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

Abstract

Background

Medical student and resident participation in short-term international trips for trainees (STINTTs) has increased in the past few decades. However, there has been no systematic review of trainees’ actual ethical experiences. The authors sought to identify what ethical issues medical trainees encounter during STINTTs, as elicited by and reported in peer-reviewed, quantitative and qualitative research papers.

Methods

The authors systematically searched five academic databases finding 659 unique titles and abstracts. The authors applied inclusion and exclusion criteria to these titles and abstracts resulting in fourteen papers, which were analyzed using qualitative thematic synthesis.

Results

The qualitative analysis of the papers generated four themes: (1) Trainees’ Concerns Over Perpetuating Medical Tourism; (2) Struggling to Identify and Balance the Benefits and Harms of STINTTs; (3) The Complicated Trainee Mens (mind); and (4) Ethical Situations Encountered by Trainees. The fourth theme, which was the largest, was further divided into (a) Navigating social and cultural dynamics, (b) Trainees’ experiences related to the learner role, and (c) Ethical situations not qualifying for other catagories. Some of these issues reported in the empirical research papers are well represented in the broader literature on STINTTs, while others were less so—such as mistreatment of trainees. All included papers were published after 2010, and comprised a total of less than 170 medical trainees.

Conclusions

Medical trainees report experiencing a wide range of ethical challenges during short-term international trips in which they engage in clinical or research activities. The authors call educators’ attention to specific challenges that trainees face. The relevant literature covering US and Canadian STINTTs is relatively young and largely qualitative. The authors briefly sketch a program for expanding the research on this increasingly common educational experience.

Background

Medical trainees increasingly participate in short-term international trips. U.S. medical student participation in global health experiences has increased from 6% in 1984 to around 30% in 2010 [1]. In the absence of an established definition, we consider medical short-term international trips to be any clinical or research experience lasting less than 3 months that took place in another country (often low- or middle-income settings). Recognizing that no accepted definition of “short-term” exists, the choice of 3 months attempts to strike a balance among competing definitions. As examples, two prior reviews on short-term international trips (not specific to trainees) define the maximum length of short term trips as 4 and 8 weeks [2, 3], a recent position paper allows for up to several months, [4] and seasoned global health professionals might consider anything less than 6 or even 12 months as short-term [5, 6].

We further characterize these trips by the types of participants and organizational affiliation. For example, some trips are organized by non-governmental agencies for fully trained physicians. In this paper, we focus on short-term international trips for trainees (STINTTs)—short-term international trips developed by a medical school or residency program for the purpose of trainee education. Other purposes include, but are not limited to, delivery of health care services, building local health care capacity, the development of collaborative partnerships, and research, among others. We stake no claims here as to which among these purposes is most important.

In the past several years, significant attention has been given to the ethical dimension of STINTTs and to developing best practice guidelines when ethical challenges arise [5]. Some papers in the existing literature note several positive aspects of STINTTs—including the development of clinical, cultural, and language skills; increased understanding of healthcare systems and tropical diseases; and personal and moral growth [7, 8].

Conversely, the literature also raises several ethical concerns—including the attitudes of trainees, trainees’ impact on host resources, the challenges of negotiating cultural differences, the safety of trainees and patients, short-sighted interventions, poor supervision of trainees, and possible neo-colonialist frameworks that value the priorities of the Western institutions over hosting institutions in developing nations [1, 5, 8,9,10,11,12,13,14,15,16,17]. Some of the ethics literature describes case studies or individual experiences of ethical challenges abroad [17,18,19,20]. Others have re-framed the understanding of STINTTs to encourage trainees to approach the trips in terms of virtues [21] or have suggested expanding the ethical discourse beyond discussion of outcomes related to goods and services [11].

Primary research studies [1, 22, 23] have slowly started to fill the identified gap of literature documenting the ethical experiences of medical trainees on STINTTs [5, 24]. Nonetheless, systematic reviews of the literature on short-term international trips have noted the lack of a robust research base. One review found that the majority (78%) of the literature on short-term medical ‘missions’ was descriptive, [2] and another pointed out the dearth of high-quality empirical studies on medical short-term international trips [3]. Neither was specific for STINTTs, whose participants (because of their trainee status) might face unique ethical challenges.

To our knowledge, only a single systematic review exists on the ethics of STINTTs. This review characterized the educational interventions that have been developed to prepare medical students for the ethical challenges on these experiences and described thirteen ethical situations that students might encounter on STINTTs [25]. Yet none of the published papers included in their final analysis were research studies of trainees’ actual experiences.

Recognizing this reported gap in the literature and the need for educators to match ethics preparation with what trainees are experiencing abroad, we formulated the research question: “what does the peer-reviewed, quantitative and qualitative literature document regarding medical trainees’ ethical experiences on STINTTs?”

Methods

To answer our research question, we conducted a systematic qualitative synthesis—a type of systematic review that synthesizes qualitative results in the existing literature.

The reporting of our methods borrowed elements (such as a flow chart of the search results) from both the PRISMA guidelines for systematic reviews [26, 27] as well as the ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research) [28]. This blended approach sought to glean the structure of PRISMA reporting for our literature search, while deferring to the ENTREQ’s suitability for qualitative synthesis of the resulting papers. This hybrid approach also reflected the natural evolution of the project which we initiated under the quantitative-oriented paradigm of systematic reviews, and transitioned to a qualitative orientation after our search resulted in mostly mixed-methods and qualitative papers. For the ENTREQ checklist, see the Appendix.

Eligibility criteria

To meet inclusion criteria, the paper had to address the ethical experiences of medical trainees involved with short term international trips. A paper’s relevance to “ethical experiences” was determined by the presence of the words, “ethics,” “bioethics,” “moral,” or related words in the paper. “Medical trainees” were defined as students at a medical training programs (both undergraduate and graduate) in the U.S. or Canada accredited by the Liaison Committee on Medical Education (LCME), Committee on Accreditation of Canadian Medical Schools (CACMS), Accreditation Council for Graduate Medical Education (ACGME), or the Royal College of Physicians and Surgeons of Canada (RCPSC). “Short term international trips” had to take place outside the U.S. or Canada and included any clinical or research-based trip for less than 3 months.

We restricted our search to papers that used research methodology (e.g. surveys, qualitative methods, or mixed-methods research) to elicit these experiences directly from trainees. Therefore, anecdotal stories and case reports would be excluded, unless the paper clearly indicated how the experiences or cases were elicited from trainees. Additional exclusion criteria included being published in a language other than English and lack of full text availability (e.g. lists of conference abstracts). Papers that interviewed faculty members, host supervisors, mentors, or others were included so long as they addressed the lived ethical experiences that medical learners faced.

Information sources and search

With a medical informationist, we translated our targeted content into search phrases for five databases: Pubmed, Embase, Education Source, Academic Search Complete, and Web of Science (Core Collection). For our full search strategy see Table 1. To correct for narrow search terms and new publications, we also allowed for the inclusion of papers that met our inclusion criteria, but were not revealed through the search strategy. Such papers were collected through reference searches, journal notices, or personal reading.

Table 1 Search Terms

Study selection

The search resulted in 659 unique titles. Two independent screeners reviewed titles and abstracts of all search results. Disagreements were adjudicated by discussion between the two screeners. When still unresolved (this occurred for 58 of the 659 titles and abstracts), the principal investigator arbitrated to determine inclusion or exclusion. Twenty-two abstracts met our inclusion criteria (as defined in “eligibility criteria” above).

After title and abstract screening, a second round of screening using the same inclusion and exclusion criteria was applied to the full text of each paper with disagreements resolved in the same fashion. The round of full-text screening eliminated nine of the 23 papers. Six were eliminated for not having a published full-text. Three were eliminated for either not including ethical content or not using a research methodology to report the experiences of medical learners (Fig. 1). One additional paper met the inclusion criteria, but was not included in the original search due being published after the search was conducted. The final 14 papers that were included are listed in Table 2.

Fig. 1

A graphical representation of the inputs and output of our systematic literature search. The number of abstracts and titles identified by systematic search through the five databases the papers identified through personal reading or citations. The flow chart then identifies the records remaining after duplicates were removed, that resulted in 659 titles and abstracts being screened, of which 23 went full-text screening. The final 14 papers that passed the full-text screening were included in our qualitative synthesis

Table 2 Final Papers Included in Systematic Review

Data extraction and analysis

Two authors independently analyzed these 14 papers using the qualitative method of thematic synthesis [29]. First, we performed line-by-line coding of the included papers, highlighting text that described an ethical issue within the papers’ findings, as reported in the abstract, results, discussion, and conclusion sections. Rather than imposing our own conceptualization of topics relevant to ethics, we deferred to each paper’s labelling of ethical issues. The goal at this first step was to describe the meaning and content of the ethical issue from codes that emerged from the data itself. There were no pre-existing codes.

To establish coder reliability, a single paper was coded simultaneously by two authors to generate an initial set of content codes and standardized definitions of those codes. The two authors then coded four more papers independently, and met again to clarify code definitions and coding practices. The rest of the papers were then coded independently. New codes could emerge at this stage. After coding was completed, the two authors met to review each instance of each code in each paper to resolve coding discrepancies by consensus. Data were managed using NVivo (version 11, QSR International).

Next, after the coding was completed, individual codes were reorganized, refined, and grouped into catagories based on a combination of the codes’ conceptual proximity to each other and relationships between codes that emerged from the texts. Reorganization and grouping were informed by the researchers’ background in classical principles of Western medical ethics, including notions of benefit and harm, respect for cultures and individuals, and justice-based concerns (such as sustainability). However, other categories were included as well, including moral distress, concepts of medical tourism, and so on, that emerged from the data.

The third and final analytic step was the most synthetic one. Categories of issues were grouped into four major analytical themes based on in-depth and iterative review of the papers, codes and categories in relation to the motivating research question regarding trainees’ ethical experiences. This step was the most interpretive of the three, as we attempted to explain in a more abstract manner how this thematic synthesis emerged from the codes, which in turn were generated by a close analysis of the texts.

Results

The thematic synthesis generated four themes: (1) trainees’ concerns over perpetuating medical tourism; (2) struggling to identify and balance the benefits and harms of STINTTs; (3) the complicated trainee mens (mind); and (4) ethical situations encountered by trainees. The fourth theme was sub-divided into (a) navigating social and cultural dynamics, (b) trainees’ experiences related to the learner role, and (c) ethical situations not qualifying for other catagories. The codebook with sources and example text is shown in Table 3.

Table 3 Themes, Sub-themes, and Codes with Sources and Example Text

Theme 1: Trainees’ concerns over perpetuating medical tourism

This theme captured findings that made evaluative statements, not about particular issues per se, but about the entire enterprise of STINTTs. Most of these statements were negatively toned, that is—they noted the negative impact of STINTTs. Some of these critiques included explicit concerns about perpetuating medical tourism [23, 30] and the related concern over the unsustainable nature of some relationships and interventions [22, 23, 31,32,33,34,35]. In one paper, this was quite striking and illustrated by the following quotations:

“The majority of participants described the IHE in negative terms… Two students also acknowledged elements of medical tourism in their own IHEs. Both described having felt like a medical tourist because of their relatively minimal contributions within the host community” [23].

These general evaluative statements appeared important, because they are relevant to how trainees ethically contextualized their trip participation. This contextualization is a component of the trainee’s overall ethical experience and likely influences how they experience other, more discrete ethical issues and situations.

Importantly, however, the concern over the perpetuation of medical tourism was not universal across studies. In fact, in one study that interviewed directors and administrators of residency training programs, 32% of programs “reported having no ethical questions or situations” [35]. This finding, while isolated, revealed two important issues. First, the finding of concern over perpetuating medical tourism, while dominant, may not be universal. Second, this observation could be partly explained by noting that this particular statistic relied upon program-level reporting, not trainees, to assess ethical questions or situations, which underscores the importance of understanding the difference between the trainees’ experiences and program leadership’s perspective of trainees’ experiences.

Theme 2: Struggling to identify and balance the benefit and Harms of STINTTs

A consequentialist way of thinking about the ethical experiences of students (and the trips in general) is to document various benefits and harms. Throughout the included studies, this was a pervasive issue, but no paper included a comprehensive analysis of both benefits and harms and a clear conception of “who” experienced them. Via our thematic synthesis, we identified potential harms and benefits both to the community (interpreted both as a collective whole, as well as individual patients who receive care from trainees) and to trainees. We characterized this theme as a struggle, because our synthesis suggested that trainees – perhaps due to their status as trainees and their newness to a particular locale – experienced challenges in assessing benefits and harms.

The effects on the community were varied and sometimes nuanced. Some students felt that they did have a positive effect on the communities that they went to serve, in part through non-clinical benefits such as giving respect and attention to patients who otherwise might not have received any [1]. A few studies included perspectives beyond those of the trainees. For example, Watzak et al [34] noted that local communities reported satisfaction and appreciation for the care provided. Another study found that administrators and staff who hosted visiting medical trainees viewed “good mature” medical students as a boon [30]. A chief concern regarding harm to the community was that supporting visiting trainees would consume limited resources, such as faculty attention for teaching or translation [22, 35,36,37]. Other trainees were concerned that they might impact patient care negatively, through language or clinical skill deficits [22, 23, 38]. On the other hand, many trainees felt that their presence neither benefited nor harmed the community they visited, noting that their limited clinical abilities left them feeling more like spectators than actors capable of creating harm or benefit [1, 22, 23, 34, 38, 39].

As far as the benefits to the trainees themselves, a wide variety of benefits to trainees were described, including gaining clinical skills, [1, 35, 39] language abilities, [1] or a better understanding of healthcare systems [1, 22, 23, 36, 39]. Other students highlighted the role STINTTs played in their professional development and desire to pursue a career in global health [23, 39].

Regarding harms to trainees, some trainees felt that risks to themselves were well-controlled [32]. Others reported physical and emotional threats, including a lack of health safety equipment such as N-95 masks [31, 36,37,38]. One particularly egregious incident involved a student reporting sexual assault [38].

The following quotation illustrates the difficulties trainees experience in identifying harms and benefits as well as in balancing them across themselves and others:

“…there were a number of [U.S. Medical School] medical students and residents there and they all had on facemasks and they were the only ones on the ward. None of the other staff were wearing masks. And I was standing there with two medical students from somewhere else and thinking to ourselves, what should we do? … The wards are filled with HIV/TB patients, who are coughing” [31].

Theme 3: The complicated trainee mens

A third theme was synthesized from descriptions of trainee’s diverse, and sometimes conflicting internal cognitive and affective components of trainees’ experiences. That is, the trainee mens (mind).

Motivation, intent, and attitudes are key parts of the mind, and here trainees expressed diverse perspectives. Some trainees reported experiencing personal maturation on the trip or the strengthening of a desire to return to global health work in the future [39]. In contrast, one of the papers that investigated the perception of hosts reported an observation that some students arrived with problematic attitudes including thinking of the trip as a holiday, occasionally skipping clinical duties, or coming in with an air of clinical superiority to the hosts [30]. Two papers reported that trainees had expectations that did not match with their actual experiences [22, 39].

Mixed motives or problematic attitudes could be compounded by lack of self-awareness about them. For example, although theme 1 above emphasized trainee awareness and concern over perpetuating medical tourism, self-awareness that the trainee had actually participated in just that could be lacking. As one study documented, “…self-identification as a medical tourist was poor despite a consensus among participants of the key aspects of medical tourism” [23].

A significant finding within this theme related to emotional or moral distress that trainees experienced. One manifestation of this distress was a feeling of guilt derived from either impeding patient care or not being able to provide more help to patients [22, 37,38,39]. Other manifestations included witnessing poor clinical outcomes, often due to a lack of resources, [38] or feeling overwhelmed by the clinical responsibilities [32]. Feelings of moral distress were not limited to medical trainees, but also involved nurses, pharmacists, and physicians when included in the study population [31].

Theme 4: Ethical situations encountered by trainees

The bulk of the codes in our analysis related to situations—tropes or repeated scenarios—that commonly recurred in the context of STINTTs. We divided this theme into (a) navigating social and cultural dynamics, (b) trainees’ experiences related to the learner role, and (c) ethical problems not qualifying for other catagories.

(a) Navigating social and cultural dynamics

This sub-theme could be further divided into codes describing power dynamics and challenges navigating a different culture.

Trainees reported noticing a power imbalance between hosts and visitors, [1, 23, 31, 37] which manifested in multiple ways. Some trainees were concerned about working with vulnerable populations [1] and wanted to avoid exploiting those populations “for one’s own clinical development” [23]. Other trainees reported concerns that their respective STINTTs might not have adequately taken the priorities of their host communities into account [1, 23, 35].

Another interface regarded the treatment of visiting trainees relative to the treatment of trainees at the host site. Some trainees reported feeling that they were given more attention, recognition, or even clinical deference than their level of training warranted because they were from Western countries [22, 31, 37]. In some instances, trainees were asked by local patients to perform procedures instead of local, more-experienced providers simply because they were foreigners [22]. A contrasting perspective was that of host staff at a particular institution who noted that visiting trainees were less of a priority than local trainees [30].

The second group of codes described trainees’ difficulties with navigating different cultures. Two of the most common points of cultural clash arose with different expectations and practices over what it meant to respect patient privacy and confidentiality [22, 31, 33, 37, 39, 40] and to obtain informed consent [1, 22, 31, 33, 34, 37].

(b) Trainees experiences related to the learner role

The most frequently reported experiences encountered by trainees were (1) lack of adequate supervision and (2) requests for trainees to practice outside of their scope of their clinical proficiency [1, 22, 23, 31,32,33, 35, 37, 38]. For example, Petrosoniak et al. [23] reported first year medical students being asked to perform lumbar punctures or to close after surgical procedures—in both instances the trainee was expected to perform these tasks without supervision. Zaidi et al. [35] describe a situation in which a resident was abruptly left in charge of overseeing patient care for several hours at a hospital. In their own, raw words, trainees recount such challenges:

“A lot of times I was put in situations where there was somebody bleeding in front of me, and I really didn’t know what to do. So I would just do what I could, and hope [I was] doing the right thing. A lot of times there was just nobody to help you and so you are all by yourself.” [38].

“You feel bad for the patient…Here we are [myself and a local trainee] learning how to do an LP on [a patient] and this is both of our first time. There is no staff to teach you…You get into a very sticky situation. It is either me doing it for the first time or that resident. You felt terrible as a human being [thinking] ‘Am I really going to help this person? No. Most likely they will die from an infection because I am doing something wrong but there is nobody to teach me.’ ” [38]

Referring to other team members, one trainee stated, “I think some people were definitely more [under] the impression that … it was okay to … [practice certain skills] even though they had no idea what they were doing…” [1]

Negotiating discussions about trainees’ level of skill was difficult, with trainees often having to address misunderstandings from hosts about their level of training [22, 23, 38]. Sometimes trainees would experience negative consequences—including feeling like an imposter, being repeatedly asked to practice outside of their scope despite having previously explained their refusal, or even being humiliated by host staff—even if they felt they were doing the right thing by refusing to participate in the procedure [22, 23, 38]. For example:

“Residents would ask: ‘why don’t you do that thoracotomy?’ ‘Well I am a first year med student. I don’t know how [so] I am not going to do it.’…A lot of times the residents or staff would laugh at you for not knowing how to do certain procedures. It was embarrassing” [38].

Notably, not all papers shared the same perspective on this topic. In a paper describing host perspectives, [30] one host staff denied that trainees were allowed to perform procedures beyond their scope of practice, while others acknowledged that supervision was indeed limited. Watzak et al., [34] while not reporting directly from trainee experiences, noted that trip organizers carefully assigned tasks to trainees appropriate to their ability. Leeds et al. [32] reported that 78% of their participating trainees thought that supervision on their trip was adequate.

Finally, many papers commented on the preparedness of trainees to participate on these trips with some suggesting that trainees were not ethically equipped to handle the situations they faced on a STINTT due to lack of pre-departure training [23, 32, 38].

(c) Ethical problems not qualifying for other catagories

There were several ‘familiar’ ethical problems that overlapped with those encountered in everyday Western clinical settings including end of life issues, [33] navigating professional obligations, [33] truth telling, [31, 33, 37] and ethical conduct of research [35].

Other ethical problems that did not directly fit into other catagories, but that were nonetheless important, included encountering corruption [31] and providing clinical care in the context of limited resources. Resource limitations were reported in many of the studies and sometimes negatively impacted patient care [22, 23, 31,32,33,34,35, 37,38,39,40]. Some papers mentioned the benefit to trainees of learning how to practice medicine with heightened awareness of resource use [35, 40].

Discussion

Our systematic qualitative synthesis produced the following principal findings. First, our findings demonstrate that the peer-reviewed literature documenting what medical trainees experience during STINTTs is relatively nascent. All 14 studies were published after 2010. Most studies were qualitative, with only a few mixed-method studies, and the entirety of the literature represents the experiences of less than 170 medical trainees. In addition, many studies investigated STINTTs from a single institution to a single host site abroad [32,33,34, 39, 40]. In several studies, trainees’ experiences were reported indirectly, for instance, by educators, administrators, trip leaders, or trip hosts [30, 31, 35, 36].

Second, our review found that medical trainees report experiencing a variety of ethical challenges on STINTTs. Many of these have been recognized by prior case studies, editorials, and best practice guidelines. These included concerns about intervention sustainability, benefits and harms of STINTTs (both to trainee and host), trainee moral distress, trainee motivations, trainee preparedness and supervision (or lack thereof), the challenges of navigating different cultures, and facing resource limitations [5, 10, 16, 17, 37, 41, 42].

At the same time, we found several issues not well reflected in this prior literature. These included overt mistreatment of medical trainees and unique ethical issues regarding perceptions of, and relationships with, other STINTT team members. Ethical challenges occurring during STINTTs may not always be experienced by individuals in isolation; instead they may be experienced within teams, and these teams can include trainees of various professional backgrounds (e.g., medical students, nurses, physician assistants, pharmacists, and others). Some educators have already touted the importance of interprofessional ethics education [43,44,45]. Interprofessional curricula might need to be developed for the STINTT setting as well.

A comprehensive comparison of our findings to those of a recent systematic review of the ethics topics addressed by ethics education for STINTTs would be beyond the scope of this study. Nevertheless, we can make several observations about the relative fit between existing ethics education (See Table 4 in Rahim et al) [25] and our findings. In general, our findings suggest that existing ethics education covers many, but not all, of the issues trainees report experiencing. For instance, ethical challenges related to demonstrating respect for other cultural norms, obtaining appropriate informed consent, dealing with limited resources, and practicing beyond one’s level of training are addressed by existing curricula [25]. In contrast, ethical challenges related to the emotional and moral distress trainees face, overall sustainability of STINTTs, and navigating medical, cultural, and social hierarchies might not be well reflected in existing ethics curricula. Educators should consider the inclusion of these topics in their pre-departure curricula.

Our findings identify a few areas requiring emphasis from medical educators. Aside from the need to develop interprofessional curricula, educators might need to attend explicitly to trainees’ distress. Some of the most vivid experiences trainees reported involved emotional or moral distress (theme 3). Educators should aim to prepare trainees for distressing situations, prevent distressing experiences when possible (e.g. by adhering to existing best practice guidelines, [5] and alleviate distress when it arises. Preparation involves knowing the types of distressing experiences that trainees face and fore-warning them pre-departure as well as giving them strategies for addressing situations should they arise. Instituting mandatory debriefing for all trainees on STINTTs might help alleviate distress through group reflection [14, 22]. Debriefing can also help educators identify trainees who need further support and connect them to further resources.

Some of the situations encountered by trainees were extremely complex and involved difficulties with communication, expectations, language barriers, and cultural and hierarchical norms (theme 4a and 4b). Trainees could be prepared for common experiences, such as being asked to do something out of one’s scope of training, by using existing predeparture training resources [46] and strategies, [25] including simulations (a pedagogy recently introduced to pre-departure training) [16]. Educators should counsel trainees on how to handle these situations in the specific context where trainees will be. Some experiences cannot be foreseen, and access to an onsite faculty mentor can be a critical strategy to address these situations [14]. Such faculty could serve as a supervisor, mentor, or liaison depending on the situation. Trip planners should provide all trainees with a way to contact a mentor. Long-term partnerships between hosting and sending sites are favorable because they allow for stable training experiences and matured expectations.

Preparing trainees to navigate ethical issues in STINNTs cannot be accomplished entirely by pre-departure training; program leadership should explore other avenues to minimize trainees’ vulnerability. A comprehensive approach to management also requires attention to the appropriate structuring of organizations and programs that serve as the vehicle for trainees’ experiences abroad [47]. For example, preparation may help trainees respond to requests to performs skills outside one’s scope of training, but organizations and programs should make efforts to ensure expectations are clear by engaging in open dialogue with local communities about what skills trainees do and do not have. Similarly, organizations and programs are primarily responsible for protecting trainees from risk of harm by providing appropriate precautions (e.g., protective equipment).

Our study has several limitations. First, in the absence of controlled vocabulary or unified definitions of STINTTs, the application of our search terms may have excluded other relevant studies. Second, in line with our principal findings (which highlight what may be a young and rapidly growing field), our search end date of December 2016 will soon be outdated. Third, the qualitative nature of our study and many of the studies we reviewed means that our findings, while systematically structured, are qualitatively subjective. This is the nature of qualitative research; in our study, for instance, we chose to characterize some text as being about ethics, even if the primary article did not explicitly frame that text as an ethical issue (see Methods: Data Extraction and Analysis for more details). Fourth, our review was geographically limited to LCME, CACMS, ACGME, and RCPSC-accredited programs within the U.S. and Canada. While these countries represent the two largest nations of origin for medical short-term international trips, [2] findings from other countries’ training programs were not included. Lastly, we excluded anecdotal reports and case studies. This focused the review on the unique perspective of trainees’ experiences as directly reported in quantitative and qualitative research studies, but could have missed other issues and rich insights from these alternative data sources [48].

Nevertheless, we believe our review has important implications for future research into the ethical challenges medical trainees face when engaging in STINTTs and for curricular design. First, future qualitative studies of trainees’ experiences abroad should focus not just on what challenges they experience, but how they manage them. For example, further qualitative documentation that trainees experience pressure to exceed their level of training abroad may no longer be necessary; instead, attention should be given to how trainees navigate these situations (e.g., what works and what does not). Second, the time may be right to move toward quantitative research methods, such as surveys, that document the epidemiology of these challenges, i.e., how often they occur and under what circumstances. Third, by systematically documenting what trainees report experiencing, our findings should inform development of future ethics education curricula before, during, and after STINTTs.

Conclusion

Medical trainees report experiencing a wide range of ethical challenges during short-term international trips in which they engage in clinical or research activities. The literature covering US and Canadian STINTTs is relatively young and largely qualitative. However, emerging consensus about the nature of ethical challenges experienced and existing best practice and ethics guidelines suggest that this area of inquiry is at an inflection point. Future research should focus on quantitative studies that examine the relative frequency of challenges experienced and qualitative studies that probe more deeply into how best to manage them.

Appendix

Table 4 Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) checklist