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Rules of Engagement: Best Practices for Trainees on Short-Term Medical Trips

  • May 8, 2018
  • Blog
Stephen P. Merry, MD, MPH, DTM&H, Chair, Mayo International Health Program, Consultant, Department of Family Medicine, Assistant Professor, College of Medicine, Mayo Clinic

Stephen P. Merry, MD, MPH, DTM&H, Chair, Mayo International Health Program, Consultant, Department of Family Medicine, Assistant Professor, College of Medicine, Mayo Clinic

Dr. Merry is an assistant professor of family medicine, and chair of the Mayo International Health Program, advises the enterprise on underserved health care at Mayo Clinic, Rochester, and serves on the boards of two NGO’s involved in health care in Africa. After residency, he received a masters with concentration in international health at Harvard School of Public Health and studied tropical medicine at the London School of Hygiene and Tropical Medicine. He spent some years teaching medical school and practicing full-spectrum medical, pediatric, and essential surgical care in East and West Africa as well as in the rural U.S.

Informed of global health disparities and compelled by altruism and an ethic of social justice, most health professional trainees today enter their training programs with a desire to be involved in global health and provide compassionate care for the medically underserved.  While they most desire experiences (e.g., caring for the underserved in their own community and travelling to resource limited settings in low income countries – LIC), preparation is required for them to help, heal and avoid harm.

Goal: Education and Capacity Building

All global health work should be evaluated by principles of service, sustainability, professionalism, and safety while ensuring reciprocity – providing a net benefit to well-defined sites where the cost of learners’ education is exceeded by the gain of the local health system and community.(Wilson, Merry, & Franz, 2012)  Sites should ideally be designated locations where the learner’s home institution is building capacity through an asset-based community development partnership.  Education (particularly “train the trainer” activities)(Wilson, Merry, & Franz, 2013), research, and clinical care should be provided there by visiting staff in a collegial fashion, led by local health care professionals, with a goal of strengthening their health system, all while promoting human dignity and the value of each life and maintaining a focus on beneficence – the primacy of the care of the individual patient.  Short-term surgical or medical trips which create dependence or adversely alter the local health care economy rather than foster its autonomy should be eschewed.

Goal: Preparation and Cultural Competence

Learners should thoroughly prepare for any international trip. Their pre-trip study should include comprehensive global health learning relevant to their planned location and field of study including the above principles, care of common diseases of poverty, local health practices, cultural beliefs about disease causation, the local process of medical decision making, and the structure of the local health system.  These may be studied through didactics, modular self-learning courses, case studies, peer-led seminars, journal clubs, and discussions with mentors.  Learners should adopt an attitude of humility, flexibility, and kindness about “the local way” of doing things given the resource limitations and resultant diagnostic and treatment protocols that may differ widely from what they’ve learned is “the right way”. Simulations or discussions which challenge the trainee to wrestle with the high prevalence of death, particularly of children presenting with curable diseases in a well-resourced environment, may help them prepare for the strong emotions many experience in a LIC, resource-poor, hospital setting.

Goal: Continuity of Care and Partnership

Trips should be planned to assure adequate supervision and mentorship by a licensed, competent health care provider who is present to teach, answer questions and provide assistance.  Continuity of care provided by the visiting trainee or team will be assured by always working in partnership with an existing health care provider(s) at the host site. The ideal site host is someone who expects the learner to work within their fund of knowledge, clinical competencies and skill sets while developing their autonomy and professional confidence.  Informing that mentor of their intended role will augment their teaching and stature.  While medical knowledge may be an obvious main goal, the trainee should take any opportunity to live in community with the poor and underprivileged while ensuring reasonable safety. Trip security requires prior planning.  Detailed review of the location’s security limits risk while avoiding surprises and reducing sending institution liability.  Requiring all trainees to visit a travel clinic assures up to date vaccinations, malaria prophylaxis, and availability of HIV prophylaxis when appropriate.

Goal: Benefit to Host Institution

The educational impact of the rotations on learners and impact of the learners on the sites must be monitored.  The benefits for the learner and indirectly for the learners’ home society are substantial.  International health rotations appear to increase cultural competency, enhance idealism, stimulate interest in primary care, improve clinical skills, increase commitment to working with the medically underserved, increase medical knowledge and patient care skills of diseases of poverty, increase cost consciousness, and decrease reliance on expensive technology.(Sawatsky, Rosenman, Merry, & McDonald, 2010)  The benefits for the host are not always apparent. The sending institution should be encouraged to work towards equity particularly in light of the resource poverty and health care disparities pre-existing in all LIC, and seek to surpass a zero sum gain by ensuring that the time and resources spent by the host institution on educating the trainee is reciprocated by an even greater benefit of being in partnership with the sending institution.



Sawatsky, A. P., Rosenman, D. J., Merry, S. P., & McDonald, F. S. (2010). Eight years of the Mayo International Health Program: what an international elective adds to resident education. [Research Support, Non-U.S. Gov’t]. Mayo Clinic proceedings, 85(8), 734-741.

Wilson, J. W., Merry, S. P., & Franz, W. B. (2012). Rules of engagement: the principles of underserved global health volunteerism. The American journal of medicine, 125(6), 612-617.

Wilson, J. W., Merry, S. P., & Franz, W. B. (2013). The reply. [Comment

Letter]. The American journal of medicine, 126(3), e17.