title: Surgeons' and Trauma Care Physicians' Perception of the Impact of the Globalization of Medical Education on Quality of Care in Lima, Peru.
abstract: The globalization of medical education-the process by which trainees in any region gain access to international training (electronic or in-person)-is a growing trend. More data are needed to inform next steps in the responsible stewardship of this process, from the perspective of trainees and institutions at all income levels, and for use by national and international policymakers.
  
  
  
  To describe the impact of the globalization of medical education on surgical care in Peru from the perspective of Peruvian surgeons who received international training.
  
  
  
  Observational study of qualitative interviews conducted from September 2015 to January 2016 using grounded theory qualitative research methods. The study was conducted at 10 large public institutions that provide most of the trauma care in Lima, Peru, and included urban resident and faculty surgery and trauma care physicians.
  
  
  
  Access to international surgical rotations and medical information.
  
  
  
  Outcome measures defining the impact of globalization on surgical care were developed as part of simultaneous data collection and analysis during qualitative research as part of a larger project on trauma quality improvement practices in Peru.
  
  
  
  Fifty qualitative interviews of surgeons and emergency medicine physicians were conducted at 10 hospitals, including multiple from the public and social security systems. A median of 4 interviews were conducted at each hospital, and fewer than 3 interviews were conducted at only 1 hospital. From the broader theme of globalization emerged subthemes of an eroded sense of agency and a perception of inadequate training on the adaptation of international standards as negative effects of globalization on surgical care in Peru. Access to research funds, provision of incentives for acquisition of advanced clinical training, increased expectations for patient outcomes, and education in quality improvement skills are ways in which globalization positively affected surgeons and their patients in Peru.
  
  
  
  Short-term overseas training of surgeons from low- and middle-income countries may improve care in the surgeons' country of origin through the acquisition of skills and altered expectations for excellence. Prioritization of evidence-based medical education is necessary given widespread internet access and thus clinician exposure to variable quality medical information. Finally, the establishment of centers of excellence in low- and middle-income countries may address the eroded sense of agency attributable to globalization and offer a local example of world-class surgical outcomes, diminishing surgeons' most frequently cited reason for emigration: access to better surgical training.
authors.affiliation: University of Washington, Seattle.
authors.forename: Lacey N
authors.initials: LN
authors.lastname: LaGrone
authors.affiliation: University of Washington, Seattle.
authors.forename: Leah N
authors.initials: LN
authors.lastname: Isquith-Dicker
authors.affiliation: Hospital Nacional Guillermo Almenara, Lima, Peru.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Huaman Egoavil
authors.affiliation: Universidad Peruana Cayetano Heredia, Lima, Peru.
authors.forename: Manuel J A
authors.initials: MJ
authors.lastname: Rodriguez Castro
authors.affiliation: Hospital Maria Auxiliadora-Universidad Cientifica del Sur, Lima, Peru.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Allagual
authors.affiliation: Hospital Nacional Guillermo Almenara, Lima, Peru.
authors.forename: Fernando
authors.initials: F
authors.lastname: Revoredo
authors.affiliation: University of Washington, Seattle.
authors.forename: Charles N
authors.initials: CN
authors.lastname: Mock
mesh_terms: D001291:Attitude of Health Personnel; D003906:Developing Countries; D020375:Education, Distance; D004501:Education, Medical; D005180:Faculty, Medical / Q000523:psychology; D013502:General Surgery / Q000193:education* / Q000592:standards; D006801:Humans; D007393:International Educational Exchange; D038622:Internationality; D007396:Internship and Residency; D007407:Interviews as Topic; D010465:Perception; D010568:Peru; D036301:Qualitative Research; D011787:Quality of Health Care; D066231:Surgeons / Q000523:psychology*; D014194:Traumatology