TABLE III.

Self-Described Impact of LMIC rotation on HIC residents^*,^†

First-Order Concept Grouping	Scope of Concept	Second-Order Concept Grouping
Learning in a unique environment	Opportunity for surgical training with less pressure and scrutiny, away from the hierarchy of the home academic institution Unique mentoring relationships with local surgeons Diversity of instruction from surgeons trained in different ways	Professional development: practicing surgery in an LMIC hospital setting may present developmental opportunities for residents beyond what they have access to at their home institutions
Positively challenged	Creativity to cope with paucity of resources Developing alternative methods to diagnose and treat surgical disease improves resident clinical and technical skill
Exposed to novel pathology	Exposure to local pathology and disease Exposure to complications and disease progression uncommon in high-income countries
Greater responsibility	Participate in cases of greater complexity and broader spectrum Residents given more authority, autonomy, and leadership opportunities Opportunity to develop managerial skills
Trained with different methodologies	Exposure to new surgical practice Rich “open surgery experience”
Fulfillment	Experience gratitude and trust from patients Have meaningful patient-doctor relationships “Truly amazing professional and personal experience” Reminds residents why they went into surgery Chance to help others in need	Finding meaning: residents describe the relationships they have with their patients and friendships they develop with LMIC colleagues as providing meaning and fulfillment beyond what they experience at their home institutions
Rejuvenation of purpose	Confirms passion for humanitarian work Trip described as the, “most important event of residency training” Answer the search for meaning that residents experience during surgical training “Opens the heart to give what we have already been given”
Friendship	Formation of friendships and close relationships Feeling of kinship Lifelong meaningful friendships around the globe aimed towards collaboration, mutual respect, understanding, and support
Global sensitization	New appreciation for home healthcare system and availability of resources Greater interest in public health Greater commitment to promoting care for underserved/vulnerable populations Increased understanding of social determinants of health and barriers to health Awareness of growing burden of operative disease worldwide Sensitization to global need for surgery	Awareness of global inequity: residents emerge from global surgery rotations with a greater appreciation for the social determinants of health, scarcity of care for the high burden of surgical disease and improved cultural awareness, understanding of, and commitment to global surgery equity
Cultural awareness	Differential diagnoses are inherently affected by the cultural framework surrounding pathology Acquire awareness and improved sensitivity to cultural differences Ability to transcend potential barriers and develop cross-cultural communication skills Broader understanding of cultural attitudes toward medical systems Development of cultural humility
Ethical concerns	Emotional challenges of dealing with preventable death Absence of “urgency” in life-threatening situations	Feeling ineffective: developing an awareness of self-limitations and need of navigating culture and protocol differences that can be frustrating and emotionally draining
Recognition of internal expectations for standards of care	Different care and protocol expectations within the clinical environment Interpretation of anesthesia care being of poor quality Interpretation of pre- and post-operative care as being low quality Absence of organized rounds New appreciation for home healthcare system and availability of resources
Underpreparedness	Difficulty functioning with limited language proficiency Unfamiliar environment and clinical issues Adjusting to different medical practices
Awareness of professional role	Concern with taking cases away from host country colleagues Challenges in navigating resident role and working relationships

^*This table was first grouped into potential benefits (3) and potential harm (1) and then ordered by frequency, with concepts that received the most mentions across included articles listed first. Lines delineate unique second-order concepts encapsulating first-order groupings.

^†HIC = High-Income Country; LMIC = Low-, Middle-Income Country.