Background

The demand for Global Health Experiences (GHEs) by medical trainees remains high both during undergraduate and graduate medical education training. Opportunities for participation in a variety of global health programs continues to grow, ranging from “voluntourism” to formalized elective health care experiences in medical school or residency . For purposes of this discussion, GHE will be defined as a program of at least one month duration sponsored by an institution of higher learning in a high-income country (HIC) working with hosts located in low and middle income countries (LMICs). The focus will be on clinical GHEs rather than on global research efforts by medical trainees. Similarly, clinical experiences in resource-constrained environments within HICs, so called “local global” experiences, are beyond the scope of this discussion though many of the ethical issues faced by sending trainees to these sites are also applicable. Finally, only medical trainees at the undergraduate medical education (medical student) or graduate medical education (resident) levels will be considered. Global health experiences directed at undergraduate students raise additional ethical issues over and above those discussed below.

Recognized benefits of GHEs for learners include improved clinical acumen and skills, increase awareness of cultural issues and sensitives, enhanced understanding of public health and social justice issues, and the ability to function in resource limited settings . There are also recognized benefits to the medical profession as a whole—trainees who participate in GHEs are more likely to enter general medical practice, work with underserved populations, focus on health policy and health disparity issues, and work in resource constrained environments . As in all patient care scenarios, with benefits comes the risk of potential harms, and this increase in GHEs for medical trainees has outpaced the critical evaluation of these programs from an ethical perspective.

Review of past American Association of Medical Colleges (AAMC) surveys shows that participation in GHEs has increased steadily from less than 10 percent in 1995 to 22.3 % in 2004 . Over the last 6 years, approximately 30% of medical students participated in a GHE at some point during their undergraduate medical education ( Figure 1 ). This experience is not unique to the United States; in a 2005 survey, 40% of British medical students traveled to LMIC for elective experiences . Per the most recent AAMC medical school exit summary, 0.6% of graduating medical students intend to practice in a foreign country other than Canada . So while almost 4,000 graduating medical students pursue GHEs during medical school, only about 80 intend to practice outside the United States; it is unclear what percentage of these students will ultimately work in a LMIC.

Medical Students with Global Health Experience at Graduation, 2010–2016 .

One explanation for this disparity is simply the overwhelming cost of medical education. Of the 13,968 U.S. medical school graduates in 2016, 66.7% entered medical school debt-free, yet only 26.9% of students graduated from medical school debt-free . Thus, even among students highly committed to global health work in LMICs, many would be unable to afford student loan repayment on the reduced salary of a global health physician once the loan deferment available during postgraduate training expires. The stark reality of these numbers highlights the need for medical trainees to make an informed decision about their post-residency career choice, particularly where there are potentially dramatic financial repercussions. Participation in GHEs is the only way in which learners can gain the information and experience necessary to direct future career choices. And while the focus on GHEs is often centered on medical trainees who decide to pursue a career in global health based on their experiences, it is important to remember that learners should also be afforded the opportunity to decide against a career in global health, a decision that must be informed by experiential learning. The disparity between the numbers of medical trainees who pursue a career in global health versus the number of students who seek out GHEs highlights the need to ensure all global health programs adhere to the highest ethical standards.

While the AAMC has included a question on undergraduate medical education GHEs since 2010, this same data is not available for graduate medical education experiences. Individual specialties may collect this data; however, there is no central clearinghouse for collection and dissemination of this information. Thus, it is impossible to determine the percentage of resident physicians participating in GHEs, nor is it possible to know how many graduating residents opt to practice in a LMIC.

Medical trainees pursue GHEs for a variety of reasons including a desire to learn more about health care in a setting outside a HIC, continuation of previous non-medical global experiences, and simple altruism. Most GHEs offered to medical trainees are short-term global health experiences (STGHEs) lasting less than one month. This is not surprising given the myriad of challenges faced by institutions when offering a GHE including costs associated with administering of the program, limitations on trainee elective time, availability of supervising physicians, and coordination with host country partners. While there are many benefits to longer-term GHEs, even STGHEs can meet important trainee learning objectives including exposure of medical trainees in HICs to disease states rare in their country of training and increased diagnostic capabilities without the availability of advanced testing and imaging . The greater concern for STGHEs is that medical students have an expectation of increased autonomy and the ability to gain more “hands-on” experience without the restrictions of supervision in HICs. This is, in part, justified by the “common perception that people who live in poverty will benefit from any medical services” regardless of the provider’s experience or level of training .

The purpose of this discussion is to highlight ethical issues inherent in medical trainee participation in GHEs and to suggest guidelines for the development and implementation of GHEs that maintain the highest ethical standards.

Professional Ethics Applied To Global Health Experiences

A profession is defined as one in which individuals have specialized training or experience and in carrying out professional duties are committed to the serve the well-being of others . Those who are members of a profession implicitly agree on moral standards that govern behavior. As applied to medicine, the four professional virtues that form the basis of moral behavior, self-effacement, self-sacrifice, compassion, and integrity, are the foundation of the physician-patient relationship. In upholding these virtues, physicians are compelled to act in the best interest of the patient. While one would hope that practicing physicians have firmly entrenched concepts of professional ethics guiding their day-to-day actions, medical trainees are still developing their understanding of “professionalism” and how that concept will inform their clinical practice in the future .

Professional Ethics Applied To Global Health Experiences

A profession is defined as one in which individuals have specialized training or experience and in carrying out professional duties are committed to the serve the well-being of others . Those who are members of a profession implicitly agree on moral standards that govern behavior. As applied to medicine, the four professional virtues that form the basis of moral behavior, self-effacement, self-sacrifice, compassion, and integrity, are the foundation of the physician-patient relationship. In upholding these virtues, physicians are compelled to act in the best interest of the patient. While one would hope that practicing physicians have firmly entrenched concepts of professional ethics guiding their day-to-day actions, medical trainees are still developing their understanding of “professionalism” and how that concept will inform their clinical practice in the future .