AMA Journal of Ethics^®

Abstract

Service learning trips can be a powerful means of fostering cultural competency as well as an opportunity for students to expand their clinical skill set. However, if not planned and executed thoughtfully, they might not provide lasting benefit to the communities they seek to serve. Through analysis of a case in which participants question the value of their short-term international service learning trip, we argue that such trips should be designed with the community’s needs in mind, preferably as identified by the community. Ideally, both the service group and the community should seek opportunities for teaching and exchange in order to expand the community’s ability to provide care to the local population long after the service learning group has left.

Case

RM decided to sign up for a spring break service learning trip to a Central American country with a team of 40 dental, medical, nursing, occupational therapy, and pharmacy students and 2 faculty members from each of those disciplines. Inside a local school, they set up a 3-day free clinic. For most members of the community, this clinic is the only one available to them throughout the year where they can receive allopathic care, so the team encountered many acute illnesses and advanced pathologies rarely seen in the United States.

The trip was a success as defined by the trip organizers, and, upon returning, RM reflects on the trip with fellow students, who agree that the opportunity was positive and life changing for them. Some students, however, also shared the same nagging feeling of worry about doing things in an international setting that they would not be allowed to do domestically. RM notes, for example, “We would not have been able to work as independently or perform the same examinations on patients here, and it doesn’t quite seem fair to the patients there. We not only are inexperienced and might have missed important things, but we can’t follow up with them, either. One often hears, ‘Well, some care is better than no care,’ but I actually don’t find that very satisfying. We get so much out of these experiences and they get student care—a standard of care below what we’re taught to deliver here, with no follow-up and no health care infrastructure development. In fact, we benefit from their lack of health care infrastructure; it allows our school and us a reason to do a service learning trip once a year. It just doesn’t feel like a just exchange, and I worry about my complicity in perpetuating it.”

Commentary

Shortly after graduating from college, the first author participated in an 8-week volunteer trip abroad with a small nongovernmental organization to gain some real-world experience abroad while also figuring out a future career path. The work involved a variety of activities including, but not limited to, assisting in school classrooms, shadowing and participating in the care of patients in a small community clinic, restocking pharmacy shelves, and helping to examine patients with acute issues at a community outreach clinic. The experience was eye opening, allowing a glimpse of what it meant to practice in a resource-poor setting and how health care disparities impact access to adequate care. It was valuable even for someone who, at the time, had limited skills and understanding of the local cultural and political context and who had nothing concrete to offer the local community other than a bag of donated medical supplies collected prior to the trip. For it was this experience that solidified the first author’s decision to attend medical school and ultimately fueled her desire to pursue a career in public health. The trip revealed large gaps in her knowledge and her lack of awareness of the complexities involved in global health work. While the trip was of great personal benefit, it might have had little, if any, beneficial impact on the community.

Multiple studies have identified medical students’ growing interest in training in international settings as driving an increase in short-term global health trips and so-called medical missions,^1,2 which have numerous benefits. These trips have potential to broaden the education of medical trainees by increasing their cultural competence and providing them with valuable insight into health inequities, the social determinants of health, and population-based health.¹ Additionally, medical students might see such trips as an opportunity to expand their clinical skill set and diagnostic acumen and increase their exposure to less common medical conditions and disease states.² Furthermore, evidence suggests that students who participate in these trips are more likely to pursue primary-care based specialties, express a desire to work with underserved populations, and address health inequities.^2,3

Although the growing interest in global health has been accompanied by an ever-expanding list of global health resources, guidelines, and literature to help guide students and schools in designing global health curricula, students are still unprepared. Often these trips occur between medical students’ first and second years of training (the only available summer break in most curricula). At this time, students are only beginning their medical training and have not yet honed their diagnostic skills or had sufficient exposure to common (or uncommon) disease states. Medical students are enthusiastic about their opportunity to serve vulnerable populations and work in underserved parts of the world; however, they must be honest about their limitations—be they clinical, cultural, or communication related.^3,4,5

This essay will explore ethical issues raised by service learning trips, including potential harms to both student volunteers and the communities they serve. We will also discuss how these ethical issues can be addressed by creating formal global health curricula, oversight by medical school accreditation bodies, and reframing service learning trips to focus less on direct clinical care and more on population health, education, and community outreach. 

Ethical Issues Raised by Service Learning Trips

A number of articles highlight beneficence, nonmaleficence, and justice as guiding principles for designing global health trips in a thoughtful and ethical manner.^1,5,6 Even in resource-poor settings, the same ethical principles that apply to providing health care in the United States should be applied. If programs are not implemented in a thoughtful manner, they run the risk of exploiting local populations and creating moral distress for medical trainees faced with ethical dilemmas who might not have adequate training for dealing with such situations.^1,4,5

Exploitation of the community. There is a potential power imbalance between volunteers from socioeconomically developed countries and the lower-income communities they serve that could very easily lead to an exploitative relationship.^4,6 This power differential allows inexperienced health care learners more freedom for clinical decision making despite their level of training² and can foster a false sense of competence on the part of the learner. Additionally, global health volunteers have the potential to impact the local health care system in which they operate. Reliance on volunteers can undermine the community’s faith in local health care professionals due to a misconception that foreign volunteers provide superior care or resources that the community might not otherwise be able to access. Furthermore, it can result in failure of local government to invest in the health system.^3,4,5,7 In a health system in which resources are already strained, local governments might come to rely on foreign volunteers to provide health care for their communities rather than invest in health care resources themselves. While foreign volunteers are seemingly a solution to the problem of scarce resources, failure to invest in sustainable health infrastructure that provides care to a community even in the absence of volunteers can exacerbate health inequities.

Learners’ moral distress. In the case presented, students felt conflicted about the clinical independence they asserted, the quality of care they provided, and whether their presence was beneficial. Multiple studies have documented moral distress on the part of learners who are unprepared for the ethical dilemmas they face in the field as a result of suboptimal global health education, lack of understanding of the local social and political context in which they operate, and failure on the part of schools to provide a formal educational structure to discuss such challenges.^1,3,5 The student RM in this case notes a “nagging feeling of worry” that the students operated outside their scope. At best operating outside one’s scope leads to suboptimal care of patients; at worst it leads to negative clinical outcomes. The negative feelings of students are worth highlighting, as they can motivate conversations about ethical problems inherent in short-term global health experiences and how to address and even prevent them.

Creating a Global Health Curriculum

Creating a more formalized global health curriculum, of which short-term global health experiences are only one component, can provide students with a framework to support quality care for the local community in an ethical manner.⁷ Ideally, training in the social determinants of health, health disparities, cultural sensitivity, health systems, and population health^1,4 would provide medical students with information regarding the social and political context of the community they are traveling to and enable them to participate in discussions about potential ethical dilemmas they might face. Language training would also be beneficial.^1,3,5,6 Furthermore, as part of the formalized global health curriculum, ethical commitments should be structured into global health experiences.⁷ Schools need to ensure that students have adequate supervision so that they do not operate beyond their scope and that they have the necessary support when ethical dilemmas arise in the field.^3,4,5,7 Moreover, having clearly delineated roles for and expectations of students, faculty, staff, and members of the local community is crucial to ensuring that service learning trips are executed in a thoughtful and ethical manner.^3,4,5,6,7

In addition to being part of a standard framework, short-term global health trips should adhere to standards put forth by medical school accreditation bodies to ensure that they are conducted in an ethical manner. Although the Association of American Medical Colleges provides a number of resources for medical students pursuing electives abroad,⁸ there is currently no universal set of guidelines that we know of governing service learning trips.⁹ As education about global health and working with underserved populations becomes incorporated into more medical school curricula, it should be evaluated and governed by the same standards that apply to the rest of medical student education.¹⁰

Reframing Service Learning Trips

These proposed curricular changes, in concert with designing trips with the needs of the host community in mind, can require medical schools and their students to reframe the way they look at short-term global health experiences. Creating trips that focus more on health education, health systems, and population health would eliminate the problems of moral distress and reduce the exploitation of communities discussed earlier. Shifting the focus away from direct patient care would mitigate the potential harm caused—and moral distress experienced—by students operating beyond their scope or without proper supervision in the clinical setting. It would also reduce, though not fully eliminate, the risk of an exploitative relationship between foreign volunteers and the communities in which they practice by allowing for a true 2-way exchange between volunteers and communities with the aim of addressing the needs of the local community, as identified by the community. Indeed, stepping back from clinical work would not eliminate all ethical issues, nor would it solve host communities’ resource and care shortages. It does, however, have the potential to address a number of problems inherent in short-term clinical work abroad by facilitating development of a skill set that students can apply throughout their careers.

Defining and Ensuring a Successful Program

The case referred to the trip as “a success,” begging the question of who defines this success. While the trip might have been a success in the eyes of some volunteers, the “nagging feeling” on the part of RM rightfully suggests that success is in the eye of the beholder and that perhaps the trip might not have been as successful from the view of the community or other participants. This again harks back to the concept that service learning trips are not one-way interactions and success must be defined accordingly. Different players enter global health projects with varying goals and expectations. When reflecting on who is best served by medical trips and global health curricula, it is important to analyze the larger mission of service trips and define success for all stakeholders. Most importantly, a conversation over resources and community needs, as lead by the host community, will paint a clearer picture of what is a true communal success.

A number of steps can be taken to ensure that service trips are successful. Host communities and clinic teams, trip facilitators, medical schools, teachers, learners, and patients ideally can identify shared goals in advance, thus setting the groundwork for a more successful mission^3,4 while serving to balance the power differential between travelers and local communities. Prior to the trip, promoting students’ self-reflection on their intentions and motivations for volunteering can address misaligned or romanticized expectations. Debriefing, ensuring that there is appropriate follow-up after volunteers depart, and incorporating routine evaluation of programs using predefined outcome measures can allow for better assessment of both the student experience and the program’s impact on the community.^2,4,5,6 The students’ feeling of doubt about the extent of lasting and sustainable change created by their own global health experiences is common and should not be ignored. These feelings of conflict indicate room for growth and can be fruitful as a means of addressing larger health system needs.