Bioethical Inquiry DOI 10.1007/s11673-014-9603-7

CRITICAL PERSPECTIVES

Teaching Corner: “First Do No Harm”: Teaching Global Health Ethics to Medical Trainees Through Experiential Learning Tea Logar & Phuoc Le & James D. Harrison & Marcia Glass

Received: 28 March 2014 / Accepted: 9 October 2014 # Journal of Bioethical Inquiry Pty Ltd. 2015

Abstract Recent studies show that returning global health trainees often report having felt inadequately prepared to deal with ethical dilemmas they encountered during outreach clinical work. While global health training guidelines emphasize the importance of developing ethical and cultural competencies before embarking on fieldwork, their practical implementation is often lacking and consists mainly of recommendations regarding professional behavior and discussions of case studies. Evidence suggests that one of the most effective ways to teach certain skills in global health, including ethical and cultural competencies, is through service learning. This approach combines community service with experiential learning. Unfortunately, this approach to global health ethics training is often unattainable due to a lack of supervision and resources available at host locations. This often means that trainees enter global health initiatives unprepared to deal with ethical dilemmas, which has the potential for adverse consequences for patients and host institutions, thus contributing to growing concerns about exploitation and Bmedical tourism.^ From an educational perspective, exposure alone to such ethical dilemmas does not contribute to learning, due to lack of proper guidance. We propose that the tension between the benefits of service learning on the one hand and the respect for patients’ rights and well-being on the other could be resolved by the application of a T. Logar (*) : P. Le : J. D. Harrison : M. Glass Division of Hospital Medicine, University of California San Francisco, 533 Parnassus Avenue, U127a, San Francisco, CA 94143, USA e-mail: [email protected]

simulation-based approach to global health ethics education. Keywords Global health . Ethics . Education . Predeparture training . Experiential learning . Service learning . Simulation

Introduction Over the last decade, American, Canadian, and European academic medical centers have witnessed an unprecedented expansion of interest in global health outreach work among their students, faculty, and staff. Surveys report that almost a third of recently graduated medical students in North America participated in global health work, and interest continues to increase (Battat et al. 2010). While medical schools strive to keep up with this growing demand by developing new global health programs and improving existing ones, there remains insufficient consensus on the exact content and teaching methods for global health curricula, especially regarding the ethics component (Battat et al. 2010; Izadnegahdar et al. 2008). Reviews of curricula addressing global health in the United States, Canada, and Europe reveal little ethics training, despite ethics being listed within a core set of topics that should be included (Crump, Sugarman, and WEIGHT 2010; Pinto and Upshur 2009). As global health work requires adapting to cultural and professional differences, a lack of preparation for distinctive ethical challenges can yield adverse clinical

Bioethical Inquiry

and emotional consequences for patients, their families, and communities and also for the trainees, their colleagues, and involved institutions (Lahey 2012; Pinto and Upshur 2009). There have been some attempts in the last few years to incorporate more substantive ethics guidelines into predeparture training; however, these tend to be too broad and often leave the trainees with very little practical guidance. Proposals have been made to introduce more substantive ethics training within global health curricula that should be informed by the returning global health trainees’ experiences and recommendations.

local providers, rather than solely educating its own trainees, should be the ultimate goal of global health initiatives (Reisch 2011). As a result of this growing awareness, guidelines have been established for forming mutually beneficial partnerships that ensure equitable collaboration. This includes equal access to resources, opportunities, influence in project administration, and budget management (Crump, Sugarman, and WEIGHT 2010; Murphy et al. 2013). A recent review of international partnerships also indicates increasing consideration of the host partners’ needs (Umoren, James, and Litzelman 2012). Sources of Ethical Dilemmas on an Individual Level

Pertinent Ethical Issues in Global Health Outreach Initiatives Ethical Challenges on a Structural Level With the increasing popularity of global health electives, there is also growing awareness that the effects of such initiatives may not be positive for many host institutions and communities (Asgary and Junck 2012; DeCamp 2007).The practice of training residents and students with underprivileged populations can be considered as exploitative as medical research on equally vulnerable populations if the latter do not incur substantial benefits from the interaction (DeCamp 2007; Gilbert et al. 2013; Philpott 2010). Moreover, placements more concerned with training visiting trainees than with serving host communities can result in actual harm to patients, especially when they fail to secure adequate supervision of practicing trainees (Ackerman 2010). Allegedly, some programs even defer already limited resources from host communities and institutions toward pedagogical demands of visiting trainees (Huish 2012). If the ultimate priority of a global health initiative is to educate visiting students and trainees, then the host institution will most likely not benefit long-term. Evidently, ensuring that the benefits of each program are mutual and reciprocal is currently becoming an increasingly important aim of global health program initiatives. For example, Barnard et al. (2011) argue that the first requirement of an ethically sound program is a genuinely collaborative partnership with the host community. Sending institutions arguably have a moral obligation to improve care and service delivery at host institutions (Crump and Sugarman 2008), and it has been argued that transferring knowledge and tools to

While it is up to the involved institutions to ensure that programs are designed to benefit all stakeholders, there are more to ethical challenges in global health than solely structural and organizational concerns. Global health trainees often report having to deal with ethical challenges on an individual level: Ethical dilemmas directly involving staff and patients are usually locally and culturally specific, and trainees are more often than not unprepared to deal with them (for an overview of ethical challenges faced by global health trainees, see Table 1). Most ethical dilemmas in global health work stem from cultural differences, differences in professional expectations, and the fact that resources (equipment, personnel, infrastructure) in such settings can be seriously limited, leaving it up to students to decide how to distribute supplies and whether to act beyond their scope of training.1 Returning trainees frequently report feeling uncomfortable by the decisions made by local staff that reflect local cultural norms but are deemed unacceptable by Western standards, for example examining patients in front of other patients or disclosing and gathering private information in the presence of family members (Elit et al. 2011). Besides cultural and language barriers to establishing truly informed consent, the concept of consent itself differs across cultures, and different interpretations can confuse a trainee used to the Western perception of the concept. In some regions, patients may be uncomfortable making important medical 1 Various combinations of these issues form the basis of ethical dilemmas that involve challenges to the preservation of patient privacy and confidentiality, obtaining informed consent, and successful relationships between host staff and visiting trainees (Barnard et al. 2011)

Bioethical Inquiry Table 1 Common ethical challenges faced by global health trainees Cultural differences

- differing notions of informed consent - less emphasis on individual autonomy - reduced significance of privacy and confidentiality - conflicting gender norms

Professional issues

- acting beyond scope of practice - lack of appropriate supervision - limits of personal involvement (e.g., paying for patients’ treatment or food) - accepting seemingly unethical decisions made by local staff (including corruption)

Limited resources

- working in understaffed environments - dealing with severely restricted and inadequate supplies - making difficult decisions about resource allocation and distribution

Personal issues

- coping with moral distress and trauma - anxiety about the limits of personal involvement - not knowing where to look for guidance when trying to resolve ethical issues

decisions on their own, without input of family members (Elansary et al. 2011), while elsewhere patients may wish to remain unaware of potential complications and side effects of recommended procedures (Barnard et al. 2011). Another widespread ethical challenge lies in the fact that local staff often present inexperienced trainees with responsibilities that go well beyond their capabilities (Crump and Sugarman 2008; Elansary et al. 2011). There are reports that patients themselves often prefer being treated by visiting trainees rather than local physicians, even when the former are significantly less qualified (Elit et al. 2011). Furthermore, there is evidence that health care staff at some host institutions allow medical students to diagnose and prescribe treatment without direct supervision; this is despite the fact that these students would not be allowed to perform these procedures at their home institutions (Radstone 2005). As some host institutions are extremely understaffed, trainees sometimes find themselves in situations where they are the only available medical professionals who can help patients, despite being insufficiently trained according to the standards of their home institutions. Trainees have reported being put in situations where they had to decide whether to perform procedures outside of their scope of training, such as Caesariansections or pericardiocenteses, or let their patients suffer serious consequences, even death (Elit et al. 2011; Kiromera et al. 2013). Adverse Effects of Inadequate Ethics Training Global health trainees are often unprepared to address these types of ethical dilemmas, either because they

underwent no predeparture training or because the training did not provide them with sufficient tools to address such challenges. Unpreparedness in this area yields an array of adverse consequences for all relevant stakeholders (Asgary and Junck 2012; Hamadani, Saciragic, and McCarthy 2009; Lahey 2012). Trainees can be overwhelmed by unfamiliar conditions and the consequences of inadequate health care in limited-resource countries, especially in the absence of suitable supervision from faculty (Reisch 2011). They often feel distressed over the effects of inadequate health care on their patients, but also on themselves, since the work may often expose them to infections they are unlikely to encounter at their home institutions (Crump and Sugarman 2008). Elit et al. (2011) have recorded feedback from several trainees who have reported feeling demoralized, frightened, and unsure about their ability to help after experiencing ethically challenging situations for which they were not prepared. Several trainees reported feeling distraught after realizing they were unable to help, either because of limited material resources or because of the limitations of their own training, and many started doubting their own capacity to contribute in the setting and were left with feelings of stress and guilt (Elit et al. 2011; Crump and Sugarman 2008). More importantly, when trainees feel distressed, their patients inadvertently carry a large part of the burden. It has been shown that morally distressed health workers are more likely to exhibit burnout and ultimately less likely to work for the underserved (Lahey 2012). Moreover, trainees cannot be expected to exhibit a respectful and patient-centered approach in resourcelimited settings if they do not understand relevant

Bioethical Inquiry

cultural issues (Anderson, Bocking, and Slatnik 2008). Without possessing adequate cultural and ethical competencies, trainees may act disrespectfully without intention and may jeopardize patients’ health by inadvertently alienating them through inappropriate behavior (Pinto and Upshur 2009). Trainees may also encounter difficulties in establishing trust and informed consent, especially if they do not realize that during their placements they may be interacting with vulnerable, oppressed, impoverished, and marginalized populations and individuals (Lahey 2012; Pinto and Upshur 2009). The concern that some trainees join global health electives for their own gain (professional or otherwise), rather than to aid underserved populations, is mentioned often throughout the literature and is frequently referred to as Bmedical tourism.^2 Because some trainees tend to see their global health work primarily as a learning opportunity, they tend not to concern themselves with the long-term effects of their interventions. Several researchers have reported that some trainees choose participation in international electives in order to Bpractice^ on patients, for example by performing surgeries and other procedures that they would not be allowed to perform at their home institutions due to lack of sufficient training or opportunity (Shah and Wu 2008). Many authors emphasize that trainees should be discouraged from intervening in ways for which they lack training, regardless of the promise of a Blearning opportunity^ (Bishop and Litch 2000; Hanson, Harms, and Plamondon 2011; Reisch 2011; Shah and Wu 2008). The principle of nonmaleficence is especially relevant in cases where trainees’ actions may be led by the idea that people who live in poverty will benefit from any kind of help, no matter how substandard by our criteria (Dowell and Merrylees 2009; Jones and Loeliger 2008). A Need for Substantive Experiential Predeparture Ethics Training Since all of the involved and affected stakeholders generally fare much better when the trainees are adequately prepared to deal with cultural differences and ethical dilemmas ahead of time, medical schools should Although the term Bmedical tourism^ is sometimes used to describe this problem, the same term is used in bioethics literature to describe the practice of individuals seeking treatment in international hospitals and clinics outside of their local health communities. For a better understanding of the difference between the two meanings, see Snyder, Dharamsi, and Crooks (2011).

2

provide their students and other trainees with tools for recognizing, assessing, and resolving ethical issues they are likely to encounter in their global health work. In recent years, numerous authors have stressed that there exists a pronounced need for a substantive and systematic ethical training that enables participants with limited prior experience in the field to develop a strategy for recognizing and resolving ethical dilemmas (Crump and Sugarman 2008; DeCamp et al. 2013; Elit et al. 2011; Hamadani, Saciragic, and McCarthy 2009; Jones and Loeliger 2008; Martin et al. 2013; Shah and Wu 2008).While some guidelines are already in existence, a more systematic approach is needed.

Global Health Ethics Training: An Overview of Current Educational Guidelines Core Issues: Cultural Competence and Professionalism While research programs in limited-resource settings have been governed by formal ethical guidelines for some time now, educational guidelines concerning ethics in clinical global health work are still relatively scarce. In recent years, global health experts have formed various committees and consortia that have proposed core competencies for trainees with interest in global health. Due to concerns about inadequate ethics preparation of global health trainees, most of these proposals include basic information on relevant ethical issues. Besides proposing general guidelines for dealing with ethical dilemmas on an individual level (e.g., cultural competency), current curricula and frameworks often emphasize the importance of educating trainees on the issues of social justice, human rights, sources of global health disparities, solidarity, economy of health, examining broader goals and burdens, and understanding long-term consequences of global health initiatives (Chase and Evert 2011; Jones and Loeliger 2008; Lahey 2012; Pinto and Upshur 2009). Relatively few authors argue that familiarity with the basics of philosophical moral theories, bioethical principles, or larger ethical frameworks is essential for an adequate approach to resolving ethical dilemmas in global health work (Lahey 2012; Pinto and Upshur 2009). Since ethics is primarily a philosophical discipline, the impact of elementary bioethical education on the effectiveness of global health ethics training certainly deserves to be explored more thoroughly.

Bioethical Inquiry

In 2010, the Working Group on Ethics Guidelines for Training Experiences in Global Health (WEIGHT) developed a set of broad guidelines for sending and host institutions, trainees, and sponsors involved in global health outreach work. Among their guidelines are recommendations for formal training of trainees, which should include the following material: norms of professionalism, standards of practice, cultural competence (e.g., behavior and dealing effectively with cultural differences), and guidelines for conflict resolution (Crump, Sugarman, and WEIGHT 2010).Various other guidebooks offer a similar scope of recommendations, with central emphasis on cultural competence and professional norms. It needs to be noted that most of these guidelines are aimed at trainees at all levels of their education and career path, although many appear to be addressing especially undergraduate medical students prior to their first global health experience. However, it seems reasonable to assume that trainees from different categories of education and at different stages of their training are likely to experience different sets of moral dilemmas during their global health work. We propose that gathering more data on the trainees’ individual experiences would importantly help to develop more targeted and valuable predeparture training. Cultural Competence Experience and data show that a substantial share of ethical challenges in global health work stems from differences in cultural values and practices. Therefore, a considerable emphasis should be placed on teaching cultural competence to future global health trainees. While a few resources include the recommendation that students must be trained in basic understanding of the concepts of culture and intercultural relationships (Anderson, Bocking, and Slatnik 2008), most authors emphasize that the trainees should be made aware of the specifics of local culture where they will be engaging in clinical work. This includes understanding socioeconomic, cultural, and historical issues that contribute to the current health status in the region and community (Reisch 2011); familiarity with moral values, religion, politics, and local health beliefs and practices are particularly relevant (Barnard et al. 2011). Trainees should be made especially aware of specific local cultural norms that are importantly different from those practiced at the trainees’ home communities, in

order to prevent offensive behavior abroad, such as wearing inappropriate dress, speaking casually with elders, or drinking alcohol (Anderson, Bocking, and Slatnik 2008). Additionally, understanding local gender dynamics is essential in most settings. Trainees also should learn ahead of time how their host institution and community deal with sexual and domestic abuse and what the alternative options are for victims (Barnard et al. 2011; Pinto and Upshur 2009). More directly related to clinical work, several resources emphasize that trainees must be aware that the BWestern^ norms of patient autonomy and informed consent may in fact not carry such weight in all cultures or may be understood differently. Trainees should be prepared to discuss confidential information and perform certain procedures in less private surroundings than that which they are used to (Elansary et al. 2011; Martin et al. 2013; Pinto and Upshur 2009; Reisch 2011).

Norms of Professionalism The fundamental principles of medical professionalism—commitment to social justice, concern for patient welfare, and respect for autonomy—are frequently challenged in global health work due to limited resources and cultural differences (Barnard et al. 2011; Jones and Loeliger 2008). In order to avoid inadvertently offensive and unprofessional behavior, trainees must be taught how to deal with differing expectations and possible conflicts that may ensue, since their professional expectations often differ from those upheld by their colleagues at host institutions (e.g., differing notions of health and disease, consent, confidentiality, clinical proficiency) (Elansary et al. 2011). Crump, Sugarman, and WEIG HT (2010) suggest that mentors encourage nonthreatening communication, as well as develop mechanisms for involving host and sending institutions when trying to resolve the conflicts. While trainees clearly need to be taught about the differences in professional norms between their sending and host institutions, experience shows that they also need to be reminded to uphold many of the same professional standards abroad that they are expected to uphold at home. Trainees should not feel that they can abandon norms such as punctuality, appropriate dress, reliability, compliance, and respectful attitude simply because they are working in a resource-limited setting

Bioethical Inquiry

with less supervision than what they are used to at home (Howard et al. 2011; Shah and Wu 2008). The most commonly addressed topic in the area of professionalism is the problem of acting outside of one’s scope of practice, and most resources feature guidelines regarding this problem. While some resources caution against performing any procedures that the trainees would not be allowed to perform at their home institution, others recognize that acting in this way may sometimes seem necessary in settings with severe personnel shortages and that trainees should exhibit caution and common sense, as well as rely on their own moral values, when deciding whether to practice beyond their formal scope of competence (Asgary and Junck 2012; Barnard et al. 2011). Suggested Educational Approaches and Available Resources The current recommended teaching methods of ethical issues in global health training include a combination of didactic and experiential components (Chan et al. 2011; Martin et al. 2013). Many trainees consider service learning, which combines community service with preparation and reflection, especially useful (Seifer 1998). However, this approach to educating trainees about ethical dilemmas in global health clinical work is often hard to establish due to lack of supervision and guidance at many host institutions. Instead, many trainees are educated about ethical issues during predeparture training. Medical Schools There are a variety of proposed frameworks within which the trainees, especially medical students, can learn about relevant ethical issues before departure. One possible venue is to mandate teaching of ethical issues in global health as a requisite within mainstream global health curriculum. The positive aspect of this approach is that students would be able to learn about the wider background of various ethical issues in global health (such as social justice, medical tourism, etc.) and be given time to reflect on their own motivations before deciding whether to engage in global health work at all. However, once trainees have made their decision to participate in global health work, it is crucial that they engage in preparation more actively, and predeparture training may be a more appropriate venue to address

such concerns. The optimal approach, therefore, is to include predeparture training within broader global health curricula; the benefits of this approach are welldocumented (Bateman et al. 2001; Miranda, Yudkin, and Willot 2005). More specifically, it is often emphasized that, prior to their departure, trainees should be exposed to an array of specific ethical dilemmas they may face and be provided with a framework to resolve them. With practical concerns in mind, many guidelines recommend the use of case studies that describe particular scenarios, preferably followed by a group discussion led by an experienced faculty member who can help guide conversations and clarify ethical issues in each case. Some suggest that students also provide written analyses of discussed cases, and many of these resources provide their own case studies that can be used in the classroom for these purposes (Anderson, Bocking, and Slatnik 2008; Barnard et al. 2011; Chan et al. 2011; Elansary et al. 2011; Jones and Loeliger 2008; Kiromera et al. 2013). Online Resources Online modules featuring case studies are available either for those who have no access to adequate inperson predeparture training or for those who wish to supplement such learning. The most recent, and also the most substantive, online resource is BEthical Challenges in Short-Term Global Health Training^—a joint project developed by experts from Stanford University’s Center for Innovation in Global Health and Johns Hopkins’ Berman Institute of Bioethics. The module features 10 case studies and encourages the participant to choose the optimal course of action (DeCamp et al. 2013). More case studies with discussion questions and post-return material can be found on the American Medical Student Association’s website: BGlobal Health Ethics Student Curriculum^ (American Medical Student Association 2013).Unite for Sight’s BVolunteer Ethics and Professionalism Online Course^ also offers material, including case studies, on professional behavior of international volunteers (Unite for Sight 2013). An additional important resource for those who wish to supplement their training is Virtual Mentor, an online debriefing forum that is the American Medical Association’s journal of ethics. Students’ descriptions of dilemmas they faced during global health fieldwork are addressed by professionals with extensive experience in the area. In March 2010, an issue was dedicated to

Bioethical Inquiry

global health ethics in practice, covering several topics which are of interest to potential global health trainees (Weinberg 2010).

A Proposal for Experiential Learning Using Simulation Didactic lectures, online modules, and discussions of case studies, while no doubt helpful, fail to provide the undeniable benefits of experiential learning. Experiential learning involves learning from firsthand experiences, rather than gaining knowledge about relevant issues through hearing about and discussing other people’s experiences or hypothetical scenarios. Successful experiential learning involves systematic reflection on one’s own experience, thus developing insights and understanding, leading to new lessons and actions (Cole et al. 2013; McCarthy and McCarthy 2006). A form of experiential learning characteristic of global health education is service learning, a method that combines community service with obtaining professional experience. Service Learning—Benefits and Shortcomings Service learning involves gaining skills and relevant knowledge through engagement in various forms of community service or volunteer work. Ideally under expert guidance, trainees engage in preparation and reflection on the relationship between their service and academic course work, as well as on the broader context surrounding the problems their work is addressing (Seifer 1998). Engaging trainees in global health fieldwork with the dual aim of trainee education and health service delivery/improvement is thus a form of service learning. Knowledge and skills that are particularly affected by engagement in global health outreach work are those that concern ethical and cultural competencies. For example, Cole et al. (2013) report that students found that they truly learned ethical principles, especially respect for autonomy and participation, when involved in a six-month practicum in Malawi. Moreover, engagement in such work fosters trainees’ overall appreciation of global social justice, understanding of social determinants of health, and awareness of ethical components of their work (Parsi and List 2008). There is, however, a definite tension between the need for the practical experience service learning offers

on one hand and respecting the rights and dignity of underserved patients on the other. The latter should not be treated as means to the trainees’ attainment of clinical skills, and the same should hold for the development of trainees’ ethical competencies; this brings us back to the requirement that global health trainees have to undergo rigorous ethics training before beginning outreach work abroad. Predeparture ethics training is crucial because direct supervision and ethics guidance required for successful service learning are often unavailable in limitedresource locations, which may exacerbate the problem of medical tourism (Parsi and List 2008). Moreover, since one of the main risks of service learning is Bleaving students paralyzed by intense experiences abroad^ (Parsi and List 2008, 18), it is essential that trainees be exposed to relevant ethical issues before departure in order to avoid culture shock that may render them incapable of providing needed service (Elit et al. 2011). Fortunately, experiential learning in global health does not have to be geographically limited to host institutions. Trainees can be exposed to experiential learning opportunities prior to their departure, namely through engaging in simulation exercises. Simulation-Based Medical Education While it is expected that predeparture training will fall short of the benefits of service learning to some degree, there is no need to resign to theoretical discussions of case studies in the classroom. Simulation-based training is becoming an increasingly important tool in medical education and has gained widespread acceptance due to the safety of the environment, the ease of simulating critical events, and the reproducibility of content, among other benefits (Ziv et al. 2006). Specifically, simulationbased training has been shown to increase acquisition and retention of new skills and knowledge in trainees (Cheng et al. 2013; Issenberg et al. 2005; McGaghie et al. 2006), as well as increase patient safety and reduce the risks to patients and trainees (Al-Elq 2010; Gaba 2004). Systematic qualitative and narrative reviews spanning across decades have shown that simulationbased training, when properly executed, produces substantial benefits to patients and trainees (Issenberg et al. 2005; McGaghie et al. 2010). It indeed seems that use of simulations in medical education may be an optimal tool for achieving the balance between the need for trainees’ practical experience on one hand and protecting

Bioethical Inquiry

patients’ rights and well-being on the other (Kneebone and Nestel 2010). Simulation in Global Health Ethics The benefits of simulation-based learning have been recognized and employed in the development of many modules aimed at improvement of clinical skills; however, they have not yet been applied to educating global health trainees about ethical issues. Yet, evidence firmly suggests that adding simulation teaching to more Btraditional^ global health ethics curricula will better prepare the trainees to resolve ethical dilemmas they are likely to encounter. In lieu of case discussions in the classroom and online settings, medical academic institutions should aim to provide simulation-based exercises for their trainees, employing actors (standardized patients) in the roles of patients and health workers. Simulation scenarios should be devised so as to urge the participants to address key concepts in medical ethics (e.g., informed consent and nonmaleficence) in extremely resource-limited settings with distinct cultural norms. Specific locales will warrant specific scenarios, and each predeparture program should focus on scenarios trainees are most likely to encounter at a given host setting. The goal should be to put the participants in situations where they are faced with a difficult ethical dilemma that they have to resolve by deciding which course of action to take—for example, whether to perform a procedure deemed beyond their scope of practice; whether to conform to local cultural norms (or professional decisions made by their local colleagues) that put their patient’s life at risk; whether to insist on a course of treatment that will leave the patient socially ostracized and marginalized; etc.3 Without proper guidance, however, participation in simulation exercises is insufficient for proper learning 3

We developed four simulation scenarios for our pilot. In the first scenario, the trainee has to decide whether to report a hospital pharmacist who secretly diverts a large amount of medications to the poor patients who cannot afford treatment. In the second scenario, the trainee has to decide whether to insist on giving HIV treatment to a woman who will become homeless and abused if her family finds out that she is HIV-positive. The third scenario features a teenager with a complicated pregnancy that demands a Caesarian section, but the proper treatment is unattainable due to various cultural limitations. In the fourth scenario, the trainee has to decide whether to perform a pericardiocentesis, which is a procedure outside of her scope of practice but at the same time the only apparent means to save the patient’s life.

experience (Petranek 2000).Therefore, simulation scenarios should be followed by a debriefing session led by a designated faculty member who is trained in global health ethics; the debriefing should involve a predefined set of questions and an open-ended discussion about the participants’ subjective feelings and thoughts regarding the ethical challenge they just faced (Fanning and Gaba 2007; Rudolph et al. 2008). Ideally, such curricula should involve post-training and post-fieldwork surveys of the participants for evaluation purposes, which can facilitate further improvement of the program. The posttraining surveys of returning trainees should question the effect of simulation exercises on their emotional readiness to engage in ethically challenging situations as well as their situational awareness and efficacy in handling actual ethical dilemmas during fieldwork. Where integrated within broader global health curricula, simulation-based modules would be preferably based on the lessons about both structural and individual ethical challenges in global health, thereby building the trainees’ awareness of social determinants of health and relevance of social justice for global health through resolution of ethical dilemmas on an individual level.

Conclusion With the increasing interest in global health work among medical students and staff, there comes a responsibility for more involved, long-reaching, and reciprocal engagement with host institutions and communities. Global health initiatives combine community service with learning experience and must therefore be carefully crafted to serve the needs of the trainees and patients as well as host institutions and broader communities. Because the circumstances at many target locations differ significantly from what trainees have been used to before arrival, trainees have to be adequately prepared to deal with ethical challenges that often arise from severe resource shortages and cultural and professional differences. We propose that medical academic institutions could significantly enhance their predeparture training by employing simulation-based approaches to educating trainees about relevant ethical issues. Simulations are an effective way of providing experiential learning under controlled circumstances without putting patients at risk, all the while helping the trainees develop their cultural, professional, and ethical competencies under

Bioethical Inquiry

proper guidance. In the absence of systematic and substantive educational guidelines regarding ethical challenges in global health work, incorporation of simulations within broader global health curricula would likely lead to significant improvement in the trainees’ ability to deal with ethical challenges they will inevitably encounter.

References Ackerman, L.K. 2010. The ethics of short-term international health electives in developing countries. Annals of Behavioral Science and Medical Education 16(2): 40–43. Al-Elq, A.H. 2010. Simulation-based medical teaching and learning. Journal of Family and Community Medicine 17(1): 35–40. American Medical Student Association. Global health ethics student curriculum: Introduction to global health clinical ethics. www.amsa.org/AMSA/Homepage/About/Committees/ Global/Ethics.aspx#clinical. Accessed October 20, 2013. Anderson, K., N. Bocking, and M. Slatnik, for AFMC Global Health Resource Group and CFMS Global Health Program. 2008. Preparing medical students for electives in lowresource settings: A template for national guidelines for predeparture training. www.cfms.org/downloads/PreDeparture%20 Guidelines%20Final.pdf. Accessed October 17, 2013. Asgary, R., and E. Junck. 2012. New trends of short-term humanitarian medical volunteerism: Professional and ethical considerations. Journal of Medical Ethics 39(10): 625–631. Barnard, D., T. Bui, J. Chase, et al. 2011. Ethical issues in global health education. In Global health training in graduate medical education: A guidebook, 2nd ed, edited by J. Chase and J. Evert, 25–43. San Francisco: Global Health Education Consortium. Bateman, C., T. Baker, E. Hoornenborg, and U. Ericsson. 2001. Bringing global issues to medical teaching. The Lancet 358(9292): 1539–1542. Battat, R., G. Seidman, N. Chadi, et al. 2010. Global health competencies and approaches in medical education: A literature review. BMC Medical Education 10: 94. doi:10.1186/ 1472-6920-10-94. Bishop, R., and J.A. Litch. 2000. Medical tourism can do harm. British Medical Journal 320(7240): 1017. Chan, K., L.L. Dillabaugh, A.L. Pfeifle, C.C. Stewart, and F. Teng. 2011. Global health education curriculum. In Global health training in graduate medical education: A guidebook, 2nd ed, edited by J. Chase and J. Evert, 16–24. San Francisco: Global Health Education Consortium. Chase, J., and J. Evert, eds. 2011. Global health training in graduate medical education: A guidebook, 2nd ed. San Francisco: Global Health Education Consortium. Cheng, A., E.A. Hunt, A. Donoghue, et al. 2013. Examining pediatric resuscitation education using simulation and scripted debriefing: A multicenter randomized trial. JAMA Pediatrics 167(6): 528–536.

Cole, D.C., L. Hanson, K.D. Rouleau, K. Pottie, and N. Arya. 2013. Teaching global health ethics. In An introduction to global health ethics, edited by A.D. Pinto and R.D. Upshur, 148–158. New York: Routledge. Crump, J.A., and J. Sugarman. 2008. Ethical considerations for short-term experiences by trainees in global health. The Journal of the American Medical Association 300(12): 1456–1458. Crump, J.A., J. Sugarman, and Working Group on Ethics Guidelines for Global Health Training (WEIGHT). 2010. Ethics and best practice guidelines for training experiences in global health. The American Journal of Tropical Medicine and Hygiene 83(6): 1178–1182. DeCamp, M. 2007. Scrutinizing global short-term medical outreach. The Hastings Center Report 37(6): 21–23. DeCamp, M., J. Rodriguez, S. Hecht, M. Barry, and J. Sugarman. 2013. An ethics curriculum for short-term global health trainees. Globalization and Health 9: 5. doi:10.1186/17448603-9-5. Dowell, J., and N. Merrylees. 2009. Electives: Isn’t it time for a change? Medical Education 43(2): 121–126. Elansary, M., L.K. Graber, A.M. Provenzano, M. Barry, K. Khoshnood, and A. Rastegar. 2011. Ethical dilemmas in global clinical electives. The Journal of Global Health 1(1): 24–27. Elit, L., M. Hunt, L. Redwood-Campbell, J. Ranford, N. Adelson, and L. Schwartz. 2011. Ethical issues encountered by medical students during international health electives. Medical Education 45(7): 704–711. Fanning, R.M., and D.M. Gaba. 2007. The role of debriefing in simulation-based learning. Simulation in Healthcare 2(2): 115–125. Gaba, D. 2004. The future vision of simulation in health care. Quality and Safety in Health Care 13(1): i2–i10. Gilbert, B.J., C. Miller, F. Corrick, and R.A. Watson. 2013. Should trainee doctors use the developing world to gain clinical experience? Philosophy, Ethics, and Humanities in Medicine 8: 1. doi:10.1186/1747-5341-8-1. Hamadani, F., L. Saciragic, and A. McCarthy. 2009. Ethics in global health: The need for evidence-based curricula. McGill Journal of Medicine 12(2): 120–125. Hanson, L., S. Harms, and K. Plamondon. 2011. Undergraduate international medical electives: Some ethical and pedagogical considerations. Journal of Studies in International Education 15(2): 171–185. Howard, C.R., S.P. Gladding, S. Kiguli, J.S. Andrews, and C.C. John. 2011. Development of a competency-based curriculum in global child health. Academic Medicine 86(4): 521–528. Huish, R. 2012. The ethical conundrum of international health electives in medical education. Journal of Global Citizenship & Equity Education 2(1). http://journals.sfu.ca/jgcee/index. php/jgcee/article/viewArticle/55/30. Issenberg, S.B., W.C. McGaghie, E.R. Petrusa, D.L. Gordon, and R.J. Scalese. 2005. Features and uses of high-fidelity medical simulation that lead to effective learning: A BEME systematic review. Medical Teacher 27(1): 10–28. Izadnegahdar, R., S. Correia, B. Ohata, et al. 2008. Global health in Canadian medical education: Current practices and opportunities. Academic Medicine 83(2): 192–198.

Bioethical Inquiry Jones, E., and S. Loeliger. 2008. Ethics for global health programming. In Developing residency training in global health: A guidebook, edited by J. Evert, C. Stewart, K. Chan, M. Rosenberg, and T. Hall, 23–35. San Francisco: Global Health Education Consortium. Kiromera, A., J. Philpott, S. Marsh, and A.K. Chan. 2013. Ethics and clinical work in global health. In An introduction to global health ethics, edited by A.D. Pinto and R.D. Upshur, 89–102. New York: Routledge. Kneebone, R., and D. Nestel. 2010. Learning and teaching clinical procedures. In Medical education: Theory and practice, edited by T. Dornan, K. Mann, A. Scherpbier, and J. Spencer, 171–192. London: Churchill Livingstone imprint of Elsevier. Lahey, T. 2012. A proposed medical school curriculum to help students recognize and resolve ethical issues of global health outreach work. Academic Medicine 87(2): 210–215. Martin, B.M., T.P. Love, J. Srinivasan, et al. 2013. Designing an ethics curriculum to support global health experiences in surgery. Journal of Surgical Research 187(2): 367–370. McCarthy, P.R., and H.M. McCarthy. 2006. When case studies are not enough: Integrating experiential learning into business curricula. Journal of Education for Business 81(4): 201–204. McGaghie, W.C., S.B. Issenberg, E.R. Petrusa, and R.J. Scalese. 2006. Effect of practice on standardised learning outcomes in simulation-based medical education. Medical Education 40(8): 792–797. McGaghie, W.C., S.B. Issenberg, E.R. Petrusa, and R.J. Scalese. 2010. A critical review of simulation-based medical education research: 2003–2009. Medical Education 44(1): 50–63. Miranda, J.J., J.S. Yudkin, and C. Willot. 2005. International health electives: Four years of experience. Travel Medicine and Infectious Disease 3(3): 133–141. Murphy, J., V.R. Neufeld, D. Habte, et al. 2013. Ethical considerations of global health partnerships. In An introduction to global health ethics, edited by A.D. Pinto and R.E. Upshur, 117–128. New York: Routledge. Parsi, K., and J. List. 2008. Preparing medical students for the world: Service learning and global health justice. Medscape Journal of Medicine 10(11): 268.

Petranek, C.F. 2000. Written debriefing: The next vital step in learning with simulations. Simulation & Gaming 31(1): 108–118. Philpott, J. 2010. Training for a global state of mind. Virtual Mentor 12(3): 231–236. Pinto, A.D., and R.E. Upshur. 2009. Global health ethics for students. Developing World Bioethics 9(1): 1–10. Radstone, S.J.J. 2005. Practising on the poor? Health care workers’ beliefs about the role of medical students during their elective. Journal of Medical Ethics 31(2): 109–110. Reisch, R.A. 2011. International service learning programs: Ethical issues and recommendations. Developing World Bioethics 11(2): 93–98. Rudolph, J.W., R. Simon, D.B. Raemer, and W.J. Eppich. 2008. Debriefing as formative assessment: Closing performance gaps in medical education. Academic Emergency Medicine 15(11): 1010–1016. Seifer, S.D. 1998. Service-learning: Community-campus partnerships for health professions education. Academic Medicine 73(3): 273–277. Shah, S., and T. Wu. 2008. The medical student global health experience: Professionalism and ethical implications. Journal of Medical Ethics 34(5): 375–378. Snyder, J., S. Dharamsi, and V.A. Crooks. 2011. Fly-by medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists. Globalization and Health 7: 6. doi:10.1186/1744-8603-7-6. Umoren, R.A., J.E. James, and D.K. Litzelman. 2012. Evidence of reciprocity in reports on international partnerships. Education Research International 2012: 603270. doi:10.1155/2012/ 603270. Unite for Sight. Volunteer ethics and professionalism online course. http://www.uniteforsight.org/internationalvolunteering/. Accessed October 20, 2013. Weinberg, J.L., ed. 2010. Global health ethics in practice [a special issue of the American Medical Association’s journal of ethics]. Virtual Mentor 12(3): 143–252. Ziv, A., P.R. Wolpe, S.D. Small, and S. Glick. 2006. Simulationbased medical education: An ethical imperative. Academic Medicine 1(6): 252–256.

Teaching corner: "first do no harm": teaching global health ethics to medical trainees through experiential learning.

Recent studies show that returning global health trainees often report having felt inadequately prepared to deal with ethical dilemmas they encountere...
255KB Sizes 0 Downloads 13 Views