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

Medical tourism

• Sub-code: exploitation

[23, 30, 38]

“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]

Negative view of short-term trips

[23, 38]

“...the majority of participants described the IHE in negative terms.” [23]

Awareness of sustainability

[22, 23, 31,32,33,34,35, 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 exploitive

Sub-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]

Perceived 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, 35,36,37,38]

“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 patient care.” [36]

Perceived benefit to trainee

[1, 22, 23, 30,31,32, 35, 36, 39, 40]

“All respondents spoke of the personal value of participating in an IHE. All respondents identified a range of benefits, including improving clinical skills, expanding perspectives on illness and poverty, developing international relationships, and exploring potential career choices.” [22]

Perceived harm to trainees

[31, 32, 34, 36,37,38]

“When I was on the wards in [host site] in January, 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” (Medicine Physician). [31]

Emotional or moral distress

• Sub-code: Debriefing—reflection or discussion

[1, 22, 23, 30,31,32, 34, 36,37,38,39]

“Trainees felt that GHEs presented ethical and psychological challenges, often as a consequence of resource disparity. Trainees primarily experienced guilt when unable to provide care to everyone. For some trainees, these challenges led to signs of poor long-term coping, often exacerbated by poor supervision and inadequate numbers of local staff.” [34] (p67)

Lacking self-awareness

[23]

“In our study, self-identification as a medical tourist was poor despite a consensus among participants of the key aspects of medical tourism.” [23]

Motivations of trainees

[1, 22, 23, 33, 39, 40]

“More than 50% of students cited social justice, to learn and teach with colleagues, an opportunity to function more independently, and travel opportunities as reasons for participation.” [33]

Problematic attitudes in trainees

[30]

“...some students do come with an attitude that because they are Western medical students they will know much more than what our clinical officers know. They will find that they are not right and they have to learn to respect the Malawian clinical officers, respect their decision making.” [30]

Mismatched Expectations

[22, 37, 39]

“Many of the challenges experienced by the students in this study reflect a mismatch between the conditions encountered in low-resource settings, student expectations of the IHE and the support and oversight available from both local and home institutions.” [22]

Trainees’ desires to help in the future

[23, 30, 31, 39]

“Western-trained respondents valued the nurturing of a group of students who may later in their careers return and serve in the region as qualified doctors:

...it’s about what they gain in terms of their future career progression rather than what they give us in [the] short term. So it’s the long-term benefit, not the short-term one.” [30]

Power Imbalance

[1, 23, 31, 37]

“Some participants voiced concerns regarding the troubling power dynamics at some destination. 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. …it was like if they think you’re White or you seem to actually know some things...’” [22]

Navigating different cultures

[22, 31, 33,34,35, 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, 32,33,34, 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. Some respondents expressed discomfort when patients did not understand that they were trainees and were not fully qualified. These respondents described feeling like ‘an imposter’ and found the lack of understanding problematic.” [22]

Autonomy, Respect for Persons

Sub-codes:

• Difficulty with Consent

• Respecting Privacy

[22, 31, 33, 34, 37, 39, 40]

“The most common sources of ethical dilemmas participants identified related to difficulties with truth-telling and establishing informed consent. Participants noted that the concept of informed consent in resource-limited settings was very different to what they were familiar with at home.” [31]

Experiencing Different Professional Norms

Sub-code:

• Practicing Contrary to Evidence-Based Medicine

[1, 22, 32, 37, 39]

“What became quickly evident was the difference in practice compared with U.S. hospitals as Indian physicians are trained under the British system. Unexpectedly, the hospitals were updated with modern technologies, had a significant community focus, and had an extremely high volume patient influx, with minimal implementation of public health and medical education in schools and clinics.” [39]

Being Seen as Other

[1, 37]

“I always thought that I had some vague connection to lower-income urban communities … [but] … then everyone was like, “Hey, look at the white man playing soccer,” to me. I was kind of taken aback and that kind of changed how I saw myself … [and] … saw my role in the community.” [1]

Realizing that Other Trainees Have Different Values

[1]

“Five students were surprised to find during the planning process or during the ISLTs themselves that their classmates did not always share the same idealistic priorities or standards. 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]

Trainee preparedness

[23, 32,33,34,35, 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. 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]

Practicing Out of Scope

[1, 22, 23, 30, 31, 33,34,35, 37, 38]

“However, four (40%) trainees did describe situations in which they had been asked to perform procedures or skills beyond their comfort level. One trainee, as a Year 1 medical student, had been asked repeatedly to perform lumbar punctures for the first time on her elective in Africa. She expressed feelings of discomfort about gaining experience at the expense of patients who often did not speak the same language as she did. She described the challenge of repeatedly declining these opportunities:

‘I don’t think everyone [in the host community] was aware of my level of clinical skill prior to going there… I didn’t care how many times I would see a lumbar puncture, I wasn’t going to do one for the first time on an African who couldn’t speak [the same language as me].’ (7 T)” [23]

(Not) Practicing Out of Scope

[30]

“I think some of them [elective students] are frustrated because we will not allow them to do things that they are not qualified to do. This is not a bush hospital; this is a hospital that has been there for 105 years... We are never enough, but I would never put a scalpel in the hand of a student, never, it has never happened.” [30]

Lack of Supervision

[1, 22, 30, 32, 35, 37, 38]

“Without enough local physicians, trainees were faced with managing sick patients independently, beyond their level of training. One student described the scenario of either treating patients without adequate knowledge or letting them suffer and die:

“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…” [38]

End of life issues

[33]

No examples were provided in the text, this topic was only briefly mentioned as a survey result. [33]

Corruption

[31]

“Another professional issue that many participants discussed was their perception of direct or indirect exposure to corruption.” [31]

Professionalism

[31, 33]

“...students reported enhanced exposure to the professional obligations of surgeons… Professional obligations first and foremost focused on issues of beneficence and non-maleficence surrounding the short-term nature of the work, especially regarding potential postoperative surgical complications and adequate follow-up.” [33]

Research Ethics

[35]

“Two programs described concerns with the ethical conduct of research; for example, one program mentioning that a resident had been accused of taking protected research material without IRB approval from the host country.” [35]

Truth Telling

[22, 31, 33, 37]

“For example, participants reported cases that compelled them to reconsider their duty to inform the patients of the true nature of their affliction and the circumstances of the proposed treatment.” [31]

Resource Limitation

[22, 23, 30,31,32,33,34,35, 37,38,39,40]

“These students also noted a number of logistical errors such as a shortage of a particular glove size or insufficient sharps containers for there to be one next to each patient bed. The final student noted observing a number of patient care risks resulting from an overwhelmed clinical team, which led to scheduled pain medications not being given at the appropriate time or a wound not being redressed per scheduled orders.” [32]