Crossing Boundaries: Mentorship in Global Health

On my first day in the NICU in Malawi, I helped care for an infant who suffered from severe lack of oxygen and trauma due to a difficult birthing process. Before this experience, I had felt ready to work at a Malawian hospital as a pediatric resident. I had taken a tropical medicine course, and my home institution mentor had run simulations and led discussions addressing the practicalities and ethics of practicing medicine within resource-limited settings. But that afternoon, when the infant became apneic, personally experiencing what had only been simulated felt much harder. The 1 available nurse and I performed compressions and manual breaths, but he never recovered spontaneous respirations. My host institution mentor arrived soon after we discontinued resuscitative efforts. With his guidance, I spoke to our patient’s family and witnessed the Malawian expression of grief in the form of wailing songs and prayers. Afterward, he and I discussed questions with which I was struggling, namely, at what point would I be causing more harm than good by continuing to resuscitate this child, knowing the limited long-term care resources available in Malawi? Both home and host institution mentors helped me navigate this clinical situation and process my patient’s death, ultimately enriching my global health (GH) experience and clinical training. Each year, more residents and fellows participate in GH rotations and face similar medically and ethically complex scenarios. Multifaceted mentorship from both home and host institution GH mentors is crucial to ensure success as a foreign physician and trainee.

Trainees working in GH settings have a unique need for proper mentorship to ensure success. In 2015, more than half of US pediatric residency programs offered international experiences and one-quarter of programs offered a GH track; 7% of residents went abroad during the 2013–2014 academic year.¹  Trainees continue to show significant interest in pursuing GH opportunities during subspecialty training, warranting further assistance from institutions to ensure adequate and appropriate mentorship.²  The majority of international experiences outside of a defined track consist of short-term elective rotations, with variable financial, educational, and emotional support for trainees. These rotations improve cultural sensitivity, bolster autonomy, encourage critical thinking regarding resource use, improve diagnostic skills with increased reliance on physical examinations, and broaden exposure to diseases less prevalent in the United States.^3,4 

Implementation of GH rotations has highlighted the lack of funding, constraints set by national accreditation bodies, and the limited number faculty members with sufficient GH experience to provide effective mentorship.³  Of these factors, the latter is most concerning because strong home and host institution mentorship is critical in promoting successful endeavors by the trainee while abroad and concurrently minimizing negative impacts on both the host institution and the trainee. With mentorship, trainees can cultivate meaningful relationships with local providers, treat patients in the context of different cultural and spiritual beliefs, design and implement research or quality improvement projects within the constraints of the host health care system, and teach local learners.⁵  Trainees hoping to achieve these goals require a supportive and seasoned mentorship team to integrate them into an unfamiliar environment, culture, and health care system.

Effective GH mentors require experience in GH settings, enthusiasm for mentoring, and time to engage regularly with trainees. Significant experience working in low-resource GH settings allows the home institution mentor to draw on personal experiences to guide the trainee. These GH mentors are able to provide practical information to help trainees navigate new systems and cultures as foreign physicians while also fostering trainees’ research, advocacy, and education interests. Similarly, finding a host institution mentor skilled in working with foreign trainees proves invaluable because this mentor facilitates introductions and promotes development of relationships within the foreign health care system. With experience, they can identify and mitigate trainees’ clinical biases or limitations. For example, my host institution mentor knew that despite rigorous predeparture training, most US trainees are uncomfortable with diagnosing and managing pediatric diseases common in Malawi, especially within resource limitations and cultural differences. He therefore organized an orientation to introduce us to these topics via a supervised clinical setting before more autonomous encounters. To promote successful GH rotations for trainees, programs must identify home and host institution mentors who ideally have both GH experience and time to regularly meet with mentees.

Home institution mentorship should include predeparture training that covers site-specific topics, simulations and discussions to prepare for common emergencies, and mental health concerns faced by physicians practicing in resource-limited settings.⁶  This training prepares learners for the complex medical and ethical situations bound to arise. In a recent publication, it was noted that almost half of health care professionals working in GH settings were asked to perform duties outside of their scope of training, and of these, 61% did so because of inappropriate host expectations, the lack of supervision at the host site, inadequate preparation in declining the request when asked, and a perceived sense of emergency.⁷  Emotional reactions to these situations range from anxiety and frustration to excitement for perceived autonomy. Unfortunately, negative emotions, such as remorse or guilt, often persist long after the rotation ends. The authors of another recent study reported that trainees who participated in GH experiences demonstrate increased empathy and spirituality; however, there was no improvement in burnout or resilience.⁸  I received extensive clinical and emotional support from my mentors, which I believe prevented burnout for me. Predeparture preparation and host institution orientation help trainees respond appropriately to such situations common in GH, although both mentors are equally important in addressing the emotional reactions these inevitable situations evoke.

Home institution mentors are pivotal in providing and promoting advocacy, policy, education, leadership, and research opportunities for trainees. Meanwhile, for trainees rotating abroad for longer periods of time, host institution counterparts are integral in helping trainees navigate local culture and politics to access other nonclinical career development opportunities. For example, with host institution support, I represented our clinic in national discussions regarding the incorporation of dolutegravir into Malawi’s guidelines for treatment of HIV and AIDS. Additionally, my host institution mentor also helped facilitate relationships with faculty members at the Malawi College of Medicine, leading to the opportunity for me to instruct Malawian medical students during their pediatrics rotation. Opportunities for leadership, advocacy, and education during training, especially within GH contexts, are invaluable, and their availability and success is dependent on host institution mentorship.

For the entirety of my time abroad, I relied heavily on my home and host institution mentors to cope with the many obstacles I encountered. Trainees participating in GH rotations encounter resource limitations, cultural differences, variations in levels of autonomy, and ethical and emotional challenges. An experienced and enthusiastic mentorship team is paramount in helping trainees to overcome challenges and successfully traverse 2 distinct learning environments. As more trainees pursue GH rotations, training programs must provide well-organized mentorship by seasoned mentors at both the home and host institutions. This mentorship team is vital to ensuring GH experiences promote academic enrichment, provide emotional support, and ultimately benefit trainees and host institutions and their surrounding resource-limited communities.

GH

global health