Abstract
Links between healthcare teams in high-income (HIC) and low- and middle-income countries (LMIC) have long provided a vehicle for medical training and equipment supply. Every link has its own approach, with mixed results – some form an excellent model for development, others less so. 1
Ethical considerations are inevitably a focus of these relationships, especially with specialty trainees. Short-term placements involving trainees in HICs travelling to LMIC settings are increasingly popular. 2 However, there is a body of international concern over the potential negative impacts on hosting communities. 3 This is especially the case with surgical specialties, where the potential for harm is most obvious.
These concerns come at a time when the unmet need in global surgery is most evident. In 2015, the Lancet Commission in Global Surgery reported that nine of ten people in LMICs cannot access basic surgical care and that ‘to meet present and projected population demands, urgent investment in human and physical resources for surgical and anaesthesia care is needed’. 4
Experienced independent clinicians in HICs may offer more to personnel-limited LMIC settings than their trainees. However, time and enthusiasm for placements in LMICs is invariably greater earlier in one’s career and HIC training programmes are easier to take a break from than substantive consultant posts. Inevitably, the later a LMIC placement is left in life, the less likely it is to happen.
So how can trainees respond to the Lancet Commission’s rallying cry?
First, keep the fire burning. Trainees should engage with, but not be put off by, the ethical considerations of placements in LMICs. These inevitably come with risk, but there is also the huge potential to be a blessing to the hospital and community one serves. The skilled, sensible trainee always has something to offer.
Second, pick well. It is more appropriate for a trainee to join a larger more established surgical service than lead a rural team in their first overseas experience. Equally, trainees would do well to select a location where they are truly needed to help meet a personnel shortage, rather than tread on the toes of local trainees.
Third, enlist support from home. The financial implications of an extended unpaid placement abroad are obvious and could be covered with fundraising efforts. Identifying a mentor or educational supervisor with previous LMIC experience ahead of the trip will undoubtedly help a trainee’s personal development and reflection.
Fourth, be patient. The best quality of care offered in a new LMIC setting may not become clear until several months into a placement. Be gentle and respectful to your local colleagues who have worked hard in resource-limited settings for their entire careers.
Fifth, fulfil local needs. While some LMIC settings require hands-on clinicians providing clinical care, many would benefit more from capacity building. Focusing on delivering training or a research and development project means a trainee is more likely to leave an institution better off and will also discourage an institution’s reliance on transitory foreign staffing. Such a project will require careful advance planning and be guided by the requirements of local clinicians, whose input must be recognised in any resulting publications.
Clinicians in LMICs describe a successful visiting trainee as possessing humility, insight and a recognition that cultural differences in healthcare are equally, if not more important, than the clinical. 5 A successful trainee will follow local and national guidance, 6 know that their natural ability is no better than their LMIC colleagues 7 and offer a collaborative approach to local problem solving in a smart, measurable and achievable fashion.
As economies in LMICs develop, the hope is that their healthcare systems will strengthen and rely less on foreign aid. But for today, as we build international relationships to help the world’s poor here and now, the African proverb holds true: If you want to go fast, go alone. If you want to go far, go together.
