Surgeons’ and Trauma Care Physicians’ Perception of the Impact of the Globalization of Medical Education on Quality of Care in Lima, Peru

Key Points

Question  What is the impact of the globalization of medical education on surgical care in Peru?

Findings  In this qualitative study, interviews of 50 surgeons and emergency medicine physicians revealed their perceptions of the impact of the globalization of medical education to be both negative (such as an eroded sense of agency and the overwhelming nature of global medical information) and positive (such as access to research funds and improved clinical standardization and expectations for patient outcomes).

Meaning  While Peruvian trauma clinicians’ perceptions of the impact of the globalization of medical education on surgical care appear to be predominantly positive, thoughtful planning of training exchange is necessary to prevent exploitation of low- and middle-income countries such as Peru.

Importance  The globalization of medical education—the process by which trainees in any region gain access to international training (electronic or in-person)—is a growing trend. More data are needed to inform next steps in the responsible stewardship of this process, from the perspective of trainees and institutions at all income levels, and for use by national and international policymakers.

Objective  To describe the impact of the globalization of medical education on surgical care in Peru from the perspective of Peruvian surgeons who received international training.

Design, Setting, and Participants  Observational study of qualitative interviews conducted from September 2015 to January 2016 using grounded theory qualitative research methods. The study was conducted at 10 large public institutions that provide most of the trauma care in Lima, Peru, and included urban resident and faculty surgery and trauma care physicians.

Exposures  Access to international surgical rotations and medical information.

Main Outcomes and Measures  Outcome measures defining the impact of globalization on surgical care were developed as part of simultaneous data collection and analysis during qualitative research as part of a larger project on trauma quality improvement practices in Peru.

Results  Fifty qualitative interviews of surgeons and emergency medicine physicians were conducted at 10 hospitals, including multiple from the public and social security systems. A median of 4 interviews were conducted at each hospital, and fewer than 3 interviews were conducted at only 1 hospital. From the broader theme of globalization emerged subthemes of an eroded sense of agency and a perception of inadequate training on the adaptation of international standards as negative effects of globalization on surgical care in Peru. Access to research funds, provision of incentives for acquisition of advanced clinical training, increased expectations for patient outcomes, and education in quality improvement skills are ways in which globalization positively affected surgeons and their patients in Peru.

Conclusions and Relevance  Short-term overseas training of surgeons from low- and middle-income countries may improve care in the surgeons’ country of origin through the acquisition of skills and altered expectations for excellence. Prioritization of evidence-based medical education is necessary given widespread internet access and thus clinician exposure to variable quality medical information. Finally, the establishment of centers of excellence in low- and middle-income countries may address the eroded sense of agency attributable to globalization and offer a local example of world-class surgical outcomes, diminishing surgeons’ most frequently cited reason for emigration: access to better surgical training.

An estimated 5 billion people worldwide do not have access to safe, timely, and affordable surgical care.¹ Addressing the lack of adequately trained and available surgical health care workers has been identified as an area for growth in addressing the global surgical care deficit.^2-4 Low- and middle-income countries (LMICs) often do not have sufficient quantity and caliber of training opportunities to meet local physicians’ aspirations or a country’s public health care needs.^5,6 “Brain drain,” the migration of health care workers from LMICs to high-income countries (HICs), is a well-described phenomenon that further depletes the already strained health care work force of LMICs.⁷ One recent examination of foreign-born surgeons’ motivation for moving to, and remaining in, the United States revealed potentially actionable results. In this study, a desire for higher income and security for family members motivated surgeons to stay in the United States after completing their education. However, the drivers for initial emigration were different; a desire for “better training” was the most important reason cited.⁸ The present study examines this aspect of brain drain through the perceived positive and negative aspects of the globalization of medical education.

Leaders at the National Institutes of Health (NIH) have responded to brain drain in research training by developing scientific, political, and economic strategies that optimize LMIC researchers’ use of training opportunities while facilitating investment in their country of origin. Many of these strategies are applicable to surgical training, including an emphasis on “sandwich training,” where trainees are physically located in the host country for only the beginning and end of their training term.⁹ The effort to keep the trainee based in their home country parallels existing practices in surgery where international partnerships allow for short-term clinical rotations. Short-term training opportunities may provide an ideal balance, facilitating acquisition of the most cutting-edge surgical skills, while maintaining ties in the home country.¹⁰ However, ultimately, any international travel by clinicians has the potential to increase their interest and interpersonal connections abroad. Thus, the ideal method to comply with Article 5 of the World Health Organization Global Code of Practice on the International Recruitment of Health Personnel—collaboration with “source countries to sustain and promote health human resource development and training”—has yet to be described.¹¹

While there is an abundance of data on the epidemiology, impact, and perception of surgeons in training from the United States or Europe rotating through clinical programs in LMICs, there are scarce data on the reverse practice, evaluating the perspective of surgeons from LMICs rotating through high-income clinical settings.^10,12-18 This imbalance may reflect a distinct form of medical education predation by HICs on LMICs; not only are clinicians from LMICs permanently lost owing to migration to HICs, but HICs most frequently send early-stage trainees to LMICs for clinical rotations. This exposes the high-income trainee to education that will be professionally valuable to them, while offering nothing to the LMIC staff but inconvenience and time lost in orienting and hosting the trainee.¹⁸

The globalization of medical education—defined herein as the process by which trainees in any region gain access to international training opportunities (electronic or in-person)—is a growing trend.¹⁹ More data are needed to inform next steps in the responsible stewardship of this globalization, from the perspective of trainees and institutions at all income levels, and for use by national policymakers and international advisory groups. Through the exploration of themes that emerged in surgical quality improvement research in Latin America, we aimed to describe the perceived impact of the globalization of medical education on surgeons and surgical care in Peru from the perspectives of Peruvian surgeons.

In Andean Latin America, an estimated 60% of the population is without access to safe, affordable, timely surgical care.¹ Peru is an upper-middle-income country and is home to 35 medical schools, most of which are not formally accredited.^20-22 It is estimated that 30% of the graduates from the top-ranking medical schools emigrate after acquiring their medical degrees, and that only 16% of those who emigrate return to Peru after their postgraduate training.^23,24 Trauma care in Lima is provided principally by 2 types of institutions: those from the Ministry of Health system, which are referred to as public—the most affordable health care option in Lima—and those from the Ministry of Labor system, termed social security—which are generally better resourced than public institutions and offer services to those individuals with formal employment who have paid into the system.

This cross-sectional, descriptive study was approved by the University of Washington and the Universidad Peruana Cayetano Heredia ethical committees; verbal consent was obtained from participants. A grounded theory approach, including the constant comparative method, was used to allow for exploration and expansion of themes.²⁵

We conducted individual interviews with clinicians who participate in the care of the injured at 10 public and social security hospitals in the capital city, Lima. These hospitals were identified by local authors and key informants from the national surgical society as centers that provide most of the trauma care in Lima. We used purposive and snowball sampling through identification of key informants at each hospital and their subsequent referrals. One author (L.N.L.) first approached and interviewed key informants and then recruited additional participants during hospital site visits. All interviews were conducted in a private location and prior to initiation, verbal informed consent was obtained. Data collection was continued until at least 1 interview had been conducted at each of the 10 hospitals and theoretical saturation was achieved.

Interviews were conducted in Spanish by 1 author (L.N.L.) and 3 research assistants with bilingual fluency and advanced degrees. Interviews were conducted using a semistructured interview guide, with open exploration of themes through probing to elaborate when novel topics arose. The interviews were not audio or visually recorded. The topics discussed were sensitive and recent political events in the country have led to discomfort with audio recording. The author (L.N.L.) took notes by hand during the interview and the assistant also took notes using a computer. After the interview, the assistant edited the interview notes for clarity and L.N.L. cross-referenced these notes with her own to confirm completeness. These cross-referenced notes were translated into English and coded in ATLAS.ti 7 (Scientific Software Development GmbH) while data collection was ongoing.

Open coding for theme identification was conducted for the original research question on the barriers and facilitators of trauma quality improvement programs. Globalization emerged as a salient theme and subsequent rounds of coding after the completion of interviews included subtheme development and structural coding for this topic. Coding for concept development allowed for the elaboration of this theme to include a subcode for the impact of access to international medical information. Structural codes were used to attribute statements to participant characteristics, such as age and leadership position.

Memos and network diagrams were used to create the codebook, record insights and areas for further exploration, and provide a visual organization of themes. The network diagram was continually revised to include emerging codes and was used as a communication tool between coders. Initially, the codebook and network diagram were developed through collaboration between L.N.L. and a research assistant, each independently coded the data and then reviewed codes together to refine the codebook and network diagram. This was done for 10 interviews. The author, L.N.L., coded the remainder of the data and added new codes as they emerged. In the results presented here, quotes are provided as close to verbatim as was possible as captured by interview notes. These represent exemplary statements related to the stated subthemes.

Fifty qualitative interviews of surgeons and emergency medicine physicians were conducted at 10 hospitals, including multiple from the public and social security systems. A median of 4 interviews were conducted at each hospital, and fewer than 3 interviews were conducted at only 1 hospital.

Throughout the course of the study, participants reported what was perceived as a sense of awareness of an international, excellent standard of care, along with a sense of inability to attain this standard. Therefore, globalization in this case, manifested as an awareness of the resources and outcomes in HICs, appeared to be a barrier to progress by leaving clinicians paralyzed by a sense of futility.

This tendency was exemplified by one surgeon’s comments regarding the lack of utility of specialty training in Latin America: “All the good surgeons go to the US or Europe. You need to see the best in the world. Not in Latin America, because they’re the same. It’s Latin America, it’s third world. What can we learn? Little.”

Another surgeon explained his institution’s lack of morbidity and mortality meetings, a simple low resource-intensive quality improvement tool, by asserting a lack of adequate resources compared with what he had witnessed in high-income settings: “…there aren’t people trained to do this type of meeting. In a hospital in the United States. . .there were 50 nurses dedicated to doing quality improvement.”

Participants cited a need to develop local care guidelines based on international evidence. However, many argued that international guidelines did not apply to their patient population owing to differences in epidemiology, genetics, and environment. One surgeon described the overwhelming nature of having access to international guidelines, without having consensus on how to adapt and apply them: “They sent guides from Canada, Infectious Disease Society of America, and we discuss them. However, there is no consensus. That stuns the resident, because the residents do not know who they should heed, as every day they have to change the procedure. It makes them dizzy.”

Participants cited the NIH or other international organizations as the only potential funding opportunity for research: “Economic incentive [to do research]? None. Unless you have one from abroad. Like working with Dr [local researcher] who worked on [multicenter NIH funded grant]. But besides international work, no, we don’t have an incentive.”

Access to international medical education opportunities, including certifications and society memberships, contributes to increased standardization of care, as described by one surgeon: “Some of us belong to the American College of Surgeons, to be part of the American College of Surgeons trauma chapter we have to take care of patients the same way.”

Participants referenced international organizations, courses, and guidelines as sources of information regarding “gold standard” of care. The globalization facilitated by national and international academic societies expands clinicians’ perspectives: “Organizing to bring care to international standards [is the goal of trauma quality improvement], to what’s best for patients with injuries. To be in agreement with the guidelines, of the Panamerican Trauma Society, American College of Surgeons, for example. We care very much what the American College of Surgeons/the American Association for the Surgery of Trauma think and do.”

Another participant described further: “…we need a standard. I learned about the standard there, in [large high-income city], and brought it here and we implemented it. It’s a mixture really, because we manage with Advanced Trauma Life Support and programs from [other middle-income country]. On our own, we travel and see the programs in [middle-income country] and adapt what suits us best, because if we do not have a standard, we cannot teach.”

Globalization was also cited as a source of expertise not only for clinical skills, but with regard to quality improvement education: “The people who have been outside to another country present [cases at morbidity and mortality conferences] well, with structured questions, review. But there are people who don’t do it well. There isn’t standardization.”

The theme of insufficient financial remuneration for physicians was central to many participants’ explanation of current quality deficits in surgical care in Peru. A few participants cited an inability to pay for certain desired expenditures, such as sending their children to the United States for education, as a consequence of insufficient salaries. Participants also asserted that salaries in neighboring Andean region countries are 50% to 200% higher than those in Peru. Thus, one impact of globalization on surgical care in Peru may be that Peruvian physicians have higher expectations for salary because of knowledge of global market norms. However, globalization may also motivate the local physician to be a better advocate for their own treatment, possibly increasing remuneration and thus diminishing problems, such as brain drain and a decreasing competitiveness, and thereby increasing the quality of medical education in the country.

This study evaluates Peruvian clinicians’ perceptions of the impact of the globalization of medical education on surgery in Peru. We identified an eroded sense of agency and inadequate level of training on the adaptation of international standards as negative effects of globalization on surgical care and education. Access to research funds, certificates and membership in prestigious surgical societies through the acquisition of advanced clinical training, increased expectations for patient outcomes, and education in quality improvement skills are ways in which globalization positively impacted surgeons and their patients.

The erosion of sense of agency—a perceived ability to effect changes in one’s environment—may be a unique consequence of globalization experienced by health care workers in middle-income countries and one source of the well-described “middle-income trap.”^26-28 Many of the interventions that provide immediate improvement in outcomes, such as access to intravenous fluids for resuscitation, have been realized in urban hospitals in middle-income countries. In these care environments, the return on investment for improvement may be more marginal, requiring monitoring to illuminate the incremental benefit achieved. With regard to access to research funds, Peru is 1 of 7 countries that participate in the Fogarty International Center Global Health Fellows program. The data suggest that this and other NIH research relationships are relatively well-known, with participants citing the NIH as one of few possible sources of research funding. Finally, the most significant impact of globalization on surgical care may be through inspiring surgeons to think more positively about what is possible in their hospital. When surgeons compare their outcomes not just to their colleagues’, but to what they have seen in a hospital in another country, or what they have read in a Cochrane review, their definition of acceptable patient outcomes may be redefined.

The perceptions of the 50 trauma care clinicians lend themselves to several recommendations for the way forward in the globalization of surgical education. The opportunity to rotate at a hospital of excellence in another country was a life- and perception-altering experience for many participants. Further research is needed on the long-term impact of these external surgical rotations, specifically regarding their impact on the likelihood of trainee emigration. It may be that with provision of guidelines to reduce brain drain,⁹ individual surgeons and societies, such as the American College of Surgeons, could be encouraged that hosting surgeons from other countries for short-term rotations, even as observerships, can have a profound positive impact on the surgeon and the future care they provide.

The presented evidence describes clinicians’ concerns regarding access to, but inability to interpret and apply, global medical information. Given the fact that this represents a barrier to ensuring that patients the world over have access to the best in medical care, a solid foundation in the practice of evidence-based medicine should be a requisite part of all clinicians’ training. Finally, establishing local centers of excellence that have long-term partnerships with overseas academic institutions would allow LMIC surgeons to gain access to international expertise. These centers would be an investment in the local infrastructure that would provide access to better training.²⁹ Participation in international and local sources for training and research, such as the NIH, American College of Surgeons, and centers of excellence, should be optimized to leverage these resources to improve quality of care.

This study had several limitations. First, snowball sampling may have resulted in oversampling of certain subpopulations. Second, the lack of audio or visual recording could have resulted in omissions or errors in written notes used for coding. Finally, the primary investigator’s positionality as a foreigner, a surgeon in training, and a non-native Spanish speaker likely influenced both the responses given and, to some degree, their interpretation. The potential for these factors to influence the validity of the results was mitigated by the inclusion of Peruvian collaborators at all stages of study design, implementation, and analysis. The candor that resulted from the choice to forgo recording likely outweighs any losses in data completeness. Dual note-taking and coding of the data also diminished these risks.

We present evidence that suggests that short-term overseas training of surgeons, as experienced by many of our LMIC participants, may sustainably raise the standard of care in the country of origin through not only acquisition of technical skill, but through fundamental alteration of the trainees’ perception of, and expectations for, clinical excellence. Further research is needed on ways to optimize such rotations, while minimizing negative consequences. This should include the perspectives of individuals in HICs involved in training surgeons from LMICs. Furthermore, prioritization of evidence-based medical skills in medical education is necessary in a world where internet access results in clinician exposure to an overwhelming volume of variable-quality medical information. Finally, the establishment of centers of excellence in LMICs may address the eroded sense of agency attributable to globalization, augment existing access to research funds, and offer a local example of world-class surgical outcomes, all while effectively diminishing surgeons’ most frequently cited reason for emigration: access to better surgical training.

Ultimately, globalization is an irreversible trend; thoughtful planning for responsible stewardship of its impact on surgical education and care is an urgent responsibility of surgical leaders from both HICs and LMICs. Particular effort should be made to develop and research strategies to prevent brain drain and the erosion of LMIC clinician sense of agency.

Corresponding Author: Lacey N. LaGrone, MD, MPH, University of Washington, Campus Box 356410, Seattle, WA 98104 (lagronel@uw.edu).

Accepted for Publication: August 1, 2016.

Published Online: November 23, 2016. doi:10.1001/jamasurg.2016.4073

Author Contributions: Dr LaGrone had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: LaGrone, Isquith-Dicker, Huaman Egoavil, Revoredo, Mock.

Acquisition, analysis, or interpretation of data: LaGrone, Huaman Egoavil, Rodriguez Castro, Allagual, Revoredo.

Drafting of the manuscript: LaGrone, Isquith-Dicker, Huaman Egoavil, Rodriguez Castro, Revoredo.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: LaGrone.

Administrative, technical, or material support: LaGrone.

Study supervision: LaGrone, Huaman Egoavil, Allagual, Revoredo, Mock.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by research training grant R25 TW009345 from the National Institutes of Health.

Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Amy K. Fuhs, BA/BS (University of Indiana School of Medicine), Rocio del Águila, BA (Pontificia Universidad Católica del Perú), and Gonzalo de la Rosa, BA, for assistance with interview notes and analysis. Ms Águila and Mr Rosa received compensation for their contributions.