The authors employed a qualitative study design drawing upon constructivist grounded theory, which emphasizes the ways in which meaning is created socially and experientially.¹¹ The authors selected focus group discussions to facilitate an open discussion between study participants. The authors developed a semi-structured discussion guide based on a review of the existing literature on professionalism in medical education, using an iterative process until authors achieved consensus on the content of the discussion guide. Discussion guides favored open-ended questions designed to elicit experiential data. Careful attention was paid so that questions and discussion probes were worded neutrally. All participants provided written informed consent to participate in the study. The only incentive provided was refreshments for each participant during the focus group discussion. Demographic questionnaires were completed by participants at the beginning of each focus group discussion. Moderators conducted focus group discussions in English.

This study was conducted at two Baylor College of Medicine Clinical Centers of Excellence in sub-Saharan Africa (Malawi and Lesotho). Annually, these sites host approximately 50 STGHE learners from multiple institutions in the United States and Canada. These sites were chosen because of the large volume of STGHE learners and because several of the authors had long-standing working relationships with these sites. STGHE learners include medical students, residents, and fellows who spend up to six weeks at these outpatient sites. These sites are part of the Baylor International Pediatric AIDS Initiative, which provides family-centered health care, health professional training for both local and international learners, and clinical research focused on HIV/AIDS, tuberculosis, malaria, malnutrition, and other conditions impacting the health and well-being of children and families worldwide.¹²

The authors used purposive sampling to identify potential participants by obtaining a list of all employees who work as host clinical preceptors. Host clinical preceptors in this study were clinicians in Malawi and Lesotho who supervise the clinical care delivered by medical learners from the United States and Canada during STGHEs. Host clinical preceptors were invited by email and by announcement at staff meetings to participate in the study if they met all of the following inclusion criteria: employees at the Clinical Centers of Excellence in either Malawi or Lesotho, had at least six months of experience supervising STGHE learners, and completed their medical training in a low- or middle-income country. Host clinical preceptors were pediatricians, clinical officers (i.e., clinicians who had three years of medical education in Malawi after the high school equivalent and two years after the high school equivalent in Lesotho), and medical officers (general practitioner physicians who have completed medical school and internship but no residency or sub-specialty training). All host clinical preceptors at the two sites were fluent in English. Host clinical preceptors were excluded if they did not meet the study’s inclusion criteria. Six host clinical preceptors participated in the focus group discussion in Malawi and five in Lesotho (Figure 1), representing 85.7% and 45.5% of all host clinical preceptors in the respective countries who met inclusion criteria. Host clinical preceptor demographics are found in Table 1.

To establish the credibility of findings, moderators trained in focus group methodology (authors CAR and EMK) conducted one focus group discussion at each of the two sites (Malawi, April 2016 and Lesotho, June 2016), with the co-moderators present to assist with logistics. The moderators and co-moderators were physicians from the United States who had each been placed in their respective site for a 12-month clinical assignment who worked alongside focus group participants. Each focus group discussion was held in a private conference room in each of the clinics. At the beginning of the session, the moderators introduced themselves and presented the rationale behind the study. Each focus group lasted between 60-90 minutes and questions were probed until saturation was achieved. To establish confirmability of the findings and to make the data available for review by other investigators, interview moderators audio-recorded and manually transcribed interviews and double-checked transcripts for accuracy. Moderators de-identified data at the time of transcription. Transcripts were uploaded into Dedoose version 7.5.17 (Los Angeles, California), a secure, cloud-based qualitative analysis software.¹³

The study protocol was approved by the Malawi National Health Sciences Research Committee, the Lesotho Ministry of Health National Health Research Ethics Committee, and the Institutional Review Board of Baylor College of Medicine.

Two authors experienced in qualitative research who did not participate in the moderation of focus groups (HL and PS) performed a thematic analysis to explore salient topics that emerged during the focus group discussions. To establish the dependability of the findings, two authors (HL and PS) independently coded the transcripts using an inductive approach. After independent coding, the two authors discussed disagreements with the larger research team and used a consensus-building process to identify codes that most accurately and completely represented the data. The authors also informally assessed the wording of questions and probes as captured in transcripts to ensure there were no leading questions. Finally, the authors discussed overarching categories, themes, and representative quotations.

Host clinical preceptors cited several attributes and behaviors among STGHE learners as professional. These attributes included adaptability and initiative. Perceived professional behaviors included active listening, gratitude, and punctuality. One host clinical preceptor commented:

“You will find that some learners are ready to learn. They are polite. They are always on time, and they are ready to listen to you.” (No. 4, Male, Malawian)

Another host clinical preceptor commented on the added benefit of exposure to new resources and information while hosting STGHE learners:

“Some learners are very interested in the patients, and they provide their input when you are seeing patients together. They even suggest resources where you can get more information.” (No. 7, Female, Mosotho)

Several host clinical preceptors commented on the empathetic attributes of STGHE learners. One preceptor remarked:

“At times, you think you are done with the patient encounter and the learner begins to talk to the caregiver about what the family is going through. They are very empathetic.” (No. 2, Male, Malawian)

It was perceived that learners experience difficulty adapting to the medical management in Malawi and Lesotho. Host clinical preceptors perceived that STGHE learners’ form of communication differed from that which is customary in the study settings. When disagreements arose regarding how a patient should be managed, many host clinical preceptors perceived that learners displayed negative attitudes, superiority, inflexibility, or authoritarianism:

“At times, I do not agree with the management that the learners propose, but I still try to listen to their input. There are many times that they are resistant to the management that I propose.” (No. 9, Female, Mosotho)

Moreover, cited unprofessional attributes and behaviors included unresponsiveness to feedback, apathy, and inappropriate interruptions. Host clinical preceptors also cited unprofessional dress including informal clothing or wearing “revealing clothing such as miniskirts” as an unwanted behavior among STGHE learners (No. 10, Female, Mosotho). Disregard for local clinical expertise, especially for health care workers that were not physicians, was commonly cited as an unprofessional behavior among STHGE learners. One host clinical preceptor stated:

“It becomes very difficult to impart knowledge on some learners because, as the saying that goes, 'You can take a horse to the well, but you can’t force it to drink.' So, they may be with you physically, but their mind is elsewhere.” (No. 4, Male, Malawian)

Host clinical preceptors stated that when STGHE learners act unprofessionally, they affect the perception of all STGHE learners. In some cases, unprofessional interactions may make host clinical preceptors hesitant to precept STGHE learners in the future. Moreover, some host clinical preceptors perceived that the pace and quality of patient care were negatively affected when STGHE learners act unprofessionally:

“Let’s say that I am sitting in the room with a learner who has annoyed me; it means that, let’s say in a day I see 15 patients, that particular day I won’t see 15. Not even close." (No. 5, Male, Malawian)

Some participants felt that vocal disagreements between host clinical preceptors and learners could undermine the patient-clinician relationship:

“If a patient sees you and the learner argue then they may not end up trusting you. That is dangerous in the eyes of the patient. It could lead to mismanagement of our patients.” (No. 8, Female, Mosotho)

Respondents described discrepancies between what may be considered professional in the United States but not in settings similar to the two sites in sub-Saharan Africa, citing differing communication styles with both colleagues and patients:

“It seems to be a problem in the West if you don’t explain to patients what they are suffering from. But here it doesn’t matter unless the patient or the guardian asks about it. That’s when you go into the details.” (No. 1, Male, Malawian)

Host clinical preceptors also cited cultural differences as a potential challenge in providing feedback to STGHE learners.

“When the feedback is troublesome it is difficult to say. We tend to think, ‘Oh, they will only be here for a month. I can live with that for a month.’ So, we don’t give negative feedback. We also don’t know how they will respond to our feedback.” (No. 11, Female, Nigerian)

Host clinical preceptors requested pre-departure preparation for STGHE learners with a clear explanation of host clinical preceptors’ expertise, learners’ role, and professionalism across cultures. Respondents requested an orientation before hosting learners with clear descriptions of the learner’s level of training.

“If we are told that these are medical doctors from the United States but you find out that the person is a medical student, it is a bit confusing. It reflects a lack of truth in it.” (No. 9, Female, Mosotho)

Host clinical preceptors also requested the creation of a formal mechanism for two-way feedback:

"Sitting down with learners to fill out evaluations may be difficult because we may also ‘swallow it’. And it should be both ways, we can evaluate them and give formal feedback and they can also give formal feedback about us.” (No. 3, Female, Malawian)

Several respondents requested improved communication between sending and hosting institutions. One such example was the following quote:

“There should be somebody that we can talk to when we have feedback. We should be able to notify them of issues so that learners do not repeat the same mistakes. This way learners will know what is expected of them based on previous experiences.” (No. 10, Female, Mosotho)

We would like to thank the host clinical preceptors who participated in this study and provided their valuable insight to improve short-term global health electives. We would also like to thank Drs David S. Sullivan and Kimberley Farr for their assistance in moderating the focus group discussions in this study.

The authors declare that they have no conflict of interest.