Support infrastructure available to Canadian residents completing post-graduate global health electives: current state and future directions.

BACKGROUND
Global health electives offer medical trainees the opportunity to broaden their clinical horizons. Canadian universities have been encouraged by regulatory bodies to offer institutional support to medical students going abroad; however, the extent to which such support is available to residents has not been extensively studied.


METHODS
We conducted a survey study of Canadian universities examining the institutional support available to post-graduate medical trainees before, during, and after global health electives.


RESULTS
Responses were received from 8 of 17 (47%) Canadian institutions. Results show that trainees are being sent to diverse locations around the world with more support than recommended by post-graduate regulatory bodies. However, we found that the content of the support infrastructure varies amongst universities and that certain components-pre-departure training, best practices, risk management, and post-return debriefing-could be more thoroughly addressed.


CONCLUSION
Canadian universities are encouraged to continue to send their trainees on global health electives. To address the gaps in infrastructure reported in this study, the authors suggest the development of comprehensive standardized guidelines by post-graduate regulatory/advocacy bodies to better ensure patient and participant safety. We also encourage the centralization of infrastructure management to the universities' global health departments to aid in resource management.


Introduction
Post-graduate global health (GH) electives are valuable opportunities for residents to increase knowledge, 1 diversify their skillset, 2 and develop cultural sensitivity. 3In 2009, a review of studies showed that residents are increasingly incorporating the availability of GH electives into their selection criteria of residency programs. 4Residents who have completed GH electives have also been found to be more confident, have greater sensitivity to cost issues, rely less on technology, and have a better appreciation for cross-cultural communication.

5
GH electives call residents to adapt to new challenges; this makes support infrastructure from the home and host institutions an important resource.

6,7
Such infrastructure includes predeparture training (PDT), bodily-fluid exposure protocols, best practice guidelines, and post-return debriefing (PRD).The Royal College of Physicians and Surgeons of Canada (RCPSC) provides a modest framework (see Appendix A) for the organization of GH electives. 8There are no such guidelines available from the College of Family Physicians Canada.
Given recent initiatives to standardize the GH elective infrastructure available to medical studentsparticularly in regards to PDT

Results
Twelve complete survey responses were received.These were completed by universities' global health directors or post-graduate vice-deans; one respondent, belonging to a global health department, self-identified as "physician."In certain cases, completed surveys were received from multiple individuals involved with global health at a single institution; these were synthesized to one response per university by including positive-over-negative responses (as one individual was likely aware of infrastructure that the other individual was not).In total, responses were received from eight of 17 universities (47%): McGill University, University of Ottawa, Laval University, University of Toronto, University of Alberta, University of British Columbia, Queen's University, and one anonymous institution.Responses were randomly coded to maintain anonymity.
Six of the eight responding universities offer PDT for residents pursuing GH electives.The training is mandatory at three of these institutions.Of the three universities with non-mandatory PDT, two are aiming to make the training mandatory; the remaining university has its residents sign a guideline document.The content covered during PDT by the six universities is outlined in Figure 1.

Figure 1. Percentage of responding universities that cover specified content during their pre-departure training of residents within the framework of a) Travel arrangements, b) Other logistical issues, c) Ethical considerations, and d) Health issues. (n=6)
The locations to which universities send their postgraduate trainees are outlined in Figure 2. Three universities permit students to work in Department of Foreign Affairs and International Trade level two or three countries while five universities restrict travel to level one settings (where higher levels-from one to four-refer to higher risk areas).All universities have a supervisor at the host institution and all but one have a supervisor at the home institution.Two of the eight universities offer best practice guidelines for practicing medicine overseas; one of eight provides a formal code of ethics.Travel registries are available at five of eight institutions; mandatory enrolment is required in three, with one additional university transitioning to mandatory enrolment.
Regarding safety, five of the eight universities require participants to sign waivers outlining the risks of practicing abroad before departure.Bodily fluid exposure protocols are available at four of eight universities.The components offered include incident reports (n=2), home-site contact (n=4), on-site contact (n=0), post-exposure assessment procedure (n=3), HIV prophylaxis (n=1), HCV prophylaxis (n=0), written post-exposure protocol (n=3), on-site testing (n=1), communication with local site (n=1), communication with home centre (n=3), designated

Discussion
GH electives provide the opportunity for medical trainees in diverse settings to develop both their clinical and cultural competencies.The results of this survey are encouraging, suggesting that Canadian residents are completing electives across the globe with more infrastructure than currently mandated by bodies such as the RCPSC; however, there is still room for growth.The present study has identified four potential areas of development regarding Canadian GH elective infrastructure: PDT, professionalism, risk management, and PRD.
PDT is available at the majority of institutions with varied coverage of content.This availability likely traces its roots back to the push for mandatory PDT for Canadian medical students 9,10 and to the growing support of PDT by resident advocacy bodies.

14,15
While post-graduate PDT has yet to be standardized, many guidelines have been published to help institutions develop more evidence-informed training. 7,11More uniform adoption will be required to bridge the gap between undergraduate and postgraduate training.
Professional guidelines are another resource that could be made more consistently available.During GH electives, residents may be exposed to ethical dilemmas beyond the scope of their home training. 16 Professional/ethical frameworks-in addition to the guidance of the host supervisor-would help trainees to better navigate these dilemmas.These standards could be developed at the level of the institution or at the level of the college and ideally should offer program-specific guidance.
Post-exposure resource availability is another important gap in GH elective infrastructure.Since medical trainees under-report bodily fluid exposure, [17][18][19] the finding that only half of responding universities have post-exposure infrastructure-with inconsistent coverage of content-is concerning.The authors recommend the standardization of safety resources for GH electives, with consideration of the resources outlined in the Results section.
Finally, universities should be encouraged to uniformly offer PRD.PRD is a continuation of a process that begins with PDT that allows for the appraisal of the elective in the context of GH objectives; 7,20 it is also helpful to address any moral distress that may have been incurred during the elective.Similarly to PDT, there is no standardized Canadian PRD.However, there are published guidelines that offer institutions a reasonable template for its development.organize post-graduate elective infrastructure.While this may require initial financial investment at the onset, the pooling of resources among programs would likely decrease overall costs in comparison to establishing independent, overlapping infrastructure.These modifications will ideally help improve the safety profiles of GH electives and allow residents to provide more meaningful service across the globe.

Limitations
One limitation of the present study was the response rate.We suspect that programs that do not offer GH electives elected not to respond to the survey.Regardless, the survey was considered geographically representative of Canadian medical institutions (with the exception of Atlantic Canada).A second limitation was the difficulty of assessing GH elective infrastructure by university.Since residency programs often organize GH infrastructure independently, the survey respondent may not have been fully aware of all the programming available at their university.Again, this points to the utility of a centralized GH body to disseminate information within, and eventually amongst, universities.In the meantime, future studies examining the availability of GH elective infrastructure by program would be useful to gauge the growth of elective infrastructure.

Conclusions
Canadian medical programs are offering more institutional support to their trainees abroad than mandated; however, there is potential for further development.• DFAIT level 2 country allowed (Y/N) • DFAIT level 3 country allowed (Y/N) • DFAIT level 4 country allowed (Y/N)

Figure 2 :
Figure 2: Locations to which responding Canadian universities send their post-graduate medical trainees for global health electives.
Questions were developed after a literature review with the help of GH leaders at McGill University.The survey was tested at the home institution before distribution.If the post-graduate dean could not answer the survey, responses were accepted from other global health authorities.Open text responses were allowed in case of perceived question ambiguity.Responses were collected from April 2014 to January 2015.Descriptive statistics were performed using Microsoft Excel™ by author LS.The McGill Institutional Research Board approved this project.
Who administers the pre-departure training (which department/office)?(Open Text Response) 8. Please list any other pre-departure training offered by your faculty that were omitted from previous questions?(Open Text response) 9. Does your faculty provide post-graduate trainees with Best Practices Guidelines for practicing medicine oversees?(Y/N, Open Text Response) 10.Does your faculty have a publicly available Code of Ethics for practicing overseas?(Y/N, Open Text Response) 11.Does your faculty offer cultural and/or language preparation resources to post-graduate trainees?(Y/N, Open Text Response) 12. Does your faculty have a publicly available Code of Ethics for practicing overseas?13.Do you have a travel registry for post-graduate trainees?(Y/N, Open Text Response) • If yes, is it mandatory?(Y/N, Open Text Response) 14.What is the safety standard applied for location of travel?Please select the highest DFAIT country level permitted.