A Northwestern Medicine study has found that almost 30 percent of healthcare professionals and trainees from high-income countries have performed outside the scope of their clinical and non-clinical training while working or volunteering in low- and middle-income countries, according to a study published in Globalization and Health.
As participation in short-term global health experiences amongst health professionals and trainees has increased, ethical challenges such as professionals performing tasks and services outside of their training have become a common dilemma, according to Ashti Doobay-Persaud, MD, co-director of the Center for Global Health Education at the Institute for Global Health and lead author of the study.
Doobay-Persaud was also an author of an additional correspondence discussing the study, published in The Lancet Global Health.
“Our findings shed a light on the fact that we need to be thinking more about global health professional activities that involve patients and that everything we do in these programs must meet the highest quality and safety standards of practice,” said Doobay-Persaud, who is also an assistant professor of Medicine in the Division of Hospital Medicine and of Medical Education.
The investigators collected a total of 223 survey responses from healthcare professionals and trainees from high-income countries who either worked or volunteered in low- to middle-income countries within the last five years. Participants were asked whether they had performed outside their scope of training during these experiences, their reasons for doing so, and feelings towards the experience.
Survey results showed that half of respondents reported having been asked to perform outside their scope of training. Of these, 61 percent reported following through on such requests. A majority of respondents also repeatedly returned to the same locations to volunteer or work for the short-term.
Additionally, trainees were around twice as likely as licensed professionals to report performing outside their scope of training, with common reasons being inadequate preparation and language training to decline such requests, a mismatch of skills with host expectations, suboptimal supervision at host sites, clinical urgency and a perceived inadequate level of available staff, equipment or resources.
Most notably, the authors found that many of the respondents who reported performing outside their scope of training felt morally distressed, which persisted over time. However, many reported acceptance of the outcome because it was “the best thing that was possible” or “the right thing in the moment,” or was due to a “lack of alternatives,” according to Doobay-Persaud.
In response, Doobay-Persaud suggested that additional efforts must be implemented to improve global health programs, including additional pre-departure training, clearer communication regarding host expectations and consistent disclosure of a physician’s skills to the host, among other recommendations.
“It’s really about the structure of these programs; sending someone who is not familiar with a certain setting and who may not have the necessary or expected skills is setting everyone up for risk and failure,” Doobay-Persaud said. “The scope of training is much, much broader in many other parts of the world for many reasons. We know that the story of global health is one of unintended consequences and ethical challenges and when we look at performing outside scope of training, our goal should be to close the gap between providing necessary care and doing unintentional harm.”
Doobay-Persaud is continuing the research, and next steps include conducting a qualitative analysis of the survey responses to determine the respondents’ level or training and the severity of patient outcomes after performing outside scope of training.
Charlesnika Evans, PhD, MPH, associate professor of Preventive Medicine in the Division of Epidemiology, Susan Sheneman, MD, clinical instructor of Medicine in the Division of General Internal Medicine and Geriatrics, and Josh Goldstein, MD, ’02 GME, associate dean for Graduate Medical Education, were co-authors of the study.