Ethical Global Outreach in Residency Training

During my (G.S.) 10 years of serving as the program director of the ophthalmology residency at Weill Cornell Medicine, I interviewed hundreds of applicants who were interested in global ophthalmology. When asked to describe their interest in global health training, applicants often replied with some variant of the same response: to help those in need and to provide care to underserved populations. When I, in turn, described our international opportunities, I always sensed their surprise, and occasionally their disappointment, at my response: “Your experience may be largely nonsurgical.”

In the residency interview setting, I was not able to delve into the complexities surrounding global health experiences. I wanted to share my experience as a Peace Corps volunteer in Nicaragua, where I, too, set out with idealistic (and rather naïve) intentions to “save the world.” I wished I could explain that, although we engage in global health experiences with altruistic intentions, we often stand to gain more from these experiences than do the communities that host us.

Given the growing interest in global ophthalmology during residency training,¹ it is important to reflect on how best to engage in global health experiences and serve host communities.

GLOBAL OPHTHALMOLOGY ROTATIONS

In July 2013, the Accreditation Council for Graduate Medical Education began to allow up to 1 month of international rotations to be applied to residency training.² Since then, a growing number of US ophthalmology residency programs have been adopting global health curricula. At least half of ophthalmology residency programs offer or support resident international experiences,^3-5 but the global health curricula offered differs substantially by program. Not all programs have mandatory requirements that residents must meet before practicing abroad, even though many faculty believe additional training outside of the standard ophthalmology curriculum is necessary to practice in an international setting. The lengths of international experiences vary from weeks to months, with the most commonly reported duration being 1 week or less.³

Given residents’ limited preparation for—and the short duration of—global health experiences, it is important to understand the motivations for these experiences from the perspective of residency programs and learners. By offering global health opportunities, US ophthalmology residency programs aim to provide residents with international experiences, deliver humanitarian aid, and engage in medical diplomacy.^3,6 Through these rotations, residents gain increased exposure to ophthalmology and other health care systems; broadened clinical, surgical, and research experience; and exposure to other cultures. To some faculty overseeing international initiatives, these benefits are viewed as having greater importance than serving the underserved.³ This is in stark contrast to the benefits perceived by trainees, who reported in one survey that the greatest benefit of engaging in international rotations is serving underserved populations.¹ The discrepancy between faculty and trainee perspectives highlights the clash between self-interest and altruism that may occur with global health training, as trainees perceive their actions as altruistic but may not acknowledge or sufficiently value the significant benefits they receive from engaging in these programs.

Host communities benefit from global rotations as well, but they may face substantial costs in the process of hosting foreign trainees. By participating in global rotations, international hosts receive surgical and nonsurgical services for their communities, share expertise with US ophthalmologists, develop research collaborations, and build a sense of global connectedness.^4,7 However, in receiving these benefits, host communities divert already limited resources toward hosting trainees, who often require faculty attention for teaching, assistance with translation, guidance in a new medical setting, and housing.⁸

GUIDELINES FOR GLOBAL HEALTH EXPERIENCES

Given the complex intersections between self-interest, altruism, and global health experiences, residents pursuing these experiences should prioritize their roles as learners and engage in practices that adhere to currently established ethical guidelines.^9,10 Some of these guidelines follow.

1. Understand Your Impact

Residents can profoundly influence patient care while rotating internationally, not only by providing services in the clinical setting but also through their interactions with community members and the local health care system. Residents should therefore familiarize themselves with local laws, customs, and health care systems. They should acquire the basic language skills necessary to engage in clinical activities and communicate with host mentors in advance about expectations for the rotation and how best to fit within the existing workflow of the host institution.

2. Embrace Your Role as a Learner

Global health experiences provide residents with an opportunity to apply their clinical skills in a new environment. Rather than view these experiences as a way to “serve” or “teach,” it is important to consider them as a continuation of resident training. Although residents may indeed provide meaningful clinical care, their goals should be to improve their clinical skills and to broaden their understanding of the global burden of eye disease as well as the delivery of eye care in diverse settings.

Residents may also refer to a number of resources provided by various institutions, such as the AAO’s Academic Global Ophthalmology course¹¹ and advisory opinion on ethical issues in global ophthalmology¹² and the Stanford University Center for Global Health and the Johns Hopkins University Berman Institute of Bioethics’s course, Ethical Challenges in Short-Term Global Health Training.¹³

3. Practice Within Your Scope

Residents should clearly express their level of training, not only to local health care staff but also to patients. They should establish boundaries based on their current training and skills to prevent the inappropriate administration of care. A global rotation is not the right setting to try a new procedure or technique, especially given the difficulties with communication, the unfamiliar surgical environments, and the limited duration of these experiences. It is irresponsible to potentially leave patients with complications that the resident cannot address once they return home.

4. Respect Privacy and Autonomy

Residents should not only abide by local rules and customs but should also adhere to HIPAA, even when practicing in another country. There may be many interesting cases to report and photos to take; however, it is imperative that necessary permissions for publication and approvals for research activities be obtained from the appropriate organizations, including the Institutional Review Board of the host institution.

5. Remain Open-Minded

Residents should be respectful of the culture of local communities and remain open-minded when encountering different perspectives. They should engage with local providers to understand how to provide care in a culturally humble manner.

CONCLUSION

As interest in global health training continues to increase, it is important to establish best practices among visiting residents to maximize benefits for and minimize harm to host communities that engage in these programs. Notably, many of these practices continue to apply even after one’s formal ophthalmology training is complete. By adhering to established ethical guidelines and acknowledging how self-interest and altruism interact with the global practice of medicine, trainees have the opportunity to ensure that host communities and residency programs continue to benefit mutually from global health experiences.