practice Guidelines for Training Experiences in Global Health. American Journal of Tropical Medicine and Hygiene. 83(6), 2010:1178-1182.
14. Crump JA, Sugarman J. Ethical considerations for short—term experiences by trainees in global health. Journal of the American Medical Association. 2008; 300:1456-1458.
15. Sarfaty S and Arnold LK. Preparing for International Medical Service. Emerg Med Clin N Am. 2005;23:149-75
16. Crump JA, Sugarman J. See above.
17. Crump JA, Sugarman J. Global Health Training: Ethics and Best Practice Guidelines for Training Experiences in Global Health. American Journal of Tropical Medicine and Hygiene. 83(6), 2010:1178-1182.
18. Busse H, Azazh A, Teklu S, Tupesis JP, Woldetsadik A, Wubben RJ, & Tefera G. Creating change through collaboration: a twinning partnership to strengthen emergency medicine at Addis Ababa University/Tikur Anbessa Specialized Hospital-- a model for international medical education partnerships. Acad Emerg Med 2013;20(12):1310-18.