Host site experiences with resident and fellow global health electives: a qualitative study

Abstract

Background

Global health electives (GHEs) are increasingly integrated into residency and fellow training programs within the United States, offering benefits for trainees and institutions. However, limited data exists on the investment host institutions make to provide these experiences. This study aimed to explore the costs, benefits, and contextual factors that influence whether hosting visiting physician trainees is viewed as a worthwhile investment by GHE host sites.

Methods

We conducted a qualitative study using reflexive thematic analysis of semi-structured interviews with 11 physician educators from nine designated Mayo International Health Program (MIHP) global partner sites across Africa, Asia, and Central and South America. Participants included both national and expatriate physicians with longstanding institutional partnerships with Mayo Clinic. Interviews were transcribed, coded, and analyzed to identify key themes related to host experiences.

Results

All participants acknowledged both the costs and benefits of hosting physician trainees on GHEs. Costs included time spent coordinating logistics, orienting and supervising trainees, and providing housing and resources, often within resource-constrained settings. Benefits included clinical workload support, educational contributions, staff morale enhancement, and institutional capacity strengthening. Perceptions of reciprocity varied where some felt their institution and the visiting trainee benefited equally, while others believed the visiting trainee gained more. Hosts identified strategies to improve reciprocity, such as stronger institutional partnerships, provision of relevant supplies, and bi-directional exchange programs. Three contextual factors strongly influenced whether hosts viewed their investment as worthwhile: trainees’ language proficiency, level of training and engagement, and rotation duration. Despite costs noted, many hosts described GHE experiences as a meaningful investment when trainees were well-prepared, engaged, and stayed for at least one month.

Conclusions

Host institutions recognize value in hosting GHEs, yet this value is contingent upon thoughtful elective design. Trainee characteristics and rotation logistics significantly impact perceived reciprocity and institutional benefit. To ensure GHEs are ethical and sustainable, sending institutions should prioritize longer rotations, match trainees’ experience to host capacity, direct pre-departure planning, and foster ongoing, reciprocal partnerships. Continuing to explore host perspectives is critical to developing more equitable and impactful global health training programs for all parties.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09824-1.

Background

Global health electives (GHEs) are offered in the United States by many residency and fellowship programs and provide numerous benefits to physician trainees, their programs, and the global health community. A 2017 review reported that many programs across specialties provide GHE opportunities for trainees [1]. Trainees identified many benefits to participating in GHEs, including gaining global health knowledge and perspectives, developing clinical skills, learning to work with limited resources and with diverse populations, increasing cultural humility, and reflecting on high-value, cost-conscious care [2–9]. GHEs provide valuable and unique opportunities to help trainees achieve the Accreditation Council for Graduate Medical Education (ACGME) core competencies [10, 11]. For training programs, offering GHE opportunities may provide an edge in recruitment [12–14]. For the global health community, GHEs may diminish healthcare disparities, as trainees who participate in GHEs are more likely to work in primary care fields and practice in underserved areas domestically and abroad [3, 15–17].

Despite the numerous benefits of GHEs, there are also challenges to trainees, training programs, and host communities. Prominent challenges identified by trainees and their programs were the financial costs of an overseas elective, difficulties overcoming cultural differences, challenges meeting host expectations, inadequate elective time, difficulty developing good relationships at the host site, and conflicting objectives between learners and their hosts [18–21]. Previous studies have highlighted limitations in the clinical and cross-cultural competencies of trainees participating in GHEs [6, 19, 20, 22–25]. Concerns have been raised regarding voluntourism, in which benefits experienced by the participant and home site outweigh the benefits experienced by the host community [6, 26]. These concerns include failure to balance the need for individual medical care versus working on public health measures best for community health, failure to provide adequate preparation for the elective, failure to adequately supervise learners, failure to engage local health providers to better understand the health needs of the host community, and failure to provide reciprocity to build capacity of the under-resourced low- and middle-income country (LMIC) host institution and country [22–25].

Recent research has explored the motivations and challenges of GHEs from host perspectives. Hosts report several difficulties with hosting GHEs, including poor attitudes of visiting trainees, lack of clear objectives and pre-departure training, and asymmetric benefits gained between visitor and host site [27–32]. While hosts agree that an engaged, culturally humble, senior trainee can lead to mutually beneficial learning for both parties, several hosts note feeling disrespected in their own institution due to the arrogant and demanding attitudes of visitors [27–29, 31–33]. Studies emphasized a need for improved pre-departure training, especially stronger and more consistent cultural and language preparation [28, 34]. Additionally, when visitors prioritize travel over clinical work, hosts fear that the current GHE approach facilitates voluntourism instead of the development of sustainable and ethical partnerships [28, 33]. Failure of trainees and their sending institutions to follow through on promises (e.g., research engagement, fundraising, and returning to the site) further deteriorates trust and reciprocity in these relationships [27, 35]. Across these studies, hosts sites had consistent recommendations for improving GHEs: clearer objectives that reflect all stakeholders, improved pre-departure training, increased financial contributions from sending institutions, and the development of structured, bi-directional exchange programs [27–29, 31, 32, 34]. While investigation of these important insights is a good step towards improving reciprocity and equity, much remains unknown about the specific costs and benefits of GHEs as perceived by host institutions and what distinguishes a meaningful investment from one that ultimately is burdensome to local communities.

As the number of global health opportunities for trainees continues to increase, careful thought is needed to structure these opportunities in a way that minimizes the cost and risks inherent in GHEs to host institutions. In this study, we interviewed key faculty at host GHE sites to explore the positive and negative impacts of hosting residents and fellows. While prior studies have described host perspectives on GHEs, we aimed to further examine how hosts interpret, assign meaning to, and justify their experiences hosting visiting trainees, particularly in relation to concepts of investment, reciprocity, and institutional burden. We used reflexive thematic analysis to allow for interpretative exploration of these experiences with the goal of defining and refining best practices and optimizing experiences for both trainees and host institutions.

Methods

We conducted a qualitative study using reflexive thematic analysis to explore the perspectives of host institutions on the costs and benefits of hosting trainees on GHEs [36]. We pursued rigor through approaches aligned with our methodology, including reflexive analysis, team-based interpretation, and thick description. As a research team, we have been involved in GHEs as participants (RLK, APS) and as Mayo International Health Program (MIHP) leaders (APS, SPM). RLK is a medical student who participated in a one-month clinical elective in Ghana as a part of the MIHP. APS has participated in the MIHP as a resident and currently serves on the leadership team. He is a medical education researcher and has explored the role of GHEs on the learning and growth of trainees [2, 8, 9, 11]. That previous research informed the current study, highlighting the need to explore the experiences of GHE host institutions. SPM serves as the immediate past chair of the Mayo International Health Program selection committee, a role he held for 17 years. This position involved direct oversight of the funding and logistical facilitation of global health electives for resident and fellow trainees at Mayo Clinic. All three members of the research team are white, of middle-class background, and were born and raised in the United States. We acknowledge that our backgrounds and institutional affiliation with a major academic medical center in the Global North creates inherent power dynamics with international host sites. We recognize that these relationships could influence how host site staff share their experiences. To address this, we utilized a reflexive approach with data collection by an independent researcher (summer undergraduate student) to ensure a nuanced understanding of host site perspectives that remains critical of institutional extractive practices.

Setting

The MIHP has been sending residents and fellows on GHEs since 2001 and has sponsored more than 647 MIHP trips in 65 countries at 195 different sites. There are now 12 MIHP designated sites in countries across Central America, South America, Africa, and Asia. Designated sites are teaching hospitals chosen based on longitudinal reciprocal relationships which strengthen capacity at host sites and a history of excellent teaching of our learners to ensure optimal educational experiences. Additionally, each of these sites regularly hosts Mayo Clinic consultants as well as trainees.

Participants

We purposively sampled physician contacts at each of our designated sites, inviting them to participate in a one-hour semi-structured interview. At some designated sites there are different contacts for separate specialties. We enrolled 11 medical and surgical physician contacts from 9 MIHP designated sites. These physician contacts have all participated in both elective coordination and trainee supervision during MIHP electives.

Interviews

We conducted one-hour virtual interviews using a semi-structured interview guide (see Additional File 1). Interview questions were developed by the research team after literature review, seeking to address key themes identified in the GHE literature, and refined through discussion with faculty involved in MIHP. Verbal informed consent was obtained, and participants were assured that their responses would be kept anonymous and would not affect their ongoing relationship with the Mayo Clinic. All interviews were conducted by the same interviewer with no prior relationship with any participant.

Data analysis

All 11 interviews were audio-recorded and transcribed verbatim and checked for accuracy by the primary author (RLK). One interview was unable to be transcribed due to poor audio quality. However, this host provided the team with written responses to the core interview questions. The remaining 10 interviews were also used for our analysis. The members of the research team (RLK, APS, SPM) read each transcription to familiarize ourselves with the data and identify interesting patterns and initial codes. Reflexive journaling was used throughout the analysis process. We then used those initial open codes to create a codebook, agreeing upon included codes and their definitions as a research team. There were nine codes included in the codebook. The primary author (RLK) uploaded all the transcripts into Dedoose (Version 10.0.35, Los Angeles, CA: SocioCultural Research Consultants, LLC) and applied the codes to all the transcripts. Coding was reviewed by a second author (APS). As a team, we reviewed the quotations included within each code and identified key themes, refining them through discussion. Key quotations were identified, and all quotations included were de-identified to protect the host institution and participant.

This study was approved by the Mayo Clinic Institutional Review Board as a minimal risk study.

Results

Demographic characteristics of the 11 host participants involved in this study are summarized in Table 1.

Table 1.

Mayo International Health Program Designated Host Sites

Country	Hospital Name	Medical vs. Surgical Specialty	Expatriate/National Physician	Trained at Mayo Clinic
Cameroon	Mbingo Baptist Hospital	Surgical	Expatriate	No
Cameroon	Mbingo Baptist Hospital	Surgical	National	Yes
Ghana	Crystal Eye Clinic	Surgical	Expatriate	No
Haiti	St. Luke Family Hospital	Medical	National	No
Kenya	St. Mary’s Mission Hospital	Surgical	National	No
Kenya	Tenwek Hospital	Surgical	Expatriate	Yes
Kenya	Tenwek Hospital	Medical	National	Yes
Malawi	Blantyre Adventist Hospital	Medical	Expatriate	Yes
Nepal	Patan Hospital	Medical	National	No
Tanzania	The Children’s Hospital at Zinga	Medical	Expatriate	Yes
Uganda	Bwindi Community Hospital	Medical	National	No

All our participants discussed the numerous costs and benefits of hosting trainees on GHEs, specifically recognizing personal and organizational costs. However, many participants described these costs as worthwhile, often framing them as an investment. One participant described the costs and the concept of investment:

It takes time to get people oriented to a new place, new country, new culture…But it’s an investment, though, as once I get them oriented, they start really jumping in and helping with the specific workload in the hospital (participant 8).

Although all hosts acknowledged some degree of benefit, perspectives varied regarding the extent to which these benefits justified the investment required. Some respondents felt that their efforts were appropriately reciprocated, while others expressed uncertainty about whether the exchange was truly equitable. To better understand the concept of host site investment, we categorized responses into four themes: (1) cost, (2) benefit, (3) reciprocity, and (4) investment factors.

Cost

Cost was a recurring concern across all interviews, including the demands of coordination, use of physical resources, and time required to orient and supervise visiting trainees. Rather than being described as exceptional, these costs were often normalized as part of participation in global health education, though their magnitude varied by site and context.

GHE coordination

Pre-departure planning required a significant coordination effort for many hosts, particularly at sites without administrative support. While some locations have education offices or third-party companies that aid in GHE coordination, others reported managing the coordination themselves, adding responsibilities to their clinical duties. As one respondent explained:

Right now, with no one to help me, it’s the planning phase [that’s most difficult]. Who’s buying their ticket? Who’s covering their health insurance and travel insurance? Someone has to send them the packet telling them what’s culturally appropriate (participant 1).

Even in the presence of administrative support or long-standing institutional relationships that make coordination simpler, planning GHEs required many hours of work from host supervisors. This commitment was significant as hosts described limited time while caring for a large volume of patients.

Physical resources

Hosts described limited physical resources, including housing and hospital infrastructure, as barriers to hosting visiting trainees. A few hosts reported offering a space within their own homes to these trainees, some providing visitors with meals. While most hosts believed the amount trainees paid for accommodations was sufficient, a few disagreed, but weren’t planning to increase costs:

The pay does not sufficiently cover the costs. We feel that regardless of where they come from, they have no source of income (participant 6).

Beyond housing, visiting trainees can place strain on clinical supplies and hospital infrastructure:

The organization does not incur direct costs apart from operational costs. For example, two pairs of gloves are required instead of one during an examination (participant 6).

Hosts described the need to be cognizant, ensuring they had enough supplies available within the clinical workflow. As housing and clinical equipment can be limited, using these resources on visiting trainees puts additional stress on host institutions.

Orientation and supervision time

The cost of time encompassed both logistical and clinical responsibilities. The time required to onboard visitors, supervise trainees in clinical activities, and even provide them with tours of the town and medical center was another significant cost. Hosts monitored decision-making, facilitated hands-on learning, and bridged communication between patients and visiting trainees, all while assuming full professional responsibility. All respondents reported the need to guide trainees and supervise their clinical decisions:

Whenever a resident goes to a new hospital, they have to learn that hospital’s policies. The international residents have to be supervised. They do not know the hospital. They also don’t know some of the diseases, and they don’t know what technology we have or don’t have. There are a lot of things they are used to that we don’t have… I see a lot of times residents will write orders that don’t get done because they do not fit into the system here. It takes a while for them to learn that, and it is important that one of the chief residents or myself review visiting doctors’ orders (participant 2).

Several hosts described picking up the trainees from the airport and spending time entertaining them:

The other challenge is on the weekends when not everybody is in the hospital: finding stuff for them to do, making sure they are safe. Some may want to see a bit of the town, so we’ll ask a few locals to take them around and maybe buy a few gifts and stuff like that (participant 3).

Across interviews, the cumulative time commitment was not described as a temporary disruption but rather a sustained adjustment to daily workflow. Throughout the duration of the GHE, hosts noted extended workdays and responsibility redistributions to ensure adequate supervision of visiting trainees.

In summary, hosts viewed cost as unavoidable when hosting GHEs, requiring sacrifices in their time and energy. There was also a cost to local communities and the clinical institutions as visiting trainees utilize housing and clinical supplies during their electives. The extent of these costs is even more appreciable because at many host sites, time and physical resources were noted to already be limited. These costs however were not framed as isolated challenges. Hosts noted these as embedded conditions of participation, shaping how they later evaluated investment and reciprocity.

Benefit

Despite the costs associated with hosting a GHE, many respondents also described the short- and long-term benefits to their institution and the broader goals of global health. Primary benefits included assistance with workload and enhancement of patient care, provision of educational material, morale enhancement, and both local and global capacity strengthening of the host institution.

Workload assistance

Hosts noted additional clinical activity as a primary benefit to hosting GHEs. Although visiting trainees required additional supervision by local staff during the initial onboarding period, many were eventually able to see patients and lessen the workload:

When they are in the hospital, we can see more patients. There are situations like when they come to subspecialty clinic where for the first few days, we may have to give some time, but once they are familiar with the system, they can see patients and increase the capacity of the clinic (participant 7).

In some cases, hosts noted that the benefits of visiting trainees in the clinical workflow extend beyond staff and benefit patients directly:

During the ward rounds, the patients benefit from the wider discussion of the case at hand because of questions and explanations. Also, this kind of interaction tends to trigger systematic approach to planning the patient care (participant 6).

Additionally, several hosts refuted the idea that international trainees dilute local learner opportunities:

There is enough work, enough patients, and enough cases to go around. In fact, we find ourselves depending on the international residents sometimes to fill in to get all the ORs running and to get the call schedule filled. So, it’s not like there’s competition or there’s diluting out of the experience for the locals. We do have to watch that, but it certainly has not been a problem (participant 2).

While visiting trainees initially require close supervision and orientation, many are able to contribute meaningfully within the workflow of the host institution. This is especially critical as host institutions have staff and other resource shortages that can make it challenging to care for all patients.

Educational contribution

Educational exchange was a way to improve local learning environments and provided both short- and long-term benefits to host institutions. Presentations from visiting trainees were a useful contribution, with many hosts adding visiting trainees to their conference schedule. Hosts had trainees present on specific disease processes, medication management, difficult cases, or updated guidelines. Additionally, three hosts mentioned that visiting trainees can have a greater impact by enhancing the culture of learning and growth at a local institution:

Residents contribute their knowledge, skills, and experience. They bring new ideas and contribute to building local capacity of clinic staff and patients. Cultural beliefs about diseases and stigmatization negatively impacts efforts to bring health care to hard-to-reach areas. Reinforcement of health education talks by expats helps break such barriers by making patients aware of the worldwide nature of disease (participant 11).

During GHEs, visiting trainees have benefited local institutions by filling conference schedules. However, the benefit can extend beyond this as cultural exchanges and perspective sharing has had long-term benefits on an institution and the local patient population.

Morale enhancement

Hosting international trainees was noted to improve staff morale, providing local clinicians and staff opportunities to engage in teaching. Many physicians at GHE host sites found value in education and hosting visiting trainees provided them an opportunity to share their knowledge:

Most of the doctors that we’ve had are teachers, and they enjoy sharing what they know. We’ve had surgeons here that just love teaching students and residents. It might add more time, but I don’t think anyone has ever, ever found that to be a burden (participant 5).

While this impact was noticed on an individual level, it was also described on an institutional level:

When we first started the hospital, it was an emergency response. It was all of us working and working and working. There was no time for learning. Once we started international rotations with medical volunteers and specifically residents, the local staff, they feel like it is not only working. They feel like they are learning, and they are also part of teaching. It makes the work much more sustainable. It’s something you feel the work is more efficient because you keep learning while you are working. Having the residents coming, it makes the staff want to learn more because you share experiences with the residents, and we also get a strong relationship with some (participant 4).

While some host sites have local trainees and teaching schedules of their own, others do not have a formal education curriculum, and GHEs have provided these staff with an opportunity to engage in teaching. For many hosts, the ability to teach can improve job satisfaction, sustaining their long-term work.

Capacity strengthening

In addition to engaging in the educational mission of the host institution, trainees have provided opportunities for ongoing capacity strengthening. In local communities, visiting trainees have promoted public health awareness by participating in health education efforts. For several sites, hosting GHEs contributed to local institutional enhancement:

We hope to continue hosting the residents as we think that way we will be constantly challenged to reach our goal of becoming a specialist center. This will greatly benefit the wider community even beyond our catchment area (participant 6).

Other hosts emphasized the benefits of global engagement for both their institution and the broader global health community. Specifically, several emphasized the transformative impact of exposing visiting trainees to global health and some of the difficulties their communities face:

We take very seriously the impact this program has on visitors, and we think that is very valuable. I think there are many visitors who come through here whose lives are changed and also who are increasingly sensitized to international needs that they would never otherwise have gotten. I don’t know how that will work out in the end, or what kind of measurement, but I do know it’s real and we have residents that come back (participant 2).

GHEs benefit host institutions by both contributing to their educational and institutional development and also fostering ongoing global engagement. While hosts noted that their specific site may not experience the benefits of improved trainee global awareness, they highlighted that it is still meaningful and important to them. For many of these hosts, the experience was viewed not only as beneficial for their site, but an affirmation of the host’s own mission and goals for global health by increasing workload capacity, allowing opportunities for education, improved staff morale, and capacity strengthening for local institutions. This future-oriented framing reflects how benefit was conceptualized beyond immediate reciprocity.

Reciprocity

While weighing the costs and benefits of hosting trainees, participants noted the idea of reciprocity when considering investment. While some felt that mutual benefit was achieved through these collaborations, others believed that visiting trainees benefited more during these rotations than the host site. All hosts shared recommendations for improving balance and equity in GHEs including ongoing relationships, provision of supplies, and bi-directional exchange.

Ongoing partnerships

When equal reciprocity was perceived, hosts attributed this to the exchange of knowledge and the formation of lasting professional and interpersonal relationships. One respondent remarked:

There is a positive effect in terms of getting to involve each other, learning from each other. There is a difference in terms of working up patients. The approach is different, there are some cultural and traditional differences. So when [visiting trainees] come here, they learn from our residents and interns, and our residents and interns learn from them. So, it’s mutually beneficial to each of them (participant 7).

While individual interpersonal relationships have created value to a host when hosting a visiting trainee, institutional collaborations also contributed to reciprocity. Several hosts noted that if more structured collaborations were in place, value could be expanded beyond the individual site itself:

If we could get a permanent collaboration to try and design a training session… I know a lot of young medical doctors and nurses that would be thrilled to get the chance to learn from Mayo. We could have some conference, once or twice or three times per year in a local organization and have people come. I think that would be much more efficient because this collaboration will not be for [our] staff only, but would be something in the greater area (participant 4).

Many hosts noted that some of these relationships extend beyond the GHE and they have remained connected with visitors after rotations. These relationships provide value to both parties participating in GHEs and contribute to reciprocity. Hosts noted that improved reciprocity could be achieved with more structured institutional collaborations, especially when those collaborations involve education and training for the local healthcare communities.

Provision of supplies

The provision of supplies by visiting trainees was also identified as a contributor to reciprocity, though the value depended on the type of material. Items such as textbooks, surgical consumables, and educational materials were noted as supplies that can be very useful to host sites:

Our hospitals are not well equipped. We do not have access to good libraries. Visual materials would be helpful in training (participant 9).

In contrast, opinions on technology varied by site. While one host noted that improved equipment could lead to a more fruitful GHE for a visiting trainee, another said:

I am of the opinion that sending machines is not beneficial, especially when they need repair or maintenance. In the end, those machines sometimes get stuck in a corner or are not used at all (participant 10).

Hosts identified contributions of resources from visiting trainees as a component of reciprocity, with educational supplies and consumables seen as particularly valuable. However, views on the usefulness of complex equipment varied depending on local capacity for maintenance and sustainability. This highlights the importance of context-specific contributions rather than generalized assumptions about need.

Bi-directional exchangeBi

All hosts were asked their opinions on ways to improve GHE reciprocity. Many recommended an exchange program, allowing their local trainees, supervisors, and hospital leadership to engage in similar global experiences, as a way to improve relationships between sending and hosting institutions. Most hosts discussed bi-directional exchange programs as a way to benefit their own trainees:

In the future, it might be helpful if we can develop an exchange program so that our residents or students can also have mutually beneficial experiences (participant 7).

However, one host shared how an exchange program for their supervising consultants could also be beneficial:

[It would be more beneficial] if there were a few supervisors who have had exposure to a similar setting to where the resident is training. That way the discussion and engagement is focused on possibilities for change other than challenges (participant 6).

Many host sites viewed bi-directional exchange programs to improve reciprocity and strengthen partnerships between institutions.

Hosts provided ideas to improve reciprocity including strengthened relationships and institutional partnerships, the provision of supplies, and the creation of bi-directional exchange programs. Hosts that believed visiting trainees benefit more from their GHE experience than the host site cited enhanced clinical learning opportunities for the visitor as the primary reason. One host described this opinion further by sharing:

It depends on the type of resident who comes, because for them, they come here where there is more clinical responsibility which helps them to develop in making decisions, learning about conditions in remote settings with limited resources, and going back to basic physical examinations where you do not have all the machines and equipment giving you all the information. I think depending on the kind of resident, most times I think they gain more from the experience. In the reverse for us, depending on if someone is sharing what they know, then you could learn one or two things (participant 10).

These mixed perceptions of reciprocity reflected a broader concern regarding equity and voluntourism in global health training. While hosts expressed appreciation for the opportunity to collaborate with visiting trainees, all articulated ideas for more balanced relationships to ensure benefits are shared between institutions.

Investment factors

Participants considered the personal and institutional costs and benefits as they weighed the investment that they make into hosting trainee GHEs. While hosts discussed general costs and benefits to their institutions, they also identified a distinct set of contextual factors that shaped whether those costs and benefits were ultimately perceived as a worthwhile investment. These included language proficiency, trainee characteristics, and rotation length.

Language proficiency

Language barriers were frequently noted as a limiting factor in the trainees’ ability to contribute meaningfully to clinical work. Sites that typically benefitted from assistance with clinical workload noted that when trainees lacked understanding of the local language, their utility was reduced:

The visiting residents also see the patients, and if they know the language, it is very helpful. But if they have a problem with the language, they usually help the [local] resident and interns (participant 7).

A language barrier impacted the investment a host site puts into hosting a visiting trainee as costs are higher with increased time for translation and supervision and there is less benefit provided as the trainees are unable to care for patients without translation services.

Trainee characteristics

Trainee characteristics, including level of training, adaptability, and enthusiasm, also influenced the perceived value of the elective. Respondents noted that highly motivated and engaged trainees were more likely to make meaningful contributions and justify the effort required to host them:

It’s a time drain to do the planning to host a resident coming. The residents I feel make it worth it are the ones who are totally engaged when they arrive. The one I mentioned earlier, it wasn’t worth all that time I spent to prepare for him. But the ones who come and are engaged, the extra time is definitely worth it (participant 1).

Additionally, trainee level and experience were noted as critical factors in determining their contributions to the host institution:

The more trained they are, the more they can do and the more they can offer. We also have medical students sometimes, and they really get stretched because they don’t have the training or background to do much (participant 2).

Differences in culture, technology, and hospital infrastructure also impacted the extent to which trainees could engage effectively, highlighting the importance of trainee adaptability and humility to create a meaningful impact. Hosts noted that learning to navigate unfamiliar systems and adapting to resource-limited environments required time and supervision. While this time is expected to some extent for all visitors, trainees who struggled to adapt their skills and knowledge to the local environment could not give back to the host institution as remarkably as their more adaptable counterparts:

Sometimes the resident is challenged by the wide technology difference, and their impact is quite minimal (participant 6).

Humility was also highlighted as a critical trainee characteristic for rotation success:

Individuals who lack cultural sensitivity, cultural humility, or who are unwilling to learn have more difficulty adjusting to the setting and have greater culture shock (participant 11).

Hosts reported that trainee characteristics significantly influenced the overall value of the elective from the host perspective, with more experienced and motivated trainees better able to overcome systemic challenges and contribute meaningfully to the host institution.

Rotation length

Rotation characteristics also played a role in level of perceived benefit with longer rotations generally being seen as more beneficial to host sites as visiting trainees have enough time to orient and then meaningfully contribute:

We want them to come for at least a month, nothing shorter than a month. Sometimes we’ve had residents for only two weeks, and it’s just not enough to be a very meaningful rotation (participant 2).

Across responses, hosts consistently indicated that the duration of the rotation was a key determinant of its success, with longer placements allowing trainees adequate time to acclimate to the clinical environment, build relationships, and contribute in a more meaningful and sustainable way.

Host institutions carefully weighed the personal and institutional investments required to support GHEs, considering both the costs and benefits. Language barriers often limited trainees’ ability to contribute clinically, increasing the burden on hosts for translation and supervision. More experienced and motivated trainees were better able to navigate unfamiliar systems and resource-limited settings, making their presence more beneficial. Finally, rotation length significantly influenced perceived value, with longer stays allowing trainees to acclimate, build rapport, and contribute meaningfully. Overall, hosts emphasized that the return on investment was highest when trainees were linguistically capable, professionally mature, humble, adaptable, and committed to engaging deeply with the local context.

Discussion

This study contributes to the literature examining resident and fellow GHEs from the host perspective, highlighting the investment sites make when hosting GHEs and the factors that allow these rotations to be worthwhile to their institutions. Consistent with existing literature, our findings report significant demands placed on sites when hosting visiting trainees [28, 29, 34]. While hosts acknowledged considerable costs including time, physical resources, and coordination efforts, they also expressed a genuine desire to continue hosting international trainees. Participants specifically highlighted the benefits of short-term workload assistance and long-term institutional capacity-strengthening and global collaboration. Several respondents also noted the transformative effect of the GHE on visiting trainees’ commitment to global health, sharing they hope this benefit extends beyond the rotation to indirectly serve the host’s mission. These future-oriented benefits, even when not directly experienced by the host institution, are enough for hosts to continue investing their time and resources into GHEs.

While some hosts viewed these rotations as reciprocal, several expressed opinions that visiting trainees gain more from their experiences than the host site. Hosts emphasized that deeper reciprocity could be achieved through mechanisms such as donation of useful resources and development of formal bi-directional exchange programs, all of which have been previously highlighted in existing literature [27–29, 34]. This indicates that while equal reciprocity may not be currently present, hosts find value in these partnerships or at least have hope for increased benefit to their site, or global health more broadly, in the future.

This study suggests that host sites and sending institutions may use language to justify GHEs despite the unequal reciprocity. Participants frequently framed their experiences in terms of investment, emphasizing future-oriented and indirect benefits. While this framing allows hosts to assign additional meaning to their involvement, it may also shift attention away from immediate imbalances in resource use and benefit distribution. From a sending institution perspective, greater attention to how these programs and their benefits are described is an important step towards more transparent and equitable global health partnerships.

This interpretation aligns with and extends prior literature examining the concepts of investment and reciprocity in GHEs. Previous work has shown that while hosts identify meaningful clinical and education benefits, they acknowledge that existing partnerships do not advantage them due to limited support and lack of reciprocal opportunities by sending institutions [30]. Others describe hosts framing participation as an investment, emphasizing long-term benefits such as cultivating globally minded clinicians and future collaborators [28]. Prior literature has also provided recommendations for elective design and structure. For instance, Reynolds et al. proposed a set of questions that a learner should ask themselves prior to participating in a GHE [37]. These questions ask learners to consider their motivations and impact, specifically noting sustainability, humility, feedback, resources, and reciprocity. In answering these questions, a trainee should consider mechanisms to explicitly address financial implications, reciprocity, and burden mitigation when designing their GHE.

However, while optimizing individual elective design is important and most prior efforts to improve GHEs have focused on preparing individual trainees, our findings suggest that the quality and equity of these experiences are shaped more fundamentally by program structure and institutional relationships. Hosts emphasized the importance of factors that extend beyond individual preparedness, such as rotation length, trainee selection, and sustained partnerships. Notably, improved pre-departure communication and training were not mentioned frequently as recommendations for GHE enhancement, which was a common report in prior host perspective studies [27–29, 31–33]. One possible explanation of this finding is the established longitudinal relationships between Mayo Clinic and the interviewed host institutions. Almost half of the hosts interviewed are expatriate physicians and almost half of them trained at Mayo Clinic. In addition to an established international health program for trainees, these hosts regularly work with Mayo Clinic staff consultants. Many of these consultants visit these clinical sites to volunteer teaching, collaborate in research, and participate in clinical care.

Taken together, these findings suggest that while responsibility for strengthening GHEs is shared between trainees and sending institutions, the greatest leverage for improving equity and sustainability lies at the structural and institutional level rather than solely with individual learners. Accordingly, while individual preparation remains an important component of GHE participation, efforts to improve these programs should prioritize intentional planning and institutional support to reduce both the obvious and hidden costs placed on host coordinators, clinical supervisors, and their institutions. Based on these findings, our recommendations for improved reciprocity within GHEs include more robust institutional partnerships with elective design prioritizing longer rotation durations, limiting opportunities to trainees with more experience, preparation of educational materials, and predeparture institutional communication to coordinate provision of necessary supplies.

This study has several limitations. The sample was limited to designated sites affiliated with a single US-based international health program, which may reflect a selection bias towards more structured and developed partnerships. Additionally, many of the interviewed participants have trained at and maintained ongoing professional relationships with the sending institution. This raises the possibility of affiliation bias and may shape expectations of reciprocity in ways that differ from those between institutions without personal connections. Another participant demographic factor of note is almost half the interviewed hosts are expatriates whose views may not fully represent those of national staff, potentially introducing a bias regarding opinions on visiting trainee electives. As past participants and leaders of this international health program, we also acknowledge the potential for bias during thematic analysis, including a tendency to interpret partnerships more favorably.

The relatively small sample size (n = 11) also restricts the breadth of perspectives captured and may limit the generalization of findings. While reflexive thematic analysis prioritizes interpretive insight, we recognize that some of the broader interpretations should be understood as grounded in this specific context rather than assumed to represent all GHE experiences. Further work incorporating larger, multi-site, or quantitative components could help further assess these themes across GHEs more broadly.

Finally, this study captures the perspectives of physician hosts alone. Further research should explore the perspectives of non-physician staff, patients, and community members to further contextualize the full impact of GHEs. Additional research could also investigate experiences for medical versus surgical trainee electives as differences in specialty-specific roles could contribute to differing host perspectives.

Conclusions

This study adds to the growing literature on GHEs by focusing on the voices of elective hosts, an essential perspective in ethical and sustainable global health education. While all interview participants acknowledged the costs of hosting visiting trainees, many expressed that it was a worthwhile investment, especially when rotations are thoughtfully structured, trainees are well-prepared, and benefits are shared. Hosts consistently emphasized that the quality of the experience was shaped by the duration of stay and level of trainee engagement.

To ensure GHEs are both ethical and mutually beneficial, sending institutions must prepare learners, support host sites, and foster ongoing dialogue to develop sustained partnerships that prioritize reciprocity with host institutions. As global health education continues to grow and evolve, incorporating host perspectives is critical to building more equitable and effective international collaborations.

Abbreviations

ACGME

Accreditation Council for Graduate Medical Education

GHE

Global Health Elective

IRB

Institutional Review Board

LMIC

Low–and Middle–Income Country

MIHP

Mayo International Health Program

Authors’ contributions

RLK uploaded all the transcripts into Dedoose and applied the codes to all the transcripts. Coding was reviewed by APS. All authors reviewed the quotations and identified key themes. All authors read and approved the final manuscript.

Funding

This project was supported by Grant Number UL1TR002377 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Data availability

The datasets generated and analyzed during the current study are not publicly available to protect the identities of our participants but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Mayo Clinic Institutional Review Board as a minimal risk study.

Consent for publication

Verbal informed consent was obtained, and participants were assured that their responses would be kept anonymous and would not affect their ongoing relationship with the Mayo Clinic.

Competing interests

The authors declare no competing interests.