How International Training Develops Innovative and Compassionate Clinicians

The rapid development of technology in the 20th and 21st centuries has undoubtedly resulted in a world in which physical and political borders have become less pronounced. Through this lens, the disparities in regional and global healthcare standards have become even more evident. The World Health Organization (WHO) reports significant need for improved O&P care, stating that only one in ten people who need that care receive it. 1 This problem is compounded by the fact that only 5 percent of those needing this care have the means to access it. Further contribution to the disparity comes from the scarcity of O&P training programs in developing countries. The highest concentration of training programs for orthotists and prosthetists still resides in high- and high-middle-income countries. Understanding the globalization of our world afforded by more available transportation and the advent of the internet, medical schools now offer international electives to meet developing curricular standards and expectations of competency in global healthcare. These curricular standards describe the importance of cultural competency, immigrant health, health disparities, and comparative governmental regulations in healthcare. 2 Following that model, many students in today's O&P programs participate in international residency experiences and clinical missions, and in turn have developed cultural competency, enduring respect for altered methods of treatment, and acceptance of variations in culture and lifestyle. Alex Dahinten, MS, CPO, who completed a three-month residency rotation in Quito, Ecuador, describes his experience: "Completing an international rotation truly allowed me an insight into an aspect of O&P that I would have never gotten if I had stayed in the U.S. I found this rotation to be the most learning-dense. I learned new methods of fabrication/care provision or coming up with ways of approaching a challenge given limited resources."

Formal international rotations are not the only opportunity for exposure; service with humanitarian organizations is also a way to provide a short-term immersion in international, rural, or historically underserved populations. Meredith Roehrs, MS, completed a residency rotation in Moshi, Tanzania, as well as a week-long trip to Guatemala with the Range of Motion Project, and states: "I encountered people who had traveled for days to receive O&P care. These patients had to pay for travel, several days to months of lodging, and device costs came out of pocket, not to mention monetary loss in not being at their job. They patiently waited without complaint to be seen, and when seen, patients effusively professed gratitude for their care and delivery of a device. Many cases and patients required me to shed constraints of technology and return to basics of meeting needs in a way that best serves them."

More than just an opportunity for exposure and appreciation of differences, international education in medicine has been demonstrated to increase the likelihood that graduates will seek employment in traditionally underserved or under-resourced settings. 3 These experiences allow students to gain perspective on the value of their profession and provide them with a confidence to take on new places and environments. Lauren Kells, MS, who completed a rotation in Moshi, Tanzania, says, "Outside of O&P I learned to live in the moment and seize the opportunities I had. When you are living in an unfamiliar place, it can be easy to retreat and not embrace what is going on around you. I tried to take every opportunity I had to do something new, such as spending four days climbing a 4,500-meter mountain, going to a goat BBQ, eating questionable street food, dancing in a Swahili music club, [and] visiting a tannery, and along the way met some incredible people."

With the unmet need for O&P care in many parts of the globe, educational programs and residencies should consider offering elective experiences in international settings and with humanitarian organizations.

Regardless of a student's interest in seeking employment in predominantly underserved areas or international communities, these experiences can help trainees and clinicians to view healthcare in a more holistic context, to consider the implications of political systems and government on the provision of care, and to explore alternative solutions in a more innovative and compassionate way. All four Baylor residents who commented share a similar view:

Dahinten says, "The way I provide care now is more holistic, and I have learned to concentrate on the person, rather than the device."

"Not only did I have to think outside the box, I had to learn how to think outside of my continent, my cozy U.S. conditions, and reach for a broader understanding of what would best help my patients through their daily lives," says Roehrs. "Working abroad expanded my imagination, perspective, compassion, and ability to think beyond the shiny cutting-edge technology."

Kells echoes this expression, "In Tanzania I would have to figure out a way to solve the issue with different tools or materials than I was used to. In O&P no two patients are ever completely the same, and different approaches to a problem and unique solutions can make a big difference in a patient's care. From my international residency, I am going to take my adaptability and problem-solving skills with me to benefit my future patients."

"Experiencing O&P care in this manner not only gave me a greater appreciation for some aspects of the field here in the U.S., but [it] also allowed me to see where we may have room to grow," says Ryan Butler, MS, CPO.

Since one anticipated outcome of an O&P residency program is the passage of board certification exams, employers and educators should consider the potential for positive impact to both a resident's approach to the provision of care and his or her performance on standardized metrics. Some researchers have demonstrated a positive relationship between the completion of international medical electives and licensing exam scores. 4 Applying O&P concepts in an under-resourced environment often forces practitioners to go back to the fundamentals and recall basic principles of care, an experience that can be incredibly meaningful for novice learners. Even in an international environment in which resources abound, the process of connecting approaches learned in the United States to the processes used in a foreign country helps solidify biomechanical principles and increase fluency in technical approach. In a well-resourced international area, residents may still benefit from seeing a new focus in care provision. Butler, who completed a rotation in Stuttgart, Germany, says, "This rotation gave me an opportunity to strengthen my technical skills and foster a greater appreciation for attention to detail so often seen in German manufacturing."

Establishing these relationships and opportunities takes time and effort, but in our experience, individuals and practices are often willing to collaborate and work together in order to welcome a trainee. At the programmatic level, Baylor College of Medicine students have participated in a variety of formats and experiences, ranging from one-week humanitarian trips to Guatemala and Haiti, a two-week research-driven needs assessment in Sri Lanka, to full three-month residency rotations in Germany, England, Ecuador, and Tanzania. Each experience has provided insight and learning experiences that were impossible to gain in a traditional U.S. residency. Butler explains how his experience differed from the provision of O&P care in the United States:

With significant differences in how health insurance is handled, there was a lot less concern about reimbursement and a lot higher emphasis on device quality. Much more time was spent in the lab on fabrication and drastically less time was devoted to working on documentation at the computer. With the worries of notes and charting removed, this gave me more time to focus on caring for patients and learning from those around me. In many instances it seemed typical to provide custom devices to patients who would normally receive an off-the-shelf item in the U.S. Also, absent was the need to off-load fabrication to a team of technicians in order to see more patients. I was therefore able to gain hands-on experience in fabricating custom laminated orthotic devices that are less frequently provided back home. These devices were all fabricated in-house according to very rigorous standards.

To qualify as a National Commission on Orthotic and Prosthetic Education (NCOPE)-approved residency experience certain criteria must be met. This includes oversight by an International Society for Prosthetics and Orthotics (ISPO) Category 1 clinician in the discipline supervised, formal affiliation and application paperwork, and approval by NCOPE prior to participation in the clinical experience. NCOPE does not stipulate formally what percentage of a residency can be completed internationally, but instead has put in place specific standards and protocols that must be met to fulfill those requirements. These standards include quarterly reporting, tracking of patient encounters, and direct and indirect supervision as warranted. When shorter rotation segments are included as part of a larger residency program, additional oversight and proper vetting of the clinical site by the primary faculty or residency director is strongly recommended, and applicable affiliation agreements should be signed to ensure all parties adhere to the outlined standards and expected outcomes. Compassion and innovation are inherent in this profession; both are required to provide the optimal solution for individuals with different needs and different backgrounds. It is clearly evident as we examine the recurring themes of comments from hose participating in international experiences that the process toward development of these traits is accelerated quickly in certain environments. Often used as a theoretical approach to adult learning, Kolb's Experiential Learning Model speaks to these developments and may account for the accelerated learning process in a new environment. 5 Students and residents adapting to a new way of doing things are challenged to go through the model's four stages of learning: concrete experience, reflective observation, abstract conceptualization, and active experimentation. These processes can also be fostered by clinical educators who may encourage students and residents to reflect on their experiences abroad.

One aspect of an international or humanitarian service experience that cannot be overlooked is the process of training or debriefing prior to travel and after returning home. 6 The process of preparation and return, the latter commonly referred to as reverse culture shock, can be challenging for some. The exposure to and experience of a place that provides a unique perspective on one's previous way of life may result in an uncomfortableness in returning to a previous lifestyle. In any way possible, it is important for support structures to be in place at the rotation and once the student or resident returns home. Many employers and academic institutions are well equipped with support services and access to counseling and mental health providers who may be needed as students and residents reassimilate to the home environment.

Ultimately, the experiences students and residents have through providing care internationally or for historically underserved populations can be invaluable. Immersion into a new culture or environment offers an opportunity to rapidly develop improved communication skills, effective problem-solving, deeper empathy, and an appreciation for a holistic approach to patient care. Adapting to the challenges of these rotations has helped students and residents develop their abilities to quickly adjust to new standards, new expectations, and new perspectives. As we consider ourselves an expanding global profession, exploring opportunities beyond our clinic walls can be the first step to aiding and appreciating those 100 million fellow humans in need of O&P care.

Ashley Mullen, MSAT, CPO/L, is an assistant professor and associate program director for the orthotics and prosthetics program in the School of Health Professions at Baylor College of Medicine. Jared Howell, MS, CPO/L, is an assistant professor and the program director for the orthotics and prosthetics program in the School of Health Professions at Baylor College of Medicine. References 1. World Health Organization. 2017. Standards for Prosthetics and Orthotics . Retrieved from https://apps.who.int/iris/bitstream/handle/10665/259209/9789241512480-part1-eng.pdf;jsessionid=F38B1F49372791E6557453204B0BC72B?sequence=1

2. Battat R., et al. 2010. Global health competencies and approaches in medical education: a literature review. BCM Medical Education 10:1-7.

3. Thompson M. J., et al. 2003. Educational effects of international health electives on US and Canadian medical students and residents: a literature review. Academic Medicine 78(3):342-47.

4. Stormann, S., and W. M. Angstwum. 2018. What do international health electives and state examination scores have in common?—a cohort study to compare the results of written medical licensing examinations with the participation in international health electives during the final year of undergraduate medical education. GMS Journal for Medical Education 35(5):1-16.

5. Kolb, D. 1984. Experiential Learning: Experience As The Source Of Learning And Development . Englewood Cliffs, NJ: Prentice Hall.

6. Purkey E., Hollaar G. 2016. Developing consensus for postgraduate global health electives: definitions, pre-departure training and post-return debriefing. BCM Medical Education 16: 1-11.

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