Applicability of working abroad for physicians with a specialization in Global Health and Tropical Medicine

Background In The Netherlands, physicians specialized in global health and tropical medicine (Ps-GHTM) are trained to work in low-resource settings (LRS) after their training program of 27 months. After working for a period of time in LRS, many Ps-GHTM continue their careers in the Dutch healthcare system. While there is limited evidence regarding the value of international health experience for medical students and residents, it is unknown to what extent this applies to Ps-GHTM and to their clinical practice in the Netherlands. Methods In this qualitative study we conducted semi-structured interviews and focus group discussions (FGDs) with Ps-GHTM to explore the perceived applicability of their experience abroad for their subsequent return to the Netherlands. Topic guides were developed using literature about the applicability of working abroad. Findings from the interviews served as a starting point for FGDs. The interviews and FGDs were analysed using directed content analysis. Results 15 themes are described relating experience abroad to healthcare delivery in The Netherlands: broad medical perspective, holistic perspective, adaptive communication skills, creativity, flexibility, cultural awareness, self-reliance, clinical competence, cost awareness, public health, leadership, open-mindedness, organization of care, self-development, and teamwork. Highlighting the variety in competencies and the complexity of the topic, not all themes were recognized by all respondents in the FGDs nor deemed equally relevant. Flexibility, cultural awareness and holistic perspective are examples of important benefits to work experience in LRS. Conclusion Ps-GHTM bring their competencies to LRS and return to the Netherlands with additionally developed skills and knowledge. These may contribute to healthcare delivery in the Netherlands. This reciprocal value is an important factor for the sustainable development of global health. Identifying the competencies derived from work experience in LRS could give stakeholders insight into the added value of Ps-GHTM and partly help in refining the specialization program.


Introduction
In an increasingly interconnected and interdependent world, global health (GH) [1] is becoming ever more important [1][2][3][4]. The COVID-19 pandemic is an example in which health issues transcend beyond national borders. Aside from the pandemic, GH also encompasses different infectious diseases, trends in non-communicable diseases, cross-cultural interactions and various healthcare systems and requires physicians having the understanding of working in a global environment [2,3,5,6].
The rise of GH historically has a strong connection with colonialist attitudes [7,8]. Understanding the role of colonialism is important to address health inequity and the calls for decolonizing GH have been growing recently to move towards health equity and sustainable partnerships with mutual benefits [9][10][11][12][13][14][15][16]. It is clear that medical tourism can be harmful, especially when performed by unsupervised students [17,18] or even laypersons [19]. In addition, physicians working in these settings, even with good intentions, may also have a negative impact [20,21].
Although training experiences in GH can offer benefits to both sending and receiving party, these experience may also raise ethical challenges. These challenges include burdens on hosts in LRS, concerns regarding sustainability, and negative impact on patients, communities and local trainees [18,22]. Therefore, there is an increasing demand that clinical work abroad should be guided by the GH ethics and aligned with the needs and priorities of local healthcare systems [18,[22][23][24]. This is a complex ethical discussion that requires an understanding of the needs and priorities of receiving parties as well as the implications for sending parties in order to come to a sustainable collaboration [14,17,25].
In the Netherlands, medical doctors can specialize as a physician in Global Health and Tropical Medicine (P-GHTM). This post-graduate training programme consists of training in obstetrics and surgery or paediatrics in Dutch hospitals, followed by a GH curriculum of 3 months and concluded with a period of training abroad under supervision. After training for 27 months the Ps-GHTM are equipped to contribute to healthcare delivery and capacity building as well as the ethical aspects of their work in low-resource settings (LRS) [26]. The training institute in Global Health and Tropical Medicine (OIGT) directs the training of Ps-GHTM and is currently investigating the needs and priorities of local partners in order to improve training of Ps-GHTM. After their training, most Ps-GHTM work abroad for several years before returning to the Netherlands to continue their career. The experience gained abroad can be of benefit to health care in high-resource settings (HRS). Understanding the needs and priorities of local partners, as well as the benefits of experience abroad can facilitate an open discussion on reciprocal collaboration. However, it is unclear what competencies are developed abroad and how they may contribute to healthcare in HRS.
We did not find prior studies investigating competency development by Ps-GHTM, or other physicians in GH, during time spent working in LRS. However, there are studies describing how experiences during international health electives (IHEs) contribute to competency development for students and medical residents [2,[27][28][29][30][31][32][33][34]. Roy et al. describe three domains in which outcomes of international mobility programs for students can be categorized: personal, professional, and cultural [32]. Studies on IHEs have found that students had increased self-confidence, self-reliance, and self-efficacy, along with improved academic performance, enhanced physical examination skills, and increased affinity with under-served populations by experiences in LRS [2,32]. For residents in general practice, enhancement of soft skills, overcoming language and cultural barriers, increased confidence in practicing medicine, increased perspective of healthcare systems, and improved management of (scarce) resources was reported [31]. In addition, improved resourcefulness and cost-effectiveness, improved medical knowledge, enhanced procedural skills, and better physical examinations was described for medical residents participating in such IHEs [29].
These studies suggest that the challenges posed by working in LRS, such as working with fewer resources, dealing with cultural differences and differences in disease presentation, facilitate competency development. Moreover, the importance of reciprocal value in collaboration between partners in high, middle and low income countries is increasingly recognized [6,15]. As such, competencies developed during a period of work abroad, can contribute to professional performance when healthcare workers continue their career in HRS. Describing competency development can help clarify the benefits of experience abroad which in turn can facilitate sustainable partnerships. Many Ps-GHTM who were training or working in the Netherlands were called in to assist in Dutch hospitals during the COVID-19 pandemic based on their assumed competencies in crises, triage and healthcare management. This unique setting provided the opportunity in which the applicability of the gained competencies could be explored. This study aims to explore the competencies of Ps-GHTM gained during their work abroad in LRS and the perceived applicability of these competencies in the Netherlands.

Study design
This is a qualitative, explorative study with interviews and FGDs to provide a rich description of perspectives on the competencies gained by participants during their training and period abroad.

Study population and sampling
Participants were Ps-GHTM who (i) enrolled in and graduated from post-graduate training from 2007 and onwards, (ii) who had worked abroad after graduating, and (iii) who worked (either in the Netherlands or abroad) during the COVID-19 pandemic.
Initially, 61 potentially suitable Ps-GHTM were approached in July 2020 through the Dutch Association of Tropical Medicine and Global Health (NVTG) and OIGT and asked if they were interested in participation. Ps-GHTM that responded positively received an information letter and informed consent. Further recruitment took place through snowball sampling using social media [35]. We aimed to include 20-30 Ps-GHTM as we expected to reach theoretical saturation with this sample size [36]. A total of 33 semi structured interviews and four FGDs were held between July until November 2020.
The study population includes 25 Ps-GHTM between 30 and 68 years old (median = 33, interquartile range (IQR) = 3,5 years.) who graduated between 2009 and 2020. The age of two participants was unknown. Ratio female-male: 17 − 8. Participants have worked in various LRS such as in India, Ghana, and Sierra Leone. The time spent working abroad at the time of the interviews ranged from 7 months to 7 years (mean = 15 months, IQR = 17 months). 24 participants worked in The Netherlands during the COVID-19 pandemic, 1 participant worked in the Gambia.

Scoping search and development of topic guides
We conducted a scoping review on competency development during electives or work abroad. This was done in order gain a general understanding of the topic and to be able to develop topic guides for the semi-structured interviews and FGDs [36,37]. According to the literature, healthcare workers are suggested to develop a variety of competencies in their time abroad. These include: improvement of cultural and interpersonal competency, professional and career development, improved understanding of healthcare systems as well as suggested competencies recognised within HRS such as leadership, collaboration and scholar as described in CanMEDS, improvement of knowledge and skills, improvement of resourcefulness and/or cost-effectiveness [29,31,38]. Based on this literature, a preliminary framework was developed through deductive category development. This allowed the researchers to focus on the research question and identify key concepts as initial coding categories, which were then categorized in three domains (cultural, personal, professional) as described by Roy et al [32,39]. The topic guides were initially developed by LO and HO and were peer debriefed with the research team. Semi-structured interviews and FGDs were chosen, as these allow participants the freedom to explain their experiences in their own words, increasing the resolution of details provided [36]. Following a constructivist approach, participants' perspective was investigated while gaining insight based on the experiences of these participants and the interaction between participants [40].

Semi-structured interviews
A pilot interview was conducted to reflect on the process of interviewing and to analyse the feasibility of the questions prior to the start of data collection. All consecutive interviews were set up online using the application 'Zoom' , or if requested 'Skype' . The interviews took between 45 and 90 minutes. The pilot interview was not analysed. The guide was not static and was periodically reflected upon based on active reflection by the research team [37,41]. Periodical reflection allowed for new items that were not previously described, to be included in the interview.

Focus group discussions
FGDs were held to confirm the data, gain more in-depth understanding of the data, reflect on our interview guide as described previously, define competencies and their themes, and to explain causes and effects of these competencies and themes [36]. By analysing the different perspectives and the conversational exchanges of participants, we defined competencies and themes and explained their causes and effects. The discussions were structured around five selected themes in a FGD guide, based on the most recurring and prominent themes from the interviews. Initially, these themes were distilled from the first six interviews: leadership, communication, organisation of care, cultural awareness and flexibility. Open questions were followed by more theme-specific sub questions to crystallise elaborate information.
Participants of the FGDs were sent ground rules beforehand as the FGD took place via 'Zoom' . The FGDs lasted between 90 and 120 minutes. All participants were asked to partake in the FGDs, but were selected based on their availability on the particular dates. The size of the FGDs were, in chronological order: 4, 6, 4, 6. A total of 13 interviewees did not participate in the FGDs.
The discussion guide was reflected upon before and after every new FGD, as an iterative process. Based on these reflections, changes as rephrasing questions and restructuring order of questions were made [37,41].

Data handling
All data was collected online through the internal recording software of video conference platforms. The audiovisual recordings were stored in a secured digital location in accordance with European General Data Protection Regulation. Transcripts were anonymised using a separate key document. For transcription purposes, files were sent through a password-protected portal. The datafiles (audio recordings, transcripts, and key-document) will be saved for ten years after which they will be deleted, as stipulated by Dutch privacy law. The participants of this study did not gain any direct benefits by participating in this study and received no compensation.

Data analysis
In total, 25 interviews and four FGDs were analysed. Up to the 27th transcript, including 23 interviews and four FGDs, new codes were created. After analysing another two interviews without creation of new codes nor themes, we concluded to have adequate information power. As such, the remaining transcripts were not analysed.
Conducting interviews and FGDs as well as coding and checking were done by HO and LO. The transcripts were coded in Atlas.Ti and analysed using directed content analysis based on the preliminary framework that was established. This iterative process was guided by the following steps [37,39,41].
After six interviews, explorative coding was done to familiarize the researchers with the main topics discussed in the interviews. At this stage, both researchers coded all interviews separately and discussed their findings with the research team. In an iterative deductive process, transcripts were coded and discussed. After the tenth interview, both researchers coded different interviews individually and checked each other's work. The codes were intermittently peer debriefed to the research group for further specification.
Main themes were created to categorise the codes and discussed within the team. The codes were periodically reflected upon and merged or split when deemed necessary. The first FGD started after six interviews, after which the interviews and FGDs were both conducted interchangeably.
The framework of themes and codes was first assessed using the next 10 interviews to test the validity and vice versa. Both researchers each coded half of the transcripts individually and checked each other's work. The framework was specified through this process as some codes required change of themes or new themes to fit into the framework. The framework was peer debriefed regularly.
After this, HO coded the remaining transcripts until no new codes were created. At this point, the codes within each theme were expanded, but no new themes were found. The results were peer debriefed.

Results
All participants perceived benefit from their experience abroad for their work in HRS. A total of 15 distinctive themes were identified after analysis of the transcripts. These themes describe the competency development during work abroad as perceived by Ps-GHTM. Below we describe five themes by using quotes from participants and describe corresponding competencies to illustrate how the competencies are derived. The quoted participants are referred to as: Px. The themes relate well to the domains of competency development as described by Roy et al., as illustrated on Fig. 1. Some themes related to more than one domain. For example, creativity can be of benefit to a P-GHTM in both professional and personal spheres. All themes are summarised in Table 1.

Cultural awareness
Ps-GHTM are experienced in working in teams with people with different cultural backgrounds. Participants reported being able to adjust their approach of others (e.g., team/team members, patients, patient family) to local norms without imposing their own standards upon others, acknowledging that these could be improper in the new context. Ps-GHTM reported adopting a humble and respectful attitude towards the hosting culture, which also increased adherence of the patient to their medical advice.
"You find out that you have a different perspective on things and so are forced to reflect on why things are done in a specific way in your own culture and that other approaches may be possible" (P41).

Adaptive communication skills
Being dependent on team members with different backgrounds and attitudes and having patients with different languages and cultures stimulated Ps-GHTM to reflect on their own ways of interaction and to expand their communication arsenal. Participants reported consciously adapting to the level of training of their team members to establish mutual understanding, even in acute situations. Interviewees emphasised the importance of communication in healthcare delivery, having experienced lack of proper communication, such as cultural and language barriers, as an obstacle for proper healthcare delivery.
"Working with so many different colleagues from different cultures speaking different languages, you develop a certain kind of flexibility in the communication, which could come in handy in the Netherlands with various colleagues but also with a variety of patient groups. You try to adapt to their level of understanding of a language and to their ideas" (P02).

Open-mindedness
Having experienced various traditions and habits, Ps-GHTM report being more open and less judgemental to different views in life, such as alternative medicine. They also reported that, due to intense experiences like frequent deaths, being able to put matters into perspective and understand that the world is not defined by their own views.
"(…) taking into account the perceptions of people and being non-judgemental and curious about it. 'What makes a person go to an alternative healer? What moves a person to do what they do?' Being more curious about it. That strengthens the communication, because people somehow feel that you don't judge them. " (P02).

Public Health
Ps-GHTM worked in settings where providing adequate basic healthcare was difficult, which highlighted the importance of public health to them. Participants report an increased affinity with vulnerable populations and reported being motivated to provide suitable healthcare to them.
"'Wanting the perfect treatment for that one patient, whilst not having enough capacity to treat everyone. What is the best option for all? Who really needs treatment, who doesn't?' I have more experience in that area. " (P07).
"I want to try my best to serve vulnerable populations, like refugees or the homeless, either abroad or in a deprived neighbourhood. To somewhat keep the spirit of what they do in northeast India" (P02).

Teamwork
Ps-GHTM describe valuing diversity within a team and being able to work in a diverse team, having a structured way of working and solving conflict. Moreover, they report considering the expectations of their team members to manage common goals. Ps-GHTM mentioned that they adjust their way of teamwork to the needs of the team, whether this is skills-, knowledge-or communication-wise.
"(…) I prioritise things and also communicate that to others, as in: 'what do we want? What is the most important matter to solve? What are the most urgent issues?' I involve others in this. That's where teamwork reappears, because you cannot do this alone. " (P03).

Discussion
This study explored competency development of Ps-GHTM during their work abroad in LRS and the perceived applicability of these competencies in the    Netherlands. Ps-GHTM perceive their experience abroad as beneficial for both personal as well as professional development. We describe 15 themes which cover a broad range of competencies: broad medical perspective, holistic perspective, adaptive communication skills, creativity, flexibility, cultural awareness, self-reliance, clinical competence, cost awareness, public health, leadership, open-mindedness, organization of care, selfdevelopment, and teamwork. Our findings suggest that a specialisation in GH and work experience abroad, can be of benefit to health care systems in HRS. Our findings are in line with earlier studies exploring the benefits of experience abroad for medical students and residents. Earlier studies found developments in practical skills, such as physical examination, as well as increased self-confidence, increased affinity with underserved populations, improved management of resources and overcoming language and cultural barriers. The differences between previous work and this study lie mainly in the study population, as Ps-GHTM generally remain in LRS for a longer time. We also describe a broader range of competencies, using data from individual interviews as well as FGDs. Ps-GHTM may develop competencies such as cross-cultural communication, management of epidemics or supervising to a higher level as a result of their specialization as well as the duration of their stay abroad. This may also explain development of competencies such as triage, training/education and awareness of community care.
The competencies we describe are a good fit to the three domains as described by Roy et al. In the following paragraphs, we discuss the relevance of these competencies categorised in these domains. Our findings may also provide indirect evidence of competency development of other specialists in tropical medicine, such as tropical medicine doctors from the United Kingdom. Future investigation of the competencies described here and their implications for healthcare delivery in HRS can further elucidate these benefits.
The professional domain goes beyond the individual professional contribution of the P-GHTM but also relates to health care systems. For example, cost awareness does not only affect choices made by a P-GHTM concerning the use of diagnostic scans or other costly tests. The P-GHTM may also influence the awareness of other health care workers of these costs. Cost-effectiveness is an important factor in reducing health expenditure and a way to reduce costs is raising cost-awareness of medical service providers [42]. Similarly, a broad medical perspective can expand the differential diagnosis and include various diseases seldomly seen in HRS. Knowledge on the global burden of disease is important when striving for health equity and improving health systems, which, in turn, will positively affect the global population [43]. A broad medical perspective can also facilitate interdisciplinary consultation and collaboration that may increase effectivity of care. Experience in acute healthcare and medical triage can enhance the necessary focus and judgement in hectic wards or emergency rooms. Of the three domains, the professional domain is most clearly related to healthcare. Development of the competencies can contribute to overcome the challenges of an increasingly complex and demanding healthcare system. In the cultural domain participants described that working abroad has enhanced their intercultural competence; improving their communication skills and enabling them to collaborate with people from various cultures, whilst overcoming language barriers. The Netherlands, like many other countries, has a high prevalence of people of foreign descent [44]. Patient-centred care increases patients' satisfaction of care [45]. Openmindedness, awareness of patients' or colleagues' contextual background and proficiency in cultural awareness helps in providing patient-centred care and may improve teamwork and treatment adherence. Furthermore, communication failures are the most common reason for medical errors [46]. Overcoming cultural and language barriers in healthcare delivery could help reduce such errors. Improving cultural sensitivity and having affinity and working with underserved populations are ways to reduce health inequity [47,48]. As such, competency development within the cultural domain is increasingly relevant to physicians treating diverse populations.
Health disparities are commonly associated with racism, xenophobia or discrimination which are deeply embedded into every modern healthcare system. This counts for many categorizations, such as ethnicity, religion, gender, and sexual orientation. There is increasing evidence it not only effects the discriminated groups but all groups within. Changing these systems requires doctors that can support legal and political measures and empowerment of affected communities to promote change [9,10,12,48,47,48].
Lastly, in the personal domain it is understood that having a global perspective improves understanding of the causes and solutions to local problems [43]. Increased self-confidence and flexibility could prove beneficial in various situations, for example in busy emergency care settings where time is limited or during the COVID-19 pandemic where flexible employment was valued. Lastly, increased stress-resistance is valuable in demanding work environments. Negative emotional states, such as burnouts, not only impede cognitive performance, but also may result in racial bias leading to negative consequences in mindful decision making [49]. Resilience to stress and appreciation of the basic necessities may improve emotional states of Ps-GHTM and aid in mindful decision making. In total, development of competencies within the personal domain improves not only Ps-GHTM, but as an extension their delivery of health care.
The competencies described here often relate to more than one domain, which is to be expected as specific experiences can contribute to development within several domains. For example, cultural awareness not only relates to the cultural domain, but is also an asset within the professional domain. Reflecting the complexity of healthcare delivery, the themes are interrelated and overlapping. The themes also relate to important factors in strengthening health systems worldwide, such as: global and public health, transcendence of professional silo's, establishing transnational networks and gaining transcultural knowledge [43].
The description of these competencies being developed by working in LRS does not necessarily imply that these competencies cannot be developed in HRS to a similar extent. However, working in LRS may offer a sharp contrast to working in HRS in which these competencies stand out more clearly. The competencies gained in LRS may differ from competencies gained through regular medical training programmes and work experience because of contextual factors. We suggest five contextual factors from our data: assuming a variety of roles and responsibilities, being resource-restricted, having great volumes of hands-on experience, having little to no supervision and being (out of one's comfort zone) in various settings, traditions and cultures. For example, multiple participants described their time in LRS as a form of 'pressure cooker' , explaining they gained a significant number of competencies in a relatively short time. On the other hand, many participants noted that not all competencies are directly transferable to their work environment in the Netherlands, such as for example obstetric skills in general practice. Competencies such as communication skills or self-confidence would be easier to apply in both settings. Future research should further investigate the competencies described here and their implications for HRS.

Strengths and limitations of this study
A scoping review prior to collection of data was done to provide meaning to competencies and to explore a broad spectrum of topics. Examining data from the interviews, validating them in FGDs, and reflecting this back onto our interviews and interview guides has led to comprehensive and rich descriptions of competencies and themes. The interviews were conducted with two researchers throughout 31 of 33 interviews and all FGDs, minimising interviewer bias. The process of coding was done by two researchers, which increased validity of the data. In this study we aimed to inductively create a theory around the experiences on participants. As such, we have continued to concurrently collect and analyse data until no new themes nor codes were found to affirm the adequacy of information power.
A number of limitations remain to this study. The questions asked during the interviews and FGDs could be directed to answer positively as to find supportive data, which could lead to positivity bias. There is considerable heterogeneity within the participants: the amount of time spent in LRS, different countries where they have worked, different roles they served in LRS as well as the Netherlands, two different curricula in which participants have been trained, and two different profiles in the training programme. These were not accounted for, although it may have benefitted the study by enriching the data. Physicians that chose to specialize in GHTM and work abroad for years may have a perspective that over-or underestimates the applicability of their competencies for the Netherlands. Having studied multiple perspectives and discussions between participants combined with a broad spectrum of expertise within the research team reduced this bias.

Further research
Several new research questions were composed from this study. As this is an initial study, the adopted themes and competencies could be defined more clearly with additional research. Future research is necessary to explore the effects of the developed competencies of Ps-GHTM on the work floor. Further studies could explore these competencies as perceived by other stakeholders that work with Ps-GHTM after their return to a HRS. Another suggestion would be a prospective study following Ps-GHTM to confirm or deepen the themes found in this research. Future studies could explore the relation of the developed competencies to conventional competency-models (e.g., CanMEDS).
Finally, in this research we have studied the competency development and specifically the applicability of these competencies in the Netherlands. Reciprocal benefit is recognized as an important factor in sustainable development of GH and as such, every effort must be made to enhance partnership and sense of ownership for all parties. The needs and priorities of receiving parties as well as the implications for sending parties must be understood to achieve sustainable collaborations.

Conclusion
This study provides a rich description of the competencies of Ps-GHTM develop in LRS and how these competencies can contribute to healthcare delivery. After their training, Ps-GHTM take their knowledge, skills, and attitudes to contribute to healthcare delivery abroad, commonly in LRS. The competencies they gain could, in turn, contribute to healthcare delivery in the Netherlands. This reciprocal value is important for a sustainable development of GH. Insight in the competencies of Ps-GHTM is essential for all stakeholders, for example in goal-oriented employment of Ps-GHTM. We believe that this study generates a foundation for possible hypothesis generation and, by extension, testing these hypotheses. Acknowledging the importance of GH and globalisation, the mutual benefit of competencies gained abroad and the themes described in this study, Ps-GHTM add to the challenge of striving for health equity worldwide.