Resident Team and Cameroon Host Expectations : A Ten Year Comparative Analysis of Evaluation Surveys , 2004-2013

Objectives The objectives were to assess strengths and weaknesses of the International Clinical Rotation (ICR) component, Georgetown Global Health Elective in Cameroon, 2004-2013, concomitantly, by Georgetown medicine resident team “guests” and Cameroon healthcare provider “hosts”. Georgetown’s ICR had 3 key elements: gradual clinical immersion, inpatient physician-pairing, and on-site American faculty supervision. Method A retrospective study was conducted using self-administered evaluation surveys by 26 Georgetown and 25 Cameroon survey participants, 2004-2013, who were asked if/how they would recommend changing 8 core components (variables) of Georgetown’s ICR. Cameroon survey participants were asked further questions about “most positive” and “most negative” aspects, to uncover additional “host”-reported ICR strengths and weaknesses. Results The percentages of survey respondents in the Georgetown and in the Cameroon survey participant groups were not statistically significantly different [50% (13/26) vs 52% (13/25), p=0.99, NS]. Of 8 variables, both survey respondent groups would not recommend changing 6 variables, including Academic content, Finances, On-call schedule, Professional relationship with other team’s physicians, Special programs, and Work schedule. Georgetown and Cameroon survey respondents disagreed whether to recommend Academic format change, with significantly more Georgetown respondents recommending change [31% (4/13) vs 0% (0/13), p=0.0478, S]. Thirty five percent (35%) of Georgetown combined with Cameroon survey respondents agreed on recommending change to duration [35% (3/13 + 6/13=9/26)]. Cameroon survey respondents ranked Clinical teaching [69% (9/13)], then Clinical care [38% (5/13)], as two “most positive” aspects. Unexpectedly, Professional relationship with other team’s physicians ranked third “most positive” aspect [23% (3/13)]. Excess lab tests [31% (4/13)], then “None” [23% (3/13)], were two “most negative” aspects. Conclusion With strengths significantly outweighing weaknesses, Georgetown’s international clinical rotation model elicited overall positive responses by Georgetown and Cameroon survey respondents. Further model optimization warrants systematic, prospective study of Academic format, Duration and Excess lab tests.


Introduction
A challenge facing academic medicine is how to structure, implement and assess an ethically-sound, non-exploitive International Clinical Rotation (ICR), as part of a global health elective.This longitudinal study informs the quality of graduate medical education by presenting concomitant assessments of Georgetown's three-part clinical model by Georgetown internal medicine resident team "guests" and by their Cameroon healthcare provider "hosts".

The Georgetown International Clinical Rotation Model
Medstar Georgetown University Hospital (MGUH) internal medicine residents' interest in a medical mission to Cameroon compelled the structuring of a safe and meaningful international clinical model.After review of other ICR models, we put forward the Georgetown clinical model with 3 key elements: gradual clinical immersion, inpatient physician-pairing and on-site American faculty supervision.
Gradual clinical immersion would foster the Georgetown internal medicine resident's provision of culturally-sensitive [18], cost-conscious medical care.
Secondly, inpatient physician-pairing would facilitate mutual teaching of local competencies [19], by the Cameroon physician and by the Georgetown medicine resident.Lastly, on-site American faculty supervision addresses a resident's educational, safety, and supervisory concerns during the international clinical experience [2,5,6,9,11,17,[20][21][22][23][24][25][26].On-site American faculty supervision would work to assure a safe clinical experience, as well as medical practice at the Georgetown resident's level of competence.This approach is responsive to the key component of inter-institutional arrangements for global health-the definition of a clearly structured educational program with appropriate supervision [19] and defined goals.

Setting
Sub-Saharan Africa (SSA) has 13% of the world's population and 24% of the total burden of disease [27], but only 1.5% of the world's physicians [28].These healthcare access disparities are even worse in remote SSA regions, making access to quality, affordable healthcare most difficult [29].In remote Kumbo, Cameroon, West Africa, the 250 bed Banso Baptist Hospital (BBH) has a developing world clinical infrastructure.Cameroonian-run BBH incorporates "guest" medical trainees into preventative and curative healthcare services-once an on-site clinical supervisor is identified.

Participant Selection Process
Participants are Georgetown "guests" and Cameroon "hosts" who participated in the Georgetown Global Health Elective in Cameroon (GGHEC) international clinical rotation from 2004 and 2013 (Table 1).Georgetown participants, predominantly internal medicine residents, are selected early in internship for their senior year GGHEC program, following a 1 hour interview by the GGHEC Director.In contrast, Cameroon participants, predominantly practicing physicians, are selected by the GGHEC Director, in consultation with Cameroon Baptist Convention Health Services (CBCHS) leadership.

Preparations
During the 10 months prior to departure, Georgetown internal medicine resident team members and the GGHEC Director meet for 10-30 hours.Cameroon medical and cultural milieu is discussed.Georgetown residents are asked to identify their anticipated special contribution to BBH (Table 2).Georgetown residents submit 3 applications [CBCHS, Catholic Medical Mission Board (CMMB) for medical malpractice, travel and evacuation insurances, and US Visa], raise funds to cover travel costs and charitable donations, prepare a lecture, obtain immunizations, malaria prophylaxis, gloves/face masks, and study global health, including tropical diseases.

The Experience
After shadowing a Cameroon physician "host" for 1-3 days, the Georgetown internal medicine resident "guest" gradually begins to care for a small cohort of hospitalized BBH patients, in consultation with an on-site American faculty supervisor.Evaluating and treating these patients is challenging, given the prevalence of severe unfamiliar communicable diseases, limited laboratory and pharmacy, and plethora (270) of tribal languages and cultures.Afternoons are spent managing outpatients and attending American faculty-taught lecture/seminars on global health and the local implementation of evidence-based management of common diseases, such as HIV/AIDS, malaria and tuberculosis (Table 3).Rounding out the 6-day work week are BBH staff lectures and meetings, weekly mid-day Georgetown residents' lectures, and call every fourth night and weekend.

Research questions
The survey questionnaires (Supplementary files, Appendix I and Appendix II) were developed to assess the structural and functional adequacy of the Georgetown International Clinical Rotation (ICR) from the points-of-view of both Georgetown healthcare provider "guests" and Cameroon healthcare provider "hosts".
In this study, we addressed 2 questions: 1. Are strengths and weaknesses of "gradual clinical immersion, inpatient physician-pairing, on-site American faculty supervision" international clinical model comparable for Georgetown and Cameroon healthcare provider ICR participants?
2. Do qualitative questions asked of Cameroon participants uncover additional, unexpected Cameroon "host"-reported ICR strengths and weaknesses, not discovered through quantitative questions?

Study population
Two (2) study populations were identified.Study populations were derived from lists of Georgetown participants in the international clinical rotation component of Georgetown Global Health Electives in Cameroon, 2004-2013, and of their close Cameroon participant partners.
The Georgetown study group consisted, primarily, of former Georgetown internal medicine and medicine/pediatrics residents in graduation classes 2004-2013 [30], and, secondarily, of an occasional Georgetown medical student, fellow or faculty member, who acted as a healthcare provider and Georgetown team member.
The Cameroon study group consisted of healthcare provider partners, who were mostly Cameroon physicians, but also included an occasional nurse practitioner or nurse, who functioned equivalently to a Cameroon physician.Prior to exclusions, Cameroon healthcare administrators were also on the Cameroon study group list.
Lists of 30 Georgetown and of 37 Cameroon study group members were generated (Table 1).Four (4) Georgetown study group members were excluded, 3 for redundancy and 1 GGHEC Director for conflict of interest.Twelve (12) Cameroon study group members were excluded, 4 for no known e-mail address/es, 1 for family medical leave, and 7 healthcare administrators for not providing direct patient care.Thus, 2 survey participant groups were identified, 26 Georgetown survey participants and 25 Cameroon survey participants.The Georgetown survey participants were significantly more white, American, female, physician trainees; the Cameroon survey participants were significantly more black, African, male, physician staff members (Supplementary file, Appendix III).

Survey procedure
Lists of Georgetown and Cameroon study group members were drawn from GGHEC records and correspondences, 2004-2013.Exclusions were applied and GGHEC ICR evaluation surveys (Supplementary files, Appendix I and Appendix II) were e-mailed to Georgetown and Cameroon survey participants, using their last known (within the last 10 years) personal e-mail addresses.
Active e-mail addresses were difficult to verify for both groups.At the time of the e-mailed survey, 88% (23/26) of Georgetown survey participants had departed Medstar Georgetown University Hospital; 84% (21/25) of Cameroon survey participants, Banso Baptist Hospital.Two (2) to 4 weeks after e-mailing the first survey, a second survey was e-mailed to non-responders, with no associated inducements or incentives.
The GGHEC Director collected and analyzed survey data from each survey respondent (Table 1).Confidentiality of responses was maintained.

Survey instrument
The survey was built with the Yale [1,5,31] and Duke [9,18] international health program studies in mind.However, in the Georgetown study, the survey participant cohort was expanded to include both Cameroon "host" and Georgetown "guest" healthcare providers, and narrowed to include one international site with the Year Special Contributions by Georgetown   same American faculty supervisor for the majority [90% (9/10)] of Georgetown team cohorts.
A core of 36 items was the same for both survey participant groups, including 16 "Recommendations for ICR Change" items and 20 work practice profile items.The remaining portions of the 2 questionnaires were group specific-with Georgetown survey participants asked additional questions about on-going and future plans for global health involvement; the Cameroon survey participants, about "most positive" and "most negative" ICR aspects, from the "host" viewpoint.In total, the Georgetown survey contained 55 items; the Cameroon survey, 70 items.
The information for this study came entirely from the survey instrument, except for some sociodemographic data which came from GGHEC ICR application records.

"Variables"
Eight (8) core determinants of structure and function of the GGHEC International Clinical Rotation (ICR) were deemed "variables".These 8 "variables" were derived from regular, on-going discussions about desired ICR characteristics with individuals from both Georgetown and Cameroon study groups, and were focused on meeting both groups' educational needs.In evaluation surveys, survey participants were asked "yes response" questions about need to change 8 "variables" or core ICR components, and were encouraged to explain if and how any "variables" should be changed.(See Table 4 for details about each "variable").Additionally, each Cameroon survey participant was asked to name the "most positive" and "most negative" aspects of the GGHEC ICR, in order to uncover additional ICR strengths and weaknesses.

Statistical methods
Because of small sample size in this study, the two-sided Fisher's exact test was used to compare binary data between two groups.All p-values <0.05 were considered to be Statistically Significant (S).

Legal, ethical issues
Evaluation surveys from both Georgetown and Cameroon survey respondent groups were gathered and analyzed.After survey data analysis revealed generalizable information for small size, international clinical rotation models, the GGHEC Director submitted and, subsequently, received IRB approval from Georgetown University Medical Center for a retrospective study.Waiver of consent was approved, and compliance with ethical regulations, with guarantee of privacy of responses, ensured.No conflicts of interest or outside funding related to this project were reported.

Agreement by Georgetown and Cameroon survey respondent groups on whether or not to recommend change to 7 of 8 international clinical rotation "variables"
The percentages of "yes responses" for each "variable" were calculated for Georgetown survey respondents and for Cameroon survey respondents (Table 5).There were no statistically significant differences between Georgetown and Cameroon survey respondent groups on 7 of 8 international clinical rotation "variables".These 7 "variables" included Academic content, Duration, Finances, On-call schedule, Professional relationship with other team's physicians, Special programs, and Work schedule.However, the Georgetown and Cameroon survey respondent groups significantly differed in their assessment of Academic format.Although almost one third of Georgetown survey respondents would change Academic format, no Cameroon survey respondents would do so [31% (4/13) vs 0% (0/13), p =0.0478, S].In the aggregate, the Georgetown survey respondents would add back various components of a traditional American academic internal medicine residency rotation, such as a preparatory course, more case-based discussions, more resident lectures, and a small research project (Supplementary file, Appendix IV).However, no specific Georgetown Academic format "change recommendation" differed significantly from the Cameroon "no change recommendation" [15% (2/13) vs 0% (0/13), p=0.48,Not Significant (NS)].Academic format, although a mild weakness for the Georgetown survey respondents, was unanimously a strength for the Cameroon survey respondents.
In summary, Georgetown and Cameroon survey respondents agreed on a majority of the strengths and weaknesses of the Georgetown international clinical rotation model.

Do qualitative questions uncover unexpected Cameroon "host"-reported ICR strengths and weaknesses not discovered through the quantitative questions?
Qualitative responses by the Cameroon survey respondents about the "most positive" and "most negative" ICR aspects were grouped and categorized by themes, then percentages calculated in order to identify additional, "host"-reported ICR strengths and weaknesses (Table 6).When the Cameroon survey respondents were asked to name the "most positive" aspect, nearly half [46% (6/13)] of Cameroon survey respondents named two "most positive" aspects; each topic was counted.Clinical teaching [69% (9/13)], followed by Clinical care [38% (5/13)], were ranked first and second "most positive" aspects.Unexpectedly, Professional relationship with other team's physicians [23% (3/13)] ranked third.

Discussion
The evaluation survey assessment of Georgetown and Cameroon survey responses shows broad agreement on the strengths and weaknesses of the International Clinical Rotation component of GGHEC, 2004GGHEC, -2013. .The disagreements between the Georgetown and Cameroon survey respondent groups are few, suggesting that the tripartite international clinical model, defined by gradual clinical immersion, inpatient physician-pairing and on-site American faculty supervision, has found a balance for an international clinical rotation.

Advanced planning and agreement on strengths of 6 "variables"
Specifically, both Georgetown and Cameroon survey respondent groups agree that Academic content, Finances, On-call schedule, Professional relationship with other team's physicians, Special programs, and Work schedule should remain unchanged, and are net strengths.These positive findings are not unexpected, since these 6 "variables" evolved into the present ICR formulation through 4 years of close, on-site consultation with Cameroon healthcare provider "hosts" by the future GGHEC Director, prior to GGHEC's 2004 initiation.

Change the duration "variable"
Duration is a mild weakness for both Georgetown and Cameroon survey respondent groups.Even with on-site American faculty supervisory assistance, the Cameroon ICR participants still expend a substantial effort during the first 2 ICR weeks to educate the Georgetown ICR participants to function medically.By the third week, Georgetown ICR participants are functioning medically, only to depart the following week.Lengthening duration could eliminate duration as a mild weakness for both groups, but especially for the overworked Cameroon ICR participant "hosts".

Adjust to an unfamiliar academic format or change it?
Strength with respect to the Academic format "variable" is different among the groups.Whereas Cameroon survey respondents unanimously agree that Academic format should remain unchanged and is strength for them, a significantly smaller fraction [69% (9/13)] of Georgetown survey respondents would agree.The Academic format, which superimposes a Georgetown supervisory format on a somewhat more informal Cameroon consultative format, is familiar to Cameroon healthcare provider "hosts", who regularly host visiting American physicians at their hospital, BBH.For Georgetown internal medicine resident "guests", this unfamiliar blend of teaching and practice methods requires on-going medical acculturation.Further questioning of both Georgetown and Cameroon groups may identify an optimum Academic format change to consider; pre-intervention and post-intervention assessments could determine the change's acceptability to both "guest" and "host" groups.

Qualitative questions uncover unexpected, additional, Cameroon "host"-reported ICR strengths and weaknesses
Of the 3 Georgetown Global Health Elective in Cameroon Goals directed towards supporting Cameroon "hosts", Cameroon survey respondents rank Goal #2 Teach Global Health, then Goal #3 Provide Clinical Care, as the first, then second, "most positive" ICR aspects.Unexpectedly, Professional relationship with other team's physicians is cited as the third "most positive" aspect.Further study as to what aspects of Professional relationship with other team's physicians are most important and meaningful to Cameroon "hosts" is warranted.
Cameroon survey respondents identify Excess lab tests as the most "negative" ICR aspect.A worrisome critique for resource-poor BBH, the Excess lab tests critique warrants further investigation to determine if/how/by whom that Excess lab tests are ordered.An analysis of lab test expenditures by Georgetown, compared to Cameroon, ICR participants on a few common Cameroon diseases, controlling for disease severity, is indicated.Results from such a study could help to focus on-going educational efforts to limit Excess lab tests and elucidate areas for future fiscal restraint.
In summary, qualitative questions did uncover unexpected, Cameroon "host"-reported ICR strengths, as well as weaknesses.

Limitations
Interpretation of these research findings is limited by the non-anonymous nature of the retrospective evaluation survey, small individual cohort sizes, and the multiplicity of factors.The 51% average response rate may be subject to bias in that respondents may assess the Georgetown Global Health Elective in Cameroon ICR more positively than their non-respondents.The small cohort sizes of both Georgetown and Cameroon ICR participant groups, render significant differences limited to the largest response differences among groups.Lastly, although tempting to attribute the survey's overall positive assessment to the tripartite international clinical rotation model, other factors, including the high caliber of Georgetown [30] and Cameroon ICR participants and leaders, consistency and continuity in leadership, as well as strong Cameroon institutional support, may equally contribute to Georgetown's tripartite international clinical rotation model's success.

Conclusion
The 10 year experience of Georgetown's international clinical model elicited comparable and overall positive quantitative responses by both Georgetown medicine resident team and Cameroon healthcare provider survey respondents.
Qualitative questions asked only of Cameroon "hosts" did uncover unexpected additional strengths, such as Professional relationship with other team's physicians, as well as weaknesses, such as Excess lab tests.Overall, though, the model's strengths significantly outweighed its weaknesses and fulfilled the four GGHEC goals.
The 3 key elements of this model are gradual clinical immersion, inpatient physician-pairing, and on-site American faculty supervision.To further optimize this tripartite model, weaknesses, such as Excess lab tests, Academic format, and Duration, as well as strengths, such as Clinical teaching, Clinical care and Professional relationships with other team's physicians, warrant additional study.A systematic prospective study of Georgetown's international clinical model could assist in further optimizing the model's strengths and minimizing its weaknesses.

1. Learn about global health 2 .
Teach global health as it relates to patient care 3. Provide clinical care to patients 4. Enhance medical infrastructure

Table 2 :
Special Contributions by Georgetown Team Members to Banso Baptist Hospital, Kumbo, Cameroon.

Table 3 :
Sample Curriculum: Georgetown Global Health Elective in Cameroon Curriculum, 2013.

Table 4 :
International Clinical Rotation "Variables", List and Descriptive Details.Cole MCS (2015) A Global Health Elective Addresses Georgetown Resident Team and Cameroon Host Expectations: A Ten Year Comparative Analysis of Evaluation Surveys, 2004-2013.J intern Med Prim Healthcare 1: 002.

Table 5 :
Comparison between Georgetown and Cameroon Survey Respondents in Their Recommendations for Change of the International Clinical Rotation.Georgetown Global Health Elective in Cameroon, 2004-2013.

Table 6 :
Qualitative Answers by Cameroon Survey Respondents on "MostPositive" and "Most Negative" Aspects of the International Clinical Rotation.