TABLE 2

Preparation Themes Identified in the Literature and Examples of Recommendations to Address Those Themes

Preparation Recommendations in the Literature
Logistics and safety
 Personal health (physical and mental)Review basic and site-specific health precautions related to international travel and working in different clinical settings (eg, malaria prophylaxis, water and food safety, postexposure prophylaxis, occupational exposures, recreational exposures [including sexually transmitted infections], pretravel immunizations, and health insurance).3,6,9,46,109,110
Consider personal medical and psychiatric history, because exacerbations of physical and mental illness are common during GH experiences.3,6,9,37,109
 SafetyResearch safety issues and travel warnings pertinent to the host site.4,6,9,13,14,109,111
Create strategies for risk reduction, including for transportation, environment, food, risk-taking behaviors, and recreational activities and emphasize that local laws (eg, seatbelts, restricted areas) apply to all visitors.6,9,14,46,55,109,111 If applicable in the training institution or partnership, consider signing a risk reduction agreement.112
Identify emergency contacts, register with the local embassy, enroll in the Smart Traveler Enrollment Program, and develop an evacuation plan (including evacuation insurance) in the event of a natural disaster, political unrest, or personal emergency.3,6,13,14,109,113
Recognize the importance of personal protective equipment (PPE), even in areas with resource limitations, and pack PPE supplies.6,9,13,14,109
Review pertinent guidelines regarding occupational exposures, such as needlesticks.3,6,9,13,14,109
Share in-country travel plans and emergency contacts with the host institution.112
 Travel logisticsIdentify passport, visa, and customs requirements.6,9,14,111
Arrange in-country transportation, money exchange plans, phone and internet communication, and housing (including alternative options).3,4,9,13,111
Pack appropriate supplies.4,6,13
 Medical licensureContact the host site and the government to determine what is required for licensure, work visas, and registration to provide clinical care.13,14
 Malpractice insuranceDetermine personal malpractice coverage while working internationally and find in-country insurance recommendations.114,115
Knowledge and skills
 Medical knowledgeParticipate in a comprehensive, longitudinal curriculum that addresses the diagnosis and management of common illnesses encountered in resource-limited settings (particularly diagnoses endemic to the region of interest).2,911,13,37,46,55,95,96,109,116,117
Seek educational opportunities that improve knowledge, attitudes, and skills pertaining to the interprofessional GH competencies.7,11
Identify local factors that may influence the epidemiology of diseases in the host population (eg, water sanitation, vector-borne illnesses, etc).37,46
Familiarize oneself with local disease patterns, reference materials, on-site formularies, and clinical practice guidelines, including resources available through the World Health Organization.4,14,37,46,118,119
If engaging in humanitarian disaster response efforts, review the Sphere Project Humanitarian Charter and Minimum Standards in Humanitarian Response.108,120
 Health systems knowledgeSeek an overview of core concepts in preventive health, public health, and health development, particularly if engaging in humanitarian disaster relief.9,37
Engage in local advocacy efforts to reduce health disparities.2,37
Familiarize oneself with the host site health system’s organization, standard practices, resources, and challenges.9,96
 Procedural and practice skills (if applicable)When applicable, refresh procedural skills for tasks that may be expected at the host site (eg, phlebotomy, intravenous line placement, lumbar puncture, etc).37
Refresh general practice skills (if normally practicing as a subspecialist), given the likelihood of needing a wider breadth of competency in resource-limited settings.37
Use simulation, case-based, and video-based modules that highlight creative approaches to diagnosis and management in resource-limited areas.2,37,96,109,121
Attitudes and behaviors
 Personal motivationsEncourage introspection regarding personal motivations for engaging in GH experiences, and discourage participation if paternalistic attitudes prevail and/or individuals plan to practice outside of their scope of expertise without appropriate supervision.12,13
 Learner humilityRecognize that learning and teaching styles may vary significantly in different cultural paradigms, that host time for teaching is often limited, and that visitors may place a burden on host time and productivity.4,14,122
Embrace the “observer” role during a GH experience, particularly for trainees and/or if requested by the host institution, and prioritize the needs of local trainees.12,13,43
Respect the depth of understanding that local health care professionals have of the local health care system, resources, diagnoses, and challenges.4,12,14,46
 Cultural humilityRecognize that behaviors, skills, and competencies of local providers are culturally based and resource-dependent, avoiding comparison with home institutions, superior or judgmental attitudes, or denunciations regarding differences in clinical care.4,6,12,14,46,96
Seek training in cross-cultural communication and culturally appropriate norms (eg, for interactions, personal dress, patient privacy, and personal conduct within and outside of the clinical setting).14
 Understanding of culture shock and reentry shockGain a basic understanding of culture shock.6,13,109
Schedule a postreturn debriefing with trusted mentors or colleagues to discuss the experience and the reentry.3,6,14,37,111
 Professionalism and behaviorRecognize that professionalism paradigms may be defined by culture, and perceptions of professional versus unprofessional behavior may differ. Identify strategies for navigating differences in professional behaviors, particularly pertaining to patient care and communication.14,43
Inquire about cultural norms for patient-clinician and clinician-clinician interactions.3,14,92
Consider signing a professional code of conduct (if applicable).3,6,13,46,50
Local resources
 Clinical resourcesFamiliarize oneself with the host site formulary, laboratory supplies, radiology capabilities, medical technology, medical transportation services, patient costs, and patient payment models before departure to best inform adaptations in diagnostic evaluations and management.2,37
 Human resourcesEstimate staffing at the host site, including the nurse/patient ratios, number and types of subspecialists (if applicable), level of training and roles of different providers, presence of trainees, etc.123
 Needs and assetsEngage in discussions with host personnel before departure to determine if there are specific projects or initiatives for which they are seeking one’s involvement and identify and/or clarify specific expectations.4
People
 History, politics, and economicsResearch the general history, political structure, and economic situation of the destination country and surrounding region.2,9,1214,37,109,111
Familiarize oneself with local laws.14,111
 CultureResearch local culture, health beliefs, and customs.2,4,6,9,13,14,37,96,109
Meet with people from the host country and/or people who have previously worked there.2,4
Identify potential risks associated with discrimination in-country for visitors (including sex, race, religious beliefs, disabilities, and sexual orientation).2,6,12,13,37,109
 ReligionFamiliarize oneself with local religions and associated practices.6
 Local health beliefsInquire about traditional medical practices and beliefs in the region.109
 LanguageDetermine the language(s) used at the host site and attempt to gain basic communication skills pretravel when feasible.4,9,13,14,96,109
Arrange plans for interpreter services during the visit, if needed, and recognize burdens imposed on local health professionals when assisting with interpretation.13,14,109,111
Seek training on how to effectively work with an interpreter.109
Ethics
 DonationsCommunicate with the host site before gathering and bringing donations to determine what is desired and/or needed.4
Follow host institution guidelines and accepted international guidelines regarding the donations of medications, technology, and supplies.14,124,125
Familiarize oneself with local fee-for-service models and, if compelled to assist patients with personal donations, work with the local institution to ensure that the donor source is anonymous to avoid setting precedents and undermining local staff.126
 Research and projectsObtain both home and host site approval for all research- and project-based initiatives.2,4,6,14,37,43,46,109
Ensure that plans for projects, research, presentations, and articles recognize contributions from international partners, including authorship, when applicable.14
 Patient privacyUphold standards for patient confidentiality and patient photography that are similar to the standards at one’s home institution, including regarding the use of patient information in online media and during presentations on return.14,37,46
 Patient care with resource limitationsReview case scenarios pertinent to the care of patients with resource and health system limitations and recognize ethical dilemmas inherent in practicing medicine in similar settings.13,14,37,50
 Scope of practiceApproach all patient care encounters with the principle of “first do no harm,” particularly in the setting of unfamiliar diagnoses, differences in scope of practice, high or emergent acuity, and limited resources.9,14,43,109
Clearly communicate one’s level of training (before and during the visit), identify roles that one will play (eg, observer versus clinical provider), and practice within one’s scope of expertise.2,3,6,9,1214,37,43,46,109
Disclose one’s level of training to patients with the same transparency as is used at one’s home institution.43
 SupervisionEnsure that appropriate administrative and logistical support and supervision is available for trainees during GH electives without diverting supervisory resources from local trainees.24,9,1214,37,46,109,111
 SustainabilityWhen making patient care decisions, ensure that interventions are appropriate to local context and will have sustained care and follow-up.8,95
 Impact on hostsEstablish supervisory and hosting agreements that recognize the burden that visiting health care providers place on hosts and offer appropriate compensation.3,9,14,46,96,109,111
Choose a visit time and duration that is tailored so that the burden to the host is minimized.14,96,111
Communication
 Predeparture, on-site, and postreturn communicationEstablish plans for routine communication, both with the traveler and, if applicable, between institutional partners.2,3,6,13,14,37,109
Create an access line at the traveler’s home institution for trainees and clinicians to contact in the event of an emergency.6,109
Identify host personnel who are available to discuss situations of concern or conflict, both for the visitor and pertaining to the visitor.2,6,14,109
Schedule a meeting with the returning traveler to assess traveler wellness, provide an opportunity for debriefing of the experience, obtain input on the program or partnership strengths and weaknesses, and determine the impact of the experience on clinical practice and career plans.2,3,6,14,37
Partnerships
 Choosing opportunitiesResearch GH opportunities and attempt to engage in experiences that are part of sustained, mutually beneficial partnerships that have explicit agreements pertaining to institutional and individual roles and responsibilities.2,4,14,37,109,127
Communicate with the host site to determine if they are amenable to visiting trainees or clinicians and if there is an appropriate fit between the host expectations and the visitor’s goals and areas of expertise, including an infrastructure for supervision when applicable.2,14,109
 Predeparture selection processesEncourage application processes for GH experiences, including a query of goals and objectives. Select providers whose skill sets are appropriate for the site and who are adaptable and demonstrate cultural sensitivity and humility; discourage participation for those with paternalistic attitudes and/or those seeking to practice outside of their scope of expertise.2,3,9,1214,37
 Clear expectationsProvide transparent goals and objectives (visitors and sending institutions) and ensure that the host institution has an opportunity to review them and modify them if necessary.9,14,109
In mutually beneficial partnerships, ensure that all parties have a clear delineation of roles and responsibilities, including sending institutions, host institutions, and visitors, with terms outlined in a memorandum of understanding.14
 EvaluationEncourage venues to provide the visitor with ongoing and timely feedback regarding performance, issues, or concerns.6,14
Complete evaluations of the experience if requested by the host site, the partnership, and/or the training institution.4,6,9,14,109
Use debriefing sessions as an opportunity to obtain feedback and inform others of changes for training partnerships.2,6,14,55,111
Develop regular opportunities for partnerships and programs to participate in joint or mutual evaluation, review of agreements, and improvements.6,14
  • Themes were obtained from a collective literature search performed by all authors pertaining to preparation recommendations for providers across all specialties. PPE, personal protective equipment.