International health electives are a component of many medical school and residency programs (1–3). A literature review reveals that international health electives have many positive effects: for example, participants are more likely to care for immigrants and patients on public assistance (4), and tend to have a positive view of health care delivery in developing countries (5) and of volunteerism (6). This research focuses on the experience of Canadian residents in a collaborative Ethiopia-Canada psychiatry training project in Addis Ababa.
This research describes the experiences of residents who participated in the Toronto-Addis Ababa Psychiatry Project (TAAPP) (7). It also clarifies whether participation in TAAPP allowed residents to gain competence as collaborators, scholars, and health advocates.
TAAPP is a partnership between the University of Toronto and the Addis Ababa University whose goal has been to establish the first psychiatric residency program in Ethiopia. The project is described in detail elsewhere in this issue (8). In 2003, Ethiopia had 10 psychiatrists for a population of 77 million (9). TAAPP aimed to increase the number of psychiatrists in Ethiopia and, secondarily, to allow psychiatric residents to participate in an international elective.
University of Toronto residents training in Toronto can apply to TAAPP after at least three years of residency. Selection is made by a committee using a standardized questionnaire. Teams comprised of two University of Toronto faculty members and one resident spend one month teaching in Ethiopia three times per year. They collaborate with psychiatrists at Addis Ababa University to train Ethiopian residents. Toronto residents should learn themselves and to teach Ethiopian residents. Thirteen teaching teams had participated by November 2008.
The project was approved by the University of Toronto health sciences research ethics board. Participation was voluntary and anonymous.
Background information was obtained through consultation with key stakeholders in Canada and Ethiopia including program planners, administrators, and clinical faculty. A questionnaire was developed through consultation and literature review (available from the authors upon request). Semistructured interviews were conducted to examine residents’ experiences. Open-ended questions focused on general and cross-cultural experiences of residents while semistructured questions focused on health advocacy, scholarship, and collaboration. Interviews were conducted, audio-taped, and transcribed. All 13 residents were invited to participate. One declined and one did not respond; 11 residents (85%) were interviewed. There was a gender distribution of six women and five men. Data on age and ethnicity were not collected in an effort to maintain anonymity within the relatively small study population. Modified grounded theory was used to highlight themes and allow for evolution of the questionnaire. This qualitative methodology operates by developing theory from systematically gathered and analyzed data (10–14). Key points are extracted from data, identified by codes, and categorized to form a basis for developing a theory. The three researchers coded data separately then reviewed transcripts, looking for omissions and discrepancies. All themes were extracted, with saturation occurring after seven interviews when no new codes were generated. NVivo7 software (QSR International, 2006) helped researchers categorize and organize themes.
Residents gained international perspective on psychiatry and understanding of advocacy, global health, and poverty issues. They identified the importance of cross-cultural collaboration, and noted that the elective fostered innovative ways of practicing. Residents believed they had become better teachers and scholars. They highlighted the value of being exposed to non-Western research and building relationships with Ethiopian colleagues.
All but one participant described experiences in Ethiopia as positive. The resident with a less positive report noted a lack of clinical experience due to language barriers and a scarcity of teaching opportunities. (All Ethiopian residents and psychiatrists spoke and wrote fluent English.) The main themes are summarized below with illustrative quotations from residents. (Detailed tables and quotes are available upon request.)
Learning to teach was described as one of the greatest opportunities of the elective.
I think that part of my commitment to teaching was forged there because I had such a good experience and saw how positive it can be if you teach in a collaborative way. [Resident 4]
Immersion in a different culture encouraged adaptive teaching styles.
It was my … most intense experience in teaching psychiatry. … I’ve learned about being adaptive in teaching—adapting to people’s needs, trying to listen and incorporate their impressions.[Resident 1]
2. Learning Clinical Skills
Exposure to another health care system broadened experience with different forms of mental illness and treatments.
The other clinical thing that was interesting … was noticing how schizophrenia is a bit different in other countries than in North America … There seems to be more catatonia. [Resident 8]
Residents learned to practice with few resources.
When you do not have resources you have to be creative. … In the Western world, because we have all these resources does not mean we do it the best way. One thing … is … aggressive patients. Here we have a tendency to physically restrain them, give medications to calm them down, but there they talked them down. [Resident 3]
3. Learning to Collaborate
Collaborations were peer-to-peer, resident-to-faculty, and transcultural.
One of the things that was interesting but also really challenging was to incorporate feedback from the residents. [E]very night we would … talk about what we’d done that day in terms of the teaching, talk
[about] feedback or comments … and then talk about what we were going to do the next day and maybe revise what we’d originally planned. [Resident 2]
I got a real sense on a personal-professional level, the collegiality that there is in academic medicine … you have the opportunity to work more side-by-side in Ethiopia and that is something that on a personal level I was really impressed with and it is made me really eager to … continue on. [Resident 10]
I’m still doing some work there so there’s a kind of ongoing professional relationship in that we’re co-investigators on a study looking at mental health outcomes and looking at migration and its influence on mental health outcomes. [Resident 4]
Residents reported learning to advocate for patients and disadvantaged populations.
I have been in emergency rooms for very vulnerable people, able to advocate more resources for them by simply reminding people how little that person has. I feel like I’ve been able to do that a bit more since coming back from Ethiopia. [Resident 8]
Residents stated the elective contributed to awareness of global health issues.
I learned the importance of providing not just aid but actually a skill set for them to become self-sufficient. The purpose of the TAAPP was so that they can build their own residency program and become self-sufficient in that way, rather than having other schools train them. [Resident 3]
5. Learning Leadership and Program Development Skills
Residents cited TAAPP’s leaders as modeling innovative program development
Ethiopia forces you take a different perspective. … It is very easy in medicine to step on the treadmill. It is such an insular culture that unless you … step out of it and critically examine it, you have blinders on. … Questioning of the systems, you start to realize that there are many ways to do things and that there’s so much opportunity to try different things. [Resident 6]
6. Ethical Considerations
Residents reported increased awareness of ethical issues in international collaborations.
[W]e have an obligation, since we’ve started this, to see it through till the end and I know the vision is really long term. … you cannot just sort of fly in, do some things and then take off. … [W]hat TAAPP is doing or trying to do is build that sustainability. [Resident 2]
Residents described decreased bias against non-Western research.
The group that is working there, the psychiatrists … are extremely good researchers who have populations in their society that have different rates of certain mental illnesses. The world does not always take … non-Western people’s research seriously … when really their methods, their methodology and everything else is top notch. [Resident 8]
We read papers done by the Ethiopians and I honestly would probably never have picked up a paper written about people in Ethiopia before that, just because I felt it is not relevant to my practice here. But they do some good research and I think that impacted me to … keep an open mind. [Resident 3]
Mentorship was cited as important in residents’ professional development and career planning.
[S]pending time with faculty mentors allowed me to say, I do want to have teaching as part of my career in the future, that I do want this involvement with residents. [Resident 3]
[T]his is a long spell with one staff, one mentor … they can boost one’s confidence and sense of belonging or feeling right. [Resident 7]
Participants grew as professionals under the guidance of Ethiopian faculty.
I feel so lucky in the mentorship … provided by our Ethiopian colleagues, the mentorship I’ve had with Y that is ongoing … it is such an intense experience for a staff person and a resident, the potential there is really for you to develop a relationship that is a little more profound than meeting once a week for an hour … you … really get to know one another a bit better and then the staff person has a chance to really foster the resident to find out what they’re interested in. [Resident 4]
Peer-to-peer mentorship with Ethiopian counterparts affected Canadian residents’ professional development.
Learning from them was very unique:
[two] residents in a courtyard with about 100 patients for an afternoon which is incredibly different from the numbers and volume that you have here: … 15 minutes to see a patient and come up with a diagnosis where we can spend 45 minutes to an hour … here. And the skills that they have for cutting to the chase are very impressive. [Resident 8]
Almost all residents found the TAAPP elective to be a highlight of their training. They reported becoming better and more adaptive practitioners, teachers, and leaders. They gained an understanding of cross-cultural scholarship, advocacy, and program development. They had opportunities for professional growth through mentorship and collaboration, and they learned the importance of ethical considerations in cross-cultural medical projects. Making connections with people was cited as particularly rewarding.
The themes above represent what residents believed they gained. They learned through the building of close relationships with resident peers as well as Canadian and Ethiopian supervisors. Personal and professional growth was described as residents had to negotiate relationships between doctor and patient, resident and faculty, and Ethiopian and Canadian culture. The elective was demanding, and the work was cited as personal as well as clinical and academic.
Residents cited interest in travel as an important reason for participation and it has been charged that international electives can serve as paid vacations. Based on our data, this is far from the case, given the heavy teaching responsibilities in TAAPP. While it is important to emphasize the benefits electives offer, costs must be considered. Financial expenses are the most evident, but there are also health and safety risks, and time away from other responsibilities. Our study revealed that one participant became ill and one teaching team left early due to political instability.
The international nature of TAAPP evoked ethical reflections. While participants described making efforts to be ethically mindful, their reflections often revealed paradoxes that can occur in collaborative relationships, particularly those across cultural divides. One resident described gaining respect for families and their contribution to patient care; at the same time he believed that encouraging Ethiopian peers to adopt a “Western style of respecting patients’ privacy” was important, as patients typically attend hospital visits with many family members. Participants struggled to synthesize their sensitivity and respect for Ethiopian culture with their own deeply held cultural values.
Our data confirmed studies of international electives describing how participants report a greater inclination to work with immigrants and patients on public assistance after such a program. The TAAPP elective provided participants with opportunities to develop as clinicians, teachers, collaborators, leaders, and advocates. Many residents engaged in advocacy or outreach work after their elective, partly attributing this to their experiences in Ethiopia. TAAPP may be encouraging residents to look for opportunities to serve underprivileged patients. Residents spoke of being inspired by mentorship experiences. They said that these interpersonal experiences were crucial in encouraging them to consider advocacy and leadership roles.
Globalization is affecting medical education with much international collaboration. These collaborations sometimes involve transplanting Western programs along with their underlying values, sometimes primarily for the financial benefit of the Western “donor” program. There is a need for extensive discussions about such collaborations (15). In contrast to these “transplants,” the TAAPP program is one where both Ethiopian and Canadian partners have collaborated in program planning, curriculum development, and resident training. It has aimed for a cultural cross-pollination of ideas between participants. The residents who participated in the current study highlighted the trans-cultural sharing of ideas, including in situations where Western and Ethiopian values differ. Residents referred to scenarios in which they struggled with the tension between the Ethiopian emphasis on family involvement in medical care and the Western emphasis on patient privacy; these situations represent a profound opportunity for cross-cultural dialogue. A similar opportunity was afforded by the tendency of Ethiopian patients to seek many traditional paths of healing before turning to a more typically Western model of medical care. Several residents cited this as thought-provoking regarding their own values.
Self-selection bias was likely present in the study. Many participants had traveled and had an interest in global issues and advocacy prior to participation in TAAPP. Residents were thoroughly oriented prior to each trip by one of the key program planners, but each teaching team was comprised of different faculty members, and thus unique. Residents’ experiences were variable and generalizations cautiously considered. An important limitation of the study was that it did not examine the experiences of Ethiopian residents, who (along with patients) are the primary intended beneficiaries of TAAPP. A follow-up project will focus on Ethiopian residents.
TAAPP’s primary mandate was to support the Addis Ababa University in establishing a psychiatric residency program to serve the needs of the Ethiopian population. Benefits to University of Toronto residents have been considerable. The strongly positive experiences that our residents reported suggest that other universities might consider TAAPP as a model for cross-cultural collaboration. We suggest that, aside from the benefits to Ethiopian psychiatry, residents at the University of Toronto were also beneficiaries of the program. Moreover, the cross-cultural training of other residents in our program may be enhanced through integrating “lessons learned” from participating residents and faculty. We hope that this in turn will enhance sensitivity to patients and overall treatment in our multicultural community.