Background
Methods
Survey design
Recruitment and data collection
Quantitative data analysis
Qualitative data analysis
Results
Demographic Description |
n
| % | |
---|---|---|---|
Degreea | MD/DO | 183 | 82.1 |
RN | 8 | 3.6 | |
Physician assistant/nurse practitioner | 8 | 3.6 | |
Other | 24 | 10.8 | |
Medical Disciplinea | Internal or Family Medicine | 62 | 27.8 |
Other specialties | 161 | 72.2 | |
Professional Statusa | Licensed practitioner | 146 | 65.5 |
Trainee | 65 | 29.1 | |
Fellow | 15 | 6.7 | |
Resident | 34 | 15.2 | |
Medical student | 15 | 6.7 | |
Other clinical field | 1 | 0.4 | |
Other | 12 | 5.4 | |
Training Region | North America | 134 | 84.3 |
Other | 25 | 15.7 | |
Latin American/Caribbean | 7 | 4.4 | |
South Asia | 5 | 3.1 | |
Europe and Central Asia | 4 | 2.5 | |
Sub-Saharan Africa | 4 | 2.5 | |
Middle East and North Africa | 1 | 0.6 | |
Unknown | 64 | – | |
STEGH Professional Rolea | Clinical | 191 | 85.7 |
Non-clinical | 32 | 14.4 | |
STEGH World Bank Regiona | Sub-Saharan Africa | 109 | 48.9 |
Latin American and Caribbean | 107 | 48.0 | |
South Asia | 44 | 19.7 | |
East Asia and Pacific | 25 | 11.2 | |
North America | 17 | 7.5 | |
Middle East and North Africa | 12 | 5.4 | |
Europe and Central Asia | 7 | 3.1 | |
STEGH Locationa | Urban | 135 | 60.5 |
Rural | 115 | 51.6 | |
District/village | 91 | 40.8 | |
Peri-urban | 41 | 18.4 | |
Other | 4 | 1.8 | |
STEGH Organization Typea | NGOs and other non-profits | 143 | 64.1 |
University | 99 | 44.4 | |
Governmental | 58 | 26.0 | |
International bilateral, multilateral, and health care foundations | 28 | 12.6 | |
Other | 13 | 5.8 | |
STEGH Care Settinga | Specialty hospital or national referral center | 94 | 42.2 |
Primary level or district hospital | 93 | 41.7 | |
Community health workers in home or village setting | 73 | 32.7 | |
Primary care clinic | 68 | 30.5 | |
Health center or dispensary | 37 | 16.6 | |
Other | 23 | 10.3 | |
Returned to STEGH location | Non-returner (1 trip) | 19 | 8.5 |
Returner (2–5 trips) | 116 | 52.0 | |
Frequent returner (6 or more trips) | 63 | 28.3 | |
No response | 25 | 11.2 |
Requests to perform outside scope of training
“[It] largely depends on the setting. A large academic center in an LMIC with multiple international collaborations, for example, may be better equipped to manage and assign duties to rotating medical students, residents, and faculty without causing an ethical dilemma. However, a site that is severely understaffed with few international connections may ask more of visitors… Out of the various experiences I have had abroad, [being asked to perform outside scope of training] was most apparent at a small, rural clinic in [Country A]. During my time at a large hospital in [Country B], however, I rarely had the problem arise.” (Allopathic medical student)
Survey Question | Response | n/N | % |
---|---|---|---|
How often do HIC professionals perform clinically beyond their scope of training? | Always | 4/223 | 1.8 |
Frequently | 81/223 | 36.3 | |
Sometimes | 75/223 | 33.6 | |
Infrequently | 48/223 | 21.5 | |
Never | 15/223 | 6.7 | |
Do you believe it is appropriate for HIC-trained clinicians to perform beyond their scope of training? | Yes | 13/223 | 5.8 |
No | 65/223 | 29.2 | |
It depends | 123/223 | 55.2 | |
No response | 22/223 | 9.5 | |
Were you ever asked to perform clinical activities beyond your scope of training? | Yes | 109/223 | 48.9 |
If yes, number of times:
| 1–3 | 39/105 | 37.1 |
4–10 | 31/105 | 29.5 | |
> 10 | 35/105 | 33.3 | |
No response | 4/109 | 3.7 | |
Did you ever perform clinical activities beyond your scope of training? | Yes | 67/109 | 61.4 |
If yes, number of times:
| 1–3 | 27/64 | 42.2 |
4–10 | 19/64 | 29.7 | |
> 10 | 18/64 | 28.1 | |
No response | 3/67 | 4.5 | |
Why do you feel you were in a situation or situations in which you practiced clinically beyond your scope of training? (May select more than one answer.) | |||
My training did not match my host’s expectations | 25/67 | 37.3 | |
I had an inadequate level of supervision in-country | 14/67 | 20.9 | |
I was inadequately prepared to decline practicing beyond my scope of training | 13/67 | 19.4 | |
I perceived an inadequate level of available staff, equipment, or resources | 9/67 | 13.4 | |
I overestimated my own capabilities | 5/67 | 7.5 | |
I wanted to be able to perform a procedure/technique I was not very familiar with | 5/67 | 7.5 | |
I did not seek adequate assistance when I needed it | 1/67 | 1.5 | |
Other | 13/67 | 19.4 |
Category | Asked to Perform Outside Scope of Training % (n/N) | Did Perform Outside Scope of Training % (n/N) | Believes it is or could be appropriate to Perform Outside Scope of Training% (n/N) | |
---|---|---|---|---|
Total | 48.9 (109/223) | 54.3 (57/105) | 61.0 (136/223) | |
Degree | MD/DO | 48.1 (88/183) | 60.0 (51/85) | 62.8 (115/183) |
Others | 52.5 (21/40) | 80.0 (16/20) | 52.5 (21/40) | |
Medical Discipline | Internal or Family Medicine | 45.2 (28/62) | 59.2 (16/27) | 62.9 (39/62) |
Other Specialties | 50.3 (81/161) | 65.4 (51/78) | 60.3 (97/161) | |
Professional Status | Licensed practitioner (MD/DO) | 44.7 (59/132) | 50.9 (29/57) | 68.9 (91/132) |
Resident/Fellow | 55.1 (27/49) | 80.8 (21/26) | 49.0 (24/49) | |
Medical student | 66.7 (10/15) | 100.0 (10/10) | 53.3 (8/15) | |
Other | 48.2 (13/27) | 58.3 (7/12) | 48.2 (13/27) | |
STEGH Professional Role | Clinical | 52.9 (101/191) | 63.9 (62/97) | 64.9 (124/191) |
Non-clinical | 25.0 (8/32) | 62.5 (5/8) | 37.5 (12/32) | |
STEGH Location | Urban | 42.2 (57/135) | 59.7 (34/57) | 65.2 (88/135) |
Rural | 45.2 (52/115) | 65.4 (34/52) | 73.0 (84/115) | |
District/Village | 46.2 (42/91) | 59.5 (25/42) | 67.0 (61/91) | |
Periurban | 43.9 (18/41) | 61.1 (11/18) | 53.7 (22/41) | |
STEGH Organization Type | NGO or non-profit | 45.5 (65/143) | 63.1 (41/65) | 69.9 (100/143) |
University | 39.4 (39/99) | 64.1 (25/39) | 59.6 (59/99) | |
Government | 55.2 (32/58) | 59.4 (19/32) | 62.1 (36/58) | |
International bilateral | 33.3 (4/12) | 50.0 (2/4) | 66.7 (8/12) | |
Foundation | 27.3 (3/11) | 66.7 (2/3) | 90.9 (10/11) | |
Multilateral | 0.0 (0/5) | 0.0 (0/0) | 100.0 (5/5) | |
STEGH Care Setting | Specialty hospital or national referral center | 45.5 (43/94) | 65.1 (28/43) | 63.8 (60/94) |
Primary level or district hospital | 47.3 (44/93) | 70.5 (31/44) | 65.6 (61/93) | |
Community health care setting | 35.6 (26/73) | 53.9 (14/26) | 71.2 (52/73) | |
Primary care clinic | 50.0 (34/68) | 67.7 (23/34) | 76.5 (52/68) | |
Health center or dispensary | 43.2 (16/37) | 56.3 (9/16) | 67.6 (25/37) | |
Returned to STEGH Location | Non-returner (1 trip) | 52.6 (10/19) | 60.0 (6/10) | 73.7 (14/19) |
Returner (2–5 trips) | 40.5 (47/116) | 53.2 (25/47) | 65.5 (76/116) | |
Frequent-returner (6+ trips) | 49.2 (31/63) | 74.2 (23/31) | 69.8 (44/63) |
Engaging in POST
Perceptions about appropriateness of and reasons for POST
“When there are no alternative providers and the situation clinically requires it, it may be the only option available to a patient.” (Licensed MD, Internal Medicine).
“For elective cases without imminent danger, clinicians should not practice beyond their scope. However, in emergencies, there may be no other alternative. This constitutes a more challenging ethical scenario.” (Resident MD, General Surgery).
“Sometimes there are situations that cannot be controlled. If someone is near death on the side of a road, for example, we would not blame a layperson for attempting to help.” (Allopathic medical student).
“Risks and benefits of providing care beyond the scope of training needs to be well accounted for. If there are other providers who are appropriately trained to provide that care, then HIC-trained clinicians should not go beyond their level of training to offer a certain care. However, if the alternative to offering this care is a high risk of an adverse health event, then I believe it is appropriate for any clinician to do their best in caring for patients as needed.” (Resident MD, Internal Medicine).
“HIC-trained clinicians often underestimate the capacity and availability of physicians in LMIC settings. They also often fail to completely understand the cultural and structural aspects of the medical systems within these settings.” (Resident MD, Obstetrics/Gynecology).
“[Visiting clinicians] need to consider urgency of situation and alternatives. Often the person from the HIC is not in the best position to judge this without understanding environment, culture, language. So such decisions should not be taken lightly.” (Licensed MD, Family Medicine).
“For trainees, it is where to draw the line with what constitutes adequate supervision when allowing the resident to operate. For professionals in general it is when to say ‘no’ to an operation that may be outside of a surgeon’s comfort level or one that is made riskier by the constraints of the environment.” (Resident MD, General Surgery).
“Local understanding of limited scope—the sense that just because I’m a doctor doesn’t mean that I can fix everything or see every kind of patient.” (Licensed MD, Pediatrics).
“[When working abroad,] I sometimes performed beyond my scope of training in the U.S. but in accordance with what my scope of training would be expected to be in the country I was in.” (Resident MD, Pediatrics).
Reactions to and sentiments about POST
Emotion | Illustrative Quote | Respondent |
---|---|---|
Anxiety | “I was anxious. There seemed to be no easy answer of what was the best thing to do.” | MD Fellow, Internal Medicine and Pediatrics |
Frustration | “I felt overwhelmed by the responsibility, terrified I was going to give suboptimal care that could result in death, and angry/frustrated that I was in the position of providing care beyond my scope or not providing care to these infants.” | Licensed advanced practice provider, Obstetrics/Gynecology |
Discomfort | “It is uncomfortable. You have years of training and are often looked to as the expert, but in reality, you have not been training in such activities and do not have the skills to complete such tasks. You don’t want to stand by and do nothing, but at the same time you don’t want to do more harm than good. I am often left feeling incredibly inadequate and inept.” | MD Fellow, Pediatrics |
Remorse | “If I didn’t do something, the patient would have a worse outcome. Something was better than nothing… I don’t regret it, but I wish it ended differently, since the patient died.” | MD student |
Excitement | “Excited… Everybody should be exposed to such challenges especially in LMICs.” | Licensed MD, Plastic Surgery |
Conflicted | “Torn. On one hand, not appropriate. On the other hand, if I didn’t do it, who would?... [I felt] bad. It was unfair to the patients.” | MD Fellow, Obstetrics/Gynecology |
“[I was] asked to perform an arthrocentesis on a patient when this was not a skill I had previously performed. I did so due to a lack of alternate providers.” (Licensed MD, Internal Medicine).
“Working outside your usual scope of practice [occurs] because there are limited specialists or referral options.” (Licensed MD, General Surgery).
“I had to attempt to perform a pars plana vitrectomy as a last-ditch effort to save the eye, as our retina surgeon was back in the U.S. on furlough and the patient wasn’t willing to go to the capital city four hours away... I was not successful in saving the vision. While I think the bad outcome of this was set regardless of whether I did something, did not do something, or whether I sent the patient to the capital city or not, I felt very out of my comfort zone.” (Licensed MD, Ophthalmology).
“Sometimes I have to reach back to medical school training and improvisation to get some things done. I see and do a greater variety of clinical scenarios when overseas but still feel like I am relying on past training when I commit to treatment/intervention. Occasionally I have felt pressured to make clinical decisions that I felt underprepared to make—usually due to the combination of the patient scenario and lack of info/diagnostics that would be helpful.” (Licensed MD, Pediatrics).
“As an internal medicine resident, I saw and cared for children... Both myself and the attending did not have training apart from medical school in pediatrics.” (Resident MD, Internal Medicine).
“[A challenge is] providing a meaningful experience for the students that will encourage them to speak positively about the program (to ensure continuation of the program) without subjecting the populations in the LMIC setting to undue harm. Often there is less concern in the general population of these areas for clear consent and patient self-advocacy, so pre-med students are often presented as higher ranking or more knowledgeable than they actually are.” (Allopathic medical student).
“Too often professionals or trainees feel obligated to provide clinical care based on their own standards and cultural norms that are either out of proportion or not aligned with local customs and practices, misuse local resources, or [are] out of the realm of their scope of practice to feel good about themselves helping patients who are in need of care. Instead, their efforts, energy, and resources could be directed at improving the clinical skills and capacity of local infrastructure to provide the same level of care they wished was being done so many more could be helped within the confines of the local health system, according to cultural practices and prioritize the local resources appropriately.” (MD Fellow, Pediatrics).