Table 2.
External experience categories generated by open and axial coding with definitions of category labels and examples from the reflective essays
| Core categories | Categories | Subcategories | Definition | Examples |
|---|---|---|---|---|
| External Experience | Congruent | Attempt to Understand Local Approach* | Visiting trainee attempted to understand the Ethiopian perspective by discussing the case or conflict with a local provider. | “I was only able to discuss this with the residents, but their perspective was one that they had tried many other systems, none of them worked very well, and this was their current attempt at making the best of what they had.” “During the process, a couple of residents explained that is seemed somewhat strange to be using this delicacy (thick cuts of high-quality steak) for a [procedure] simulation, especially since it would be discarded once we finished the simulation.” |
| Concern about Local Practice | Medical care witnessed is viewed as substandard by both visiting and local providers. | “I witnessed a critically ill patient receiving poor medical care. … The Ethiopian residents were managing the patient as well as they knew how. They clearly were overwhelmed and my impression was that they did not receive much training on how to manage situations like this.” “A prior biopsy read … was clearly not the correct diagnosis. The team did not have access to necessary reconstruction hardware including plates and screws. They acknowledged that the standard of care would have been resection, however in light of their limitations, they elected to perform a [different procedure].” | ||
| Cultural Differences | A perceived difference in approach to patient care between U.S. and Ethiopian training but with the same anticipated outcome. | “The culture in the United States to weigh the risks and benefits of treatment and sometimes withholding chemotherapy for the benefit of the patient may not be as well accepted in Ethiopia. When deciding to withhold treatment from a patient, the patient and his/her family should also be involved in the decision, but this is not the case based on patient interactions we observed.” | ||
| Issue Also Present in United States | The conflict details or themes are acknowledged to be an issue within the visiting trainees home institution. | “In the setting of poor prognosis for a progressive disease, it benefits both the clinician and the patient/family to discuss their wishes prior to an emergent event. This could prevent a similar conflict, but this is difficult to do in the U.S. let alone in a resource-limited setting. I do not think this was an ethical dilemma unique to Ethiopia.” “Thankfully there are enough resources in the U.S. that there wouldn’t be that kind of waiting list to be treated, however we do have similar problems with VIPs or people with a lot of money getting preferential treatment.” | ||
| Opportunity for Collaboration* | Acknowledged as an opportunity for teaching or learning between visiting and local trainees/providers. | “I think in the future I would engage in a more detailed discussion of how Ethiopian physicians approach informed consent. … I would ask the residents more about the consent process and what their typical discussion is with a patient.” “One of our teaching [topics] was requested by the Ethiopian faculty and became a collaboration. … The faculty and hospital have a huge need in their patient population for Palliative Care and identified our program as a way to help with establishing that mentoring and teaching.” | ||
| Responsibility to Patient vs. Community | Direct conflict between a provider’s responsibility toward an individual patient and their responsibility to the community. | “Our main conflict is that we will have to choose between operating in a limited resource setting despite knowing that we will have complications and poor follow up vs. choosing to not intervene at all.” “It was a child born with multiple birth defects who would need advanced surgical and medical interventions and there was a delay in diagnosis due to use of [an imaging] modality which was not standard. It was also unclear whether they could offer the interventions the child would need, and so that posed the question, is there a way to get this child to a center which could? Would that be the right thing to do? Why would we offer that to this child and not everyone?” | ||
| Systems-Based Analysis* | Conflict prompted a review of how this conflict could be improved at a system-wide level. | “The resolutions are justifiable on a case-by-case basis, but do not remedy the deeper systems problems. … An attempt at resolution would require changes from the top down: hospital funding, laboratory capacity, pharmacy dispensing, as well as clinical reasoning.” “In the current system, there is no systematic process to re-evaluate current MICU patients’ status and de-escalate care quickly in the situation where a bed is urgently needed [for a sick patient].” | ||
| Witnessed External Conflict | Perception of that Ethiopian providers experienced similar distress at the outcome of a case. | “Although the faculty and staff held the perspective that the patient should be made comfortable and ultimately aggressive care removed in a timely manner, the influence of the hospital administration prohibited them from caring out what was ethically the most appropriate for the patient.” “The residents feel unsupported and not well equipped to make good management decisions. As a result, they often make minimal changes to the management plans.” | ||
| Other/Unable to Determine | Lack of Autonomy | Lack or patient or family autonomy in medical decision-making. | “The patient was not involved in any of the decision making as she was not even present during the visit. Her family had traveled 200km and there was no way for them to transport this elderly woman that long of a distance safely.” “Patients’ autonomy was frequently usurped in Ethiopia. Perhaps due to cultural norms, the expected doctor’s role, or provider preference, many patients were given limited autonomy in their own medical care.” | |
| End-of-Life/Palliative Care | Conflict involving issues around palliative or end-of-life care. | “[CPR] prolonged the child’s life by a few days. He was intubated and sedated for the remainder of his time. … As a clinician, I believe that the resolution was justifiable in an emergent situation. However, I do wish that the situation could have been prevented to begin with.” “Because of the acute and urgent situation, the medical team did not have explain to the father what they were doing, and they certainly did not discuss the father’s wishes regarding code status or for the patient’s end of life care… Unfortunately, this is a common occurrence in Ethiopia as Palliative Care is a developing field in both adult and pediatric care. I witnessed very few discussions regarding end-of-life care or code status despite seeing many critical patients.” | ||
| Income Differences | Acknowledgment of income status difference between visiting trainee and their Ethiopian colleagues and patients. | “Radiology is by its very nature a very expensive and technology-dependent field, certainly among the most so of any of the medical specialties. This makes a stark contrast between the United States and its near-decadent approach to healthcare and any developing nation.” “The hospital has no thrombolytics available. A private hospital down the road does. The initial cost is quoted at 3000 ETB or ∼100 USD—a cost that does not initially seem prohibitive. [The patient’s] family explains that they are unable to afford it. Between your [American] team you easily have that amount in cash. What do you do?” | ||
| Lack of Communication | Ineffective or lack of communication between interprofessional stakeholders and medical team members. | “There was little discussion (among the treatment team, and also with the patient/family) regarding risks/benefits of chemotherapy prior to initiation, at least per our observation.” “The ethical conflict could have been resolved if there was a system in place to allow for urgent communication for acute findings such as paging or telephone. Having the ability to contact different services or attendings directly could provide a streamlined system allowing for prompt medical care.” | ||
| Limited Materials and Resources | Lack of access or materials or resources considered by the visiting trainee to be within the standard of care. | “The resident started bagging the patient but there was no oxygen tank available – someone had to go get it … there are no blood pressure measurements because the patient does not have a blood pressure cuff…ICU attending mentions using fiberoptic to confirm placement, but fiberoptic was just used on another patient and is dirty.” “Our first day in the operating room we quickly learned that we would have limited access to their cystoscopy equipment. Upon realizing this, we discussed with the consultants and residents how this will limit our work in certain compartments of the pelvic floor. We explained that in the spirit of “do no harm,” we cannot perform surgeries where we are unable to properly detect iatrogenic injuries, especially if they can lead to chronic infection and organ failure later on.” | ||
| Limited Patient Follow-Up | Lack of patient follow up within the clinical setting. | “This patient was sent home relatively quickly after minimal examination; both patient numbers and distance travelled make it impossible to personally follow patients beyond the post-operative day one visit.” “Many times, in Ethiopia, due to the great distance in being able to receive treatment, family members will come to pick up medications for their loved one and the doctor has not seen the patient for months.” | ||
| Power Dynamics | Decision inequities within a medical team related to interpersonal dynamics. | “I did not want to be paternalistic and jump in when the Ethiopian residents’ management of the patient was inadequate, especially because there was an [American] ICU attending supervising and not correcting them.” “We let the Ethiopian attending lead the surgery and watched the surgeon leave small bits of tumor attached to the underlying mucosa. In our attempt to remove this excess tumor made the attending very uncomfortable and almost defiant that he did not want us to remove any further tissue.” | ||
| Incongruent | Conflict in Cultural Norms | Differences in what is considered an acceptable or anticipated outcome between visiting and local providers. | “Once he did develop neutropenic fever, he was not able to receive the hospital’s standard of care with regard to antibiotics since he couldn’t afford it. Such a massive change will require a change in provider attitudes. There may be some cultural differences that may be difficult to change.” “In the US if this complication were to happen, we would do daily checks on the patient’s eye and pressure and follow up very closely. [In Ethiopia] this patient was sent home relatively quickly after minimal examination.” | |
| Delay in Care | Delay in medical care correlated with adverse patient outcome. | “No electronic medical record and radiology reports are typed on Microsoft Word with significant delay in turn-around time.” “Neurosurgery had not seen the patient by morning report and were called again and asked to see the patient. During the course of the day the patient’s right sided weakness became full paralysis and he had multiple episodes of grand mal seizures. The next day neurosurgery still had not seen the patient.” | ||
| Lack of Informed Consent | Perception of visiting trainee that informed consent was not obtained. | “We discussed informing the patient and allowing her to decide, but the language and practice barriers limited our ability to ensure that this would be done correctly.” | ||
| Lack of Infrastructure | Effectiveness of available or recommended resources is undermined by a lack of institutional or societal support. | “The fundamental question was: can we justify offering a potential lethal treatment of myeloablative chemotherapy for an also lethal condition (leukemia) if we cannot also offer adequate supportive care?” “This conflict involves the triage process and the motivations for accepting patients to the MICU. … The scenario described is more of a system malfunction.” | ||
| Utilization of Resources | Inappropriate or ineffective use of resources that are available. | “We realized that the residents were not screening the patients for diabetes complications and comorbidities even though the resources were readily available.” “She then explained that this patient had lung cancer, had a poor long-term prognosis, and should not have been intubated. The ED only has two ventilators and by intubating this woman who had likely chronic respiratory failure, you wouldn’t be able to use the ventilator for another patient.” |
*
Denotes a category that is not of ethical conflict but describes the downstream effect of experiencing a conflict and constructing a framework to explore potential solutions.