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• Am J Public Health
• v.104(7); Jul 2014

Short-Term Medical Service Trips: A Systematic Review of the Evidence

Short-term medical service trips (MSTs) aim to address unmet health care needs of low- and middle-income countries. The lack of critically reviewed empirical evidence of activities and outcomes is a concern.

Developing evidence-based recommendations for health care delivery requires systematic research review. I focused on MST publications with empirical results. Searches in May 2013 identified 67 studies published since 1993, only 6% of the published articles on the topic in the past 20 years. Nearly 80% reported on surgical trips.

Although the MST field is growing, its medical literature lags behind, with nearly all of the scholarly publications lacking significant data collection. By incorporating data collection into service trips, groups can validate practices and provide information about areas needing improvement.

With globalization, there has been significant growth in short-term medical service trips (MSTs) from high-income countries (HICs) to low- and middle-income countries (LMICs). Although MSTs deliver significant amounts of care, relatively little attention is given in the medical and public health literature to the impact of these interventions on the populations being served. The following review offers a step forward by addressing this gap with a systematic analysis of the existing empirical work and suggestions for further study.

According to the World Health Organization, the highest proportions of the global burden of disease fall on the regions that also suffer significantly from physician shortages. 1 A growing group from HICs aims to address both medical and surgical unmet needs in LMICs through MSTs, sometimes referred to as medical missions.

For purposes of this review, MSTs are defined as trips in which volunteer medical providers from HICs travel to LMICs to provide health care over periods ranging from 1 day to 8 weeks. Both faith-based organizations and non–faith-based organizations facilitate these trips, a feature that will be discussed in more detail later. Team composition can range from members of academic departments from a single institution to collections of individuals affiliated only by friendship, geography, or the organization facilitating the trip.

Authors of several published articles have noted that MSTs as a form of aid do not address the primary sources of the health care problems in the developing world: poverty and overstretched health care infrastructure. 2–4 There are, however, significant resources, financial and human, dedicated to MSTs annually. Although there is no central monitoring group or agency for MSTs, conservative estimates that do not take into account opportunity costs for the volunteers place the annual expenditures at $250 million. 5 With expenditures of this magnitude, questions naturally arise about the return on investment. If noteworthy returns exist and organizations are simply not measuring or reporting them, then this can be remedied. If the returns do not exist and the missions continue, an ethical dilemma may be emerging.

Over the past 20 years, publications describing MSTs have largely aimed to promote models of health care delivery in these settings. The pressure to develop practice guidelines has created some standardization in care, but the lack of critically reviewed empirical data continues to be a concern. Assumptions that the safety and acceptable risk or rates of complications from HICs are automatically transferable to MSTs are unwarranted and could be dangerous. 6

The lack of evidence is particularly concerning when one considers the vulnerable nature of patients living in LMICs. 2 Under the best circumstances, MSTs address an unmet medical need with high-quality care. Under the worst circumstances, they serve, as one author states, as an opportunity for physicians to practice techniques for the treatment of conditions that are less common in the developed world. 7 This example is extreme and is unlikely to play a role in the justification for most contemporary MSTs, but the possibility is concerning. One report in the faith-based literature (of an evangelical short-term mission trip in this case) suggested that some trips may benefit the volunteer as much as or more than the recipient of aid as well as potentially costing the hosts valuable time and resources. 8

Martiniuk et al. recently provided a starting point in the review of MST evidence; however, they included articles with mixed goals and did little to assess the quality of the articles presenting empirical data from MSTs or their participants. 9 The authors described benefits associated with MSTs, including personal gains for the volunteers and an increased sense of solidarity between the recipients and volunteers. They went on to identify common criticisms of MSTs, namely questions about efficacy or impact and unintended consequences.

The present review differs in several ways. First, it specifically targets publications with empirical results based on intentional data collection regarding activities associated with MSTs. These empirical results include work discussing treatment interventions, cost-effectiveness, quality assessment and assurance, or the perspectives of MST participants and target communities. Second, it addresses the assessment of quality. Third, the final section of this article suggests a framework drawn from the existing literature and its remaining gaps for the minimum data collection requirements necessary to expand the evidence base for MSTs.

Investments in MSTs continue to grow while their impact remains largely unmeasured. This demands a critical review and illustrates the need to measure the quality and impact of MSTs. 2,5,10–13 Analyzing the status of existing empirical evidence will help to establish some basic guidelines and a research agenda for future work in this area. Scholarship in the fields of social psychology and tourism also addresses aspects of MSTs; however, this review focuses solely on the medical literature.

This review follows the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for constructing the review methodology. 14 The aim is to standardize the reporting of reviews. PubMed and ISI Web of Knowledge were the primary sources for identifying relevant publications ( Figure 1 ), using queries for the medical subject headings “medical missions, official” and a “medical missions” topical search for each engine, respectively. After adding limitations for English-language publications, I limited the pool further to those articles with a date of publication between January 1, 1993, and May 15, 2013. Exclusionary terms (e.g., “not dental” and “not disaster response”) narrowed the data set. Finally, I used the terms “study” or “analysis” to identify publications with the empirical level of analysis to establish evidence for MSTs.

Literature search for research on short-term medical service trips (STMSTs): January 1, 1993–May 15, 2013.

To be included in this review, publications had to report on work performed in association with a short-term MST. I defined short-term as trips with a duration of less than or equal to 2 months. Because the intent for this work was to focus on the available evidence produced by these publications, it includes only publications with intentional data collection regarding procedures, patients, volunteers, or the MST literature.

A review of the full-text versions of each publication determined inclusion. In some cases, the abstracts did not reveal enough information to accurately characterize the publication; therefore, a subsequent review of the full-text article was necessary to assess for exclusionary characteristics. Finally, I reviewed the bibliographies of the included articles to identify additional publications missed by the previously described methods. I then subjected these to the same process of inclusion and exclusion analysis.

I collected authors and the date and journal of publication from the final list of studies. This was followed by the collection of study-specific data including focus (literature, patients, participants, equipment, community, or cost-effectiveness), medical specialty or subspecialty, nature of the trip (surgical, medical, or both), study design, sample size, location, duration of the trip, affiliated organizations, and the terms used to refer to MSTs.

The search process identified 1164 unique publications. Abstract reviews reduced the number to 112 for full-text review. As noted by other authors, one significant limitation on searches for this literature base is the diversity of terms used to refer to seemingly the same activity. 15 I identified more than 45 terms used to refer to MSTs ( Table 1 ). The final group of publications included 67 studies for the quantitative and qualitative analysis.

TABLE 1—

Terms Used in Publications to Refer to Medical Service Trips From Literature Search: January 1, 1993–May 15, 2013

Note . DENCAP = dental civilian aid/assistance projects; MCMO = medical civilian–military operation; MEDCAP = medical civilian aid/assistance projects; MEDRETE = medical readiness training exercise; MOOTW = military operations other than war; OHDACA = overseas humanitarian disaster and civic aid.

When one considers the entire eligible group of publications on the topic of MSTs, these studies represent a mere 5.7% of the more than 1100 publications on the topic in the past 20 years. Figure 2 illustrates the increase in annual publications on this topic in recent years. The peak of 15 publications per year occurred in 2012. The most common journal for these reports was the World Journal of Surgery with 15% of the publications (10 of 67).

Medical service trip publications by year (included and excluded), from literature search: January 1, 1993–May 15, 2013.

The results presented here synthesize the emerging and diverse nature of the MST literature. Results are organized around a series of questions that this literature attempts to answer. There are obvious gaps in the scope of the questions posed here. Moreover, much of the data generated by these publications lacks adequate support to answer fully these questions. Thus, the review closes with a proposal for the basic data points that participants in MSTs could collect during their efforts to answer the bigger yet still unanswered questions.

In spite of a diverse group of study designs, nearly all of the publications (98%) represent low-level evidence when judged against standard research design evaluation tools. Nearly two thirds of the publications can be classified in 3 groups on the basis of their study design. The largest proportion of the studies (49%) employed a retrospective study design or simple descriptive statistics to report their findings. Quality improvement or quality assurance projects represent the second most common among the published reports, with 9 studies (13%). Surveys of individuals that volunteer on MSTs and organizations that operate MSTs represent 10% of the publications.

Although the included articles all contained empirical results based on the use of systematic data collection, approximately one third of the studies did not describe their data collection process and 70% failed to describe approval from institutional review boards or their equivalents, leaving it unclear whether the organizations affiliated with these publications had their efforts overseen by an institutional review board. Most organizations freely reported the frequency of the procedures or visits that occurred during an MST (essentially outputs), but the data fail to include demographic characteristics such as socioeconomic status of patients or even gender and age distributions. 16 These are the most basic elements required to describe patient populations for the majority of scholarly literature.

Characteristics of MSTs That Publish Empirical Findings

This group of publications represents the broad scope of activities and locations in which MSTs are performed. With the exception of Antarctica, every continent is represented as either a provider or a recipient of care, with the majority of the recipients being distributed across regions of Africa, Central and South America, and Southeast Asia. Some publications (24%) describe individual trips to a single location. 17–32 Others (34%) describe multiple trips to single countries. 3,9,33–53 Finally, the last group (42%) describes multiple trips to multiple countries that in some cases are completely unrelated to one another. 5,6,15,54–78

The fields of optometry, medicine, pharmacy, and surgery were represented. Nearly 81% (54 of 67) of the studies reported on surgical trips, with 17 of the 54 referring specifically to cleft lip and palate interventions. Thirty-one percent (n = 21) of the publications included pediatric care. Trip duration ranged from 1 day to 8 weeks. Patient sample sizes varied considerably ranging from a single case to up to 8151 patients. Thirty-six (56%) of the 64 studies included reported a sample size of 200 or smaller.

Reported Magnitude of MST Efforts

Magnitude can be defined as both the financial expenditures and the volume of procedures associated with MSTs. According to 2 publications, respondents indicated that the total costs of MSTs ranged from $12 600 to $84 000 per trip (mean ranging from $22 650 59 to $34 400 5 ), and conservative estimates for annual expenditures from teams departing from the United States totaled $250 million. 5

McQueen et al. published the results of their survey of medical service organizations and reported that the organizations perform 223 425 surgical cases per year. 70 Many of these organizations and others may be focusing on maximizing the number operations in a short-term setting at the potential expense of quality of care. 78 Approximately 13% of the organizations surveyed provided more than 1000 cases per year. 70 Again, with estimates of expenditures from the United States alone reaching one quarter of a million dollars and with hundreds of thousands of patients treated annually, questions naturally arise about the return on investment.

Cost-Effectiveness in Low- and Middle-Income Countries

An increased focus on the publication of projects that measure the cost-effectiveness of their interventions is a promising and emerging trend in the development of the evidence base for MST activities. 17,45,67 Three publications used cost-effectiveness analysis as a mechanism for evaluating the efforts of MSTs. Two of the 3 cost-effectiveness studies reviewed cleft lip and palate surgeries performed by 2 organizations. 45,67 As noted in the article by Moon et al., both their study 45 and the previous study by Magee et al. 67 concluded that intervening surgically for cleft lip and palate patients represents a cost-effective intervention with a cost per disability-adjusted life year (DALY) of $68 and $34, respectively.

The third cost-effectiveness study evaluated orthopedic surgical trips to Nicaragua and comparably defined the interventions as cost-effective, but at a much higher investment level of $352.15 per DALY averted. 45

Factors That May Limit the Evaluation of MSTs

The contributions of some of the included publications are limited because of the lack of priority for research among medical service organizations and the absence of standardized evaluation tools. Medical service organizations do not regularly include research as a part of their goals.

A survey of 10 international volunteer organizations revealed specifically that they see it as a luxury or side project that yields limited benefits to their mission. 78 Maki et al. contributed a tool for use with MSTs 5 ; however, only 1 of the 21 publications subsequently citing this article described using the proposed tool in any form. 60 Current evaluative measures fail to assess any unintentional harm resulting from MSTs. 2

Reasons Why People Participate in MSTs

Numerous publications, including those from scholars in business, economics, sociology, and tourism, have explored the motivations of volunteers participating in MSTs. Some have claimed that participation in an MST provides an opportunity for personal development, and others have reported an opportunity to promote diplomatic relations. 60 Beyond the article by Chiu et al., 60 only the literature discussing the work of military MSTs explicitly addresses the concept of diplomacy.

Withers et al. reported emotional benefits, as well as career and professional benefits derived from participation in MSTs. 53 Panosian and Coates asserted that the global perspective emerging in students that have matured in the era of globalization materializes in the form of MSTs throughout the US medical education, from aspiring medical students to the postgraduate level. 79 Although they may get these same emotional benefits, they also hope to gain exposure to medical care, show a compassion for the less fortunate on their medical school application, and gain connections in the field. 53

Personal connections to the mission of an organization play a role in a volunteer’s interest, and the emotional experiences draw volunteers together creating relationships that extend beyond the trips. 53 Relationships and the volunteer’s ability to feel valuable and useful are reportedly among the most important factors in motivating volunteers to return for future MSTs. 53 Withers et al. also reported that only 1 of the 30 interviewees discussed a religious or spiritual reason for volunteering. 53

Role of Religion or Faith-Based Organizations

From the 19th century through the early 20th century, MST efforts appear to have been predominantly faith-based. Current efforts, however, are increasingly secular. 80

Among the reviewed literature, Internet searches of the organizations described revealed that only 18% (12 of 67) of the publications refer to activities performed in conjunction with a faith-based organization. This is lower than the 33% of faith-based organizations represented in a survey of 40 medical service organizations from 2010 59 ; thus, the proportion of faith-based organizations reported in this review may slightly underrepresent the proportion performing these activities overall. 53

Role of Education in MST Activities

Medical service organizations often tout reciprocity for their public image in the form of bilateral education—that is, providers from HICs learning from providers in LMICs and vice versa. Therefore, education has 3 forms on these trips: (1) education of students from HICs by providers from HICs and LMICs, (2) education of providers in LMICs by providers from HICs, and (3) education of providers from HICs by providers from LMICs.

Two studies from this review focused solely on the education of pharmacy students or surgical trainees resulting from MSTs. 57,58 Both studies reported a strongly positive experience and the second claimed to be the first to demonstrate the ability of an MST to provide positive training in cultural competency. The concept of cultural competency is a key training item for the Accreditation Council for Graduate Medical Education. Campbell et al. argued that some residency training programs in the United States could use MSTs as a mechanism for meeting that training competency. 58

Almost half (48%) of the included studies indicated that their trip included an educational component or exchange aimed at increasing the medical knowledge of local providers or community members. Several of these publications discussed the third educational form loosely, but they fail to formally evaluate or measure this practice. Compiling results from 3 studies that included surveys of medical service organizations reveals that respondents reported an educational or training component in 43%, 59 60%, 5 and 89% 70 of trips.

Publications associated with various international partnerships between providers in HICs and LMICs included the term “independence” when referring to local provider achievements. 36,41,44,46,52,61,73,74 Independence seems to mean that the providers achieve a level of competence that reflects the observable ability to safely manage patients and treat them in a manner equivalent to the quality achieved in HICs. All of these partnerships began as MSTs, or MSTs continually support and augment the care provided by local providers. All but 1 evaluated their ability to establish independence among the local providers (although they failed to include descriptions of methods for evaluating it). The publications reported on relationships that ranged in length from 2 to 15 years. Although there is not a clear timeline to independence, publications describing partnerships lasting 10 years or less at least showed independence in postoperative management. The 2 publications reporting relationships of greater than 10 years showed a mixed level of independence. 52,73 One reported complete independence at 15 years and one reported independence at 75% of their sites 14 years into the relationships. 44

Patient Outcomes From MSTs

When asked about patient outcomes and the processes in place for the collection of patient outcomes, volunteers or the organizations that facilitate MSTs reported 1 to 3 days of follow-up and surgical trips included follow-up ranging from 1 day to 1 week. 5 Surveys by Maki et al. and others revealed that 60% to 80% of organizations tracked morbidity and mortality data. 5,70,78 This is in stark contrast to the standards in HICs that track this information and in some cases pay providers according to performance on these measures.

In this review, 13 of the 67 publications (19%) reported mortality in a total of 59 patients. Nearly half of these (n = 30) were likely the result of progression of the disease being treated or a comorbidity. Five died from unknown causes. Four deaths were attributable to sepsis, allergic reactions, or a blood transfusion reaction. Two deaths reportedly resulted from complications associated with pre-existing conditions that patients failed to report preoperatively. 6 One case of malignant hyperthermia was reported in this group of publications. The remaining deaths related largely to cardiopulmonary complications in operative cases for various cardiac conditions.

For our purposes, outcomes are classified in 2 ways: early and late. I defined early outcomes as the immediate postintervention or perioperative periods ranging from zero to 7 days. I defined late outcomes at minimum as 8 days after treatment or as the period after the trip on which the patient received initial treatment.

Among the 50 publications (75%) focusing on the patients of MSTs, only 26% (n = 13) reported late outcomes. The length of follow-up included in these publications ranged from approximately 3 months to 7.6 years. The proportion of patients included in those follow-up statistics ranged from 14% to 84%. The remaining 74% (n = 37) of publications excluded any documentation of outcomes or they were limited to early outcomes.

One qualitative study aimed to establish the feasibility of collecting late outcomes in cleft palate patients. 49 This study presents a unique view into the world of these patients in some cases years after their surgeries. These patients received care from numerous groups and the results do not represent outcomes for one specific intervention. 49 Most notably this publication revealed that patients and their families attribute multiple benefits to surgical intervention despite the absence of the HIC standard level of follow-up care for speech and swallow therapy.

Noma describes an often fatal rapidly spreading and invasive gangrene with edema of the face originating from an ulcer of the mucous membrane and extending outwardly to destroy bone and soft tissue in surrounding regions. 81 In HICs, interventions for noma may have failure rates as high as 73%. 56 Bouman et al. reported complications in 64% of patients and outcomes that were classified as “bad” in 41%. 56 This article presented data regarding early outcomes alone.

How Those Affected by MSTs Perceive Teams and Activities

Green et al. provided the first empirical evidence regarding the perception of people directly and indirectly connected to the work of MSTs in Guatemala. 3 This interview group (n = 72) was composed of health care providers, family members of patients, government officials, foreign medical providers, and nonmedical personnel that work with or around MSTs. One Guatemalan physician indicated that medical service volunteers inaccurately perceive that everyone is poor, thus relieving them from the need to assess the socioeconomic status of patients. 3 The authors covered a few benefits that Guatemalans attribute to MSTs including providing necessary specialty services to patients, education for local providers, and donations of supplies, but even the benefits they described came with strong caveats about problems that may result from improperly distributing services and materials. The authors also explored unintended consequences of the actions of MSTs and attributed causality largely to a lack of knowledge of the surrounding medical and sociological environment.

Reeve et al. used open-ended survey questions to explore the beliefs and expectations of patients and families receiving care from MSTs for cleft lip or palate. 29 The patients expressed that they believed that the surgery would make a dramatic difference in their lives and that their primary goal for the surgery was improving their speech. According to the authors, most informants inaccurately perceived the origins of the developmental disorder. Finally, the primary concern for patients’ parents going into surgery was pain management.

Deonandan et al. described an MST aiming to improve health literacy among tribal people in Guyana awaiting care from their team. 40 The MST identified a basic disconnect between some of the ideas expressed in public health messaging and the knowledge base of the community. Although many describe the presumed benefits of repeat trips to an area, only Jewell described the phenomenon of gender empowerment as a benefit. 21 The observation of female involvement in the MST prompted women to express feelings of a new ability to move toward gender equity. 21 This empowerment differs from the standard definitions employed in the United States, but nonetheless the presence of the MST and the distribution of authority on the team across both genders promoted female empowerment in this setting.

Outputs vs Outcomes of MSTs

Because of their study design and isolated data that may be difficult to reproduce, one group of publications (n = 18) has extremely limited generalizability and benefit for the MST knowledge base. These studies did not include any assessment of the outcomes of interventions. In some cases, they reported on early clinical outcomes associated with morbidity and mortality that occurs during the stay of the team, but intervention efficacy remained absent from their discussions. In the Methods section for some of these publications, there was little or no information about the data collection process or any analysis plan. The focus of the Methods section in these articles was the model of delivery or the intricacies of the setting of the MST.

Among the medical interventions (n = 2) in this group of publications, one described the utilization of a needs assessment in the planning process for their MST, but there was no description of the tool. 25 This represents the only publication in the entire group of 67 that explicitly mentioned employing this practice. This group also elected to focus on only 2 conditions (hypertension and parasite infection). Outcomes related to these goals are not available. One publication focusing on nonsurgical patients described the conditions observed and the interventions performed for these patients. 9 There are no outcomes associated with this publication. None of the publications relating to surgical care (n = 16) from this subgroup included outcomes beyond the perioperative period, and they failed to provide much information beyond descriptive statistics for specific MSTs.

Reporting outputs rather than outcomes appears to be the default approach for quantifying the value added to the communities and individuals served by MSTs. This criterion, however, falls short of the measures used to identify high-quality evidence-based medicine. In some cases, the included publications relied on personal judgments or anecdotes to support their conclusions. This weak form of evidence has the potential to overshadow some of the more promising work in this field. Most of the questions raised in the Results section are unanswered by the included publications, and more research is necessary to strengthen the evidence available. The assessment of process output data, without assessing the short-term or long-term impacts of MSTs, 82 precludes the ability to measure efficacy of interventions performed.

Aiming to assess the quality of the evidence in some cases justifies the use of a standardized hierarchical evaluation tool. For instance, the tool developed by the US Preventive Services Task Force classifies evidence on the basis of the employed study design, with randomized controlled trials representing the highest level of evidence. However, because of the emerging nature of this body of literature, distinctions based on study design have limited benefits. The assumption with that form of evaluation is that authors have unified research questions and are aiming to move up the hierarchy with their work. In the case of the wide-open nature of the MST literature, authors are not united in their research questions nor study designs to advance the scientific rigor of their efforts.

Students and Trainees as Volunteers

The motivations and expectations of MST volunteers may be as diverse as the trips in which they participate. The enormous number of available MSTs, their short-term nature, and the relatively low cost associated with travel makes MSTs a common choice to fulfill the desire for international experience among students and nonstudents alike.

Some disparities research argues that cultural competence plays a role in the quality of care provided to minority populations. 58 That assertion prompted academic medicine to encourage training in cultural competence. Some institutions utilize MSTs as a mechanism for cross-cultural training and integrate these programs into their medical education curriculum. The sample sizes and limited scope of the work regarding the relationship between MSTs and educational benefits limit conclusions at this point.

The answers and conclusions from a limited survey of pharmacy students participating in MSTs are largely unrevealing about the motivations and expectations of the students. They note that experiences on the trips have a positive impact on participants, but the brevity and close-ended form of the survey does not allow for an exploration into specifics about how they will put those positive experiences into action beyond possibly traveling on another trip. 57 The overwhelmingly positive responses among surveyed surgical trainees raises concerns about bias, particularly social desirability. 58

Students and trainees may elect to participate in MSTs for reasons similar to those of nonstudents, but their motivations also may include the desire to receive career and professional benefits. 53 There is a limited number of studies assessing the impact these trips have on the life trajectory of students, their participation in future mission-related activities, or the actual benefits of the social capital on their academic pursuits. Another gap exists in the literature regarding MST organizations and their view of the role they play in medical education process.

Education Through Partnerships

The term partnership should not imply reciprocity between providers from HICs and those from LMICs. The intention behind every partnership appears to be the education or training of surgeons and other providers in communities with limited access to specialty care. In some cases, these partnerships bring patients that local providers refer to HICs for treatment. One organization that sends children to the United States for care cites this as a far more expensive model, increasing costs 10-fold. 74 That contrast prompts most organizations to opt for traveling to countries to train local providers in operative techniques utilized in HICs. Evaluations of the outcomes of that training yield mixed results and seem to require an extended, possibly 15 years or more, presence and partnership to ensure quality.

Many partnerships also include the donation of materials and durable medical equipment. One publication notably reports the inclusion of biomedical engineers in their traveling teams as a way of managing donated equipment that often falls out of repair. 74 This addition is often absent from MSTs and has been the source of published concerns historically. 83

Faith Communities and MSTs

In the mid-1880s, to pursue their mission of caring for the soul, the mind, and the body, the Catholic Church began sending missionaries throughout the world, establishing churches, schools, and hospitals. 80 Such origins may lead to the assumption that faith is motivational for volunteers. Although the assumption may have validity, there is limited evidence for it in the published literature reviewed here. Surveys of medical service organizations reveal a higher proportion of faith-based activities than the 18% of publications included in this review. This is almost certainly a publication bias related to the absence of organizational motivation to publish findings in the medical literature.

The absence of informants describing religious reasons for participation raises some interesting questions about whether the majority culture of medical service is outside the faith-based community, if there is change in the comfort with discussing religion, or if this simply an anomaly among the groups that are participating in research. There is no known work comparing outcomes or the impact of faith-based MSTs versus secular efforts.

Creating and Implementing Evidence in MSTs

There is no shortage of opinions about the ideal framework for an MST, but there is a significant shortage of evidence to support any particular framework. 10 By developing or planning MSTs that include data collection in the mission, practitioners can begin to address some of the concerns and validate the practice or provide information about areas that need improvement.

Maki et al. attempted to address this gap by creating a tool for use by MSTs 5 ; however, for unknown reasons, this tool has not been widely implemented or its use has not been subsequently published. One possible explanation for the apparent lack of adoption of this tool could be that the dissemination of the instrument failed to reach the organizations that could put it into action. Another explanation could be that the organizations faced challenges with its implementation that reduced the return on investment for the process to an unfavorable level. Regardless of the reason, tools for organizations to evaluate their work remain a need.

Critics argue that because of the lack of research on structure, process, or outcomes, a fraction of the care provided as a part of MSTs in the developing world has any evidence base at all. 84 Implementing evidence faces significant challenges in this health care delivery model. First, it assumes that providers are aware of evidence-based practices and only treat patients that fall under the spectrum of populations covered by guidelines. Second, it assumes that providers will deliver medical care in a standardized manner including the provision of continuous or follow-up care by either the group or a local provider. Finally, it assumes that they will perform outcome analyses. By definition, MSTs do not typically deliver care under this model.

The primary goal for medical service organizations is health care delivery and these organizations do not commonly prioritize the collection and subsequent evaluation of data. 71 Delivering care without understanding the impact or the outcome of that care presents ethical challenges. 2 Long-term outcome measurement is difficult, but necessary. 49 The consensus for the ethical challenges of MSTs is that there should be no assumed ethical immunity solely based on the altruistic nature of these efforts. 2

Guidelines and Unintended Consequences in MSTs

In some cases, experts and workgroups are establishing guidelines and standards for humanitarian health care delivery. The dissemination and implementation of these standards again faces challenges related to the unregulated and uncoordinated nature of these activities. Chapin and Doocy expressed a concern about their finding that only 25% of respondents were aware of the World Health Organization Guidelines for Drug Donations. 59 Reflecting that absence of knowledge, 20% of the respondents reported that they did not leave their donations with qualified medical professionals or health organizations. Drug accountability may be tightening globally and the practice of leaving behind medications is receiving a growing level of scrutiny.

The ethical concerns raised by critics, such as Crump, DeCamp, and others, suggest a need for ethical standards that will guide the work toward measurable benefits in light of the inherent risks. 85–90 There is a need for objectives and long-term plans developed in coordination with recipient communities. 78

Outcomes Associated With MSTs

Bureaucrats, consumers, and researchers commonly measure the quality of health care on the basis of patient outcomes, defined according to recovery, restoration of function, and survival. 91 Morbidity and mortality associated with treatments are standard; however, changes in the quality of life resulting from medical interventions are rarely measured in this literature.

Although it is not safe to assume that health care providers are solely responsible for these outcomes, their actions play a role in the process and represent an opportunity for inquiry. Patient outcomes are the most concrete measure of quality, but they are among the least commonly described concepts in the MST literature. Outcomes in this literature may also refer to the impact on the volunteer, on the patient relative to the cost, and on the local health care providers.

Determining Outcomes and Success

The challenges of medical resource shortages come to bear in discussions of patient outcomes. Following patients or obtaining reports regarding the outcome of the interventions performed by MSTs after a team departs remains uncommon and requires intentional effort and resource allocation. 49 The challenges are inherent with the transient nature of the patient population and the distances traveled to seek care from service teams. Most teams do not have the ability or data to attest to their psychological, financial, or sociological impact.

The 13 studies that included a measurement of late outcomes all related to surgical interventions, and there seems to be no data regarding the late outcome of any intervention performed by a strictly medical team. In some cases, the best follow-up available is the vital status of patients, but a few of these publications do attempt to evaluate the efficacy of the intervention.

Focusing largely on fistulas and cleft palates, the bulk of the outcomes literature falls under the auspices of general or plastic surgery. A few of these reported outcomes are bad enough to raise serious concerns. Preconceived ideas about the risks and benefits of surgery have a sociocultural component, particularly in the context of plastic or reconstructive surgery. Patients and their families have beliefs about the origins of congenital conditions, concerns about the reconstructive procedures, and expectations for the outcomes of the intervention. Understanding the role of the MST to address the perceived origins of conditions in a culturally sensitive way may provide another opportunity to reduce the marginalization of the affected.

Cultural awareness is one of the most important parts of defining successful patient interactions and surgical interventions. Learning that parents fear the pain for their children more than other factors allows providers to concentrate on that aspect of the consultation to alleviate their fears. 29 Realizing that speech outcomes were the primary interest for patients allows surgeons to manage the expectations for each individual procedure. 29

Although the aesthetic changes resulting from this type of surgery may provide a dramatic background for fund-raising efforts, aesthetic outcomes, though important to the patients, were less significant than speech outcomes in their definition of success. 29 Speech assessments after cleft lip and palate surgeries were seldom completed and, when they are completed, may reveal unsatisfactory results. 49,63 Operative success in HICs does not stop with satisfactory aesthetics and MSTs should find creative ways to match that standard.

Although organizations aim to provide high-quality care, evaluating outcomes should be universally included in their activities. 70 Yeow et al. summarized the aims of surveyed organizations, and conducting research was considered by most to be a luxury only. 78 The combined results from publications included in the present systematic review report a total of 59 deaths in association with the care provided during MSTs. Simply assuming the care provided is safe and has minimal risks is no longer adequate for these activities.

Comparing Outcomes in Light of Expenses

Recent trends in global health evaluation employ cost-effectiveness analysis to compare interventions and their ability to address the United Nations Millennium Development Goals. These goals aim to increase access to high-quality cost-effective care in LMICs. Comparing the cost-effectiveness of interventions associated with MSTs assists with resource allocation decisions. Disability-adjusted life years serve as the unit of analysis for comparative purposes by accounting for the years of life lost because of disease or injury. These calculations have been widely utilized in public health and health economics.

Interpreting the cost per DALY of interventions introduces subjectivity when determining their cost-effectiveness, especially as they relate to MSTs. The World Bank established guidelines for these determinations in 1993, approximating $150 per DALY as the cutoff for determining cost-effectiveness. 45 Although the costs vary substantially, 3 publications in this review reported their interventions to be cost-effective even though one nearly doubles the World Bank cutoff. 18,45,67 There are limitations to this type of work, but it does represent a promising area for comparative evaluation of MSTs. The basic data necessary for these calculations should include diagnoses and treatments (already collected by most teams), costs for the hosts and volunteers for all treatment and follow-up activities, and a measure of the costs for patients including opportunity costs associated with missed income from work. Decisions about cost-effectiveness may translate to comparisons between trips within organizations or they could relate to comparisons of the costs to employee local providers rather than the standard MSTs. Both raise questions about sustainability, and the limited cost-effectiveness data for MSTs leaves these issues open for debate.

The diversity of terms associated with MST activities in the published literature increases the likelihood of underestimating the number of eligible articles. This review was limited to English-language publications, which may have created a selection bias if we consider the global nature of these activities. This review is also limited to the medical literature, which may exclude notable work in other fields of study.

Conclusions

The popularity of MSTs is increasing along with publications on the topic; however, nearly 95% of all publications lack any significant data collection and the outcomes from the interventions that do exist are not well understood. The MSTs that travel to LMICs are largely unregulated and often lack evaluative procedures. Unfortunately, because of the largely disorganized and diverse nature of these efforts, health care providers choosing to participate in these activities are largely left to their own impetus to participate in evaluative data collection and critical process or activity reviews. The vulnerable nature of the patient populations served by MSTs raises frequently discussed ethical concerns including the provision of care within the regular scope of practice of the provider 92 and the adoption of standards comparable to those of routine research with human participants. 2 The self-imposed standards for MSTs should also include basic critical reviews powered by data collection and evaluation.

Collecting data about the quality of care from patients served by MSTs is a challenge and only a few organizations have shown the initiative to publish the data they collect. Organizations may be evaluating their efforts for internal quality improvement, but the volunteer nature of these efforts and the absence of incentives for publication may mean that these results are not widely disseminated. If these reports do exist, their dissemination could benefit MST efforts in general by allowing others to learn from successes and failures of similar groups.

Evaluation of cost-effectiveness is relatively new to the MST arena. Relative comparisons to United Nations standards may be problematic and the value of these assessments may be limited to internal comparisons between trips for medical service organizations. The educational benefits and impact on cultural competency from these trips for students may represent a relatively easy area for objective evaluation in the future.

An emphasis on evaluation is warranted to improve the planning, implementation, and outcomes of MST investments. Furthermore, the limited number of publications describing rigorously evaluated MSTs may lead to the conclusion that the data do not exist and further support the historical criticisms of these activities.

Suggested Data Elements

There is a need for comprehensive data collection and outcome assessment to justify, quantify, and verify the impact of MSTs. Organizations and volunteers participating in MSTs should at minimum collect data related to patient demographics, the socioeconomic status of the patients including their household income and liabilities, the availability of regular care in the community, and the cost of delivering the care provided by the MST. Information regarding the outcome of the intervention performed by the MST is pivotal for decision-making and quality improvement.

Future research in the area of MSTs needs to focus on the development or implementation of materials or instruments capable of measuring the psychological, financial, and sociological benefits or costs of interventions in this setting. At this point, I am not aware of any validated and reliable instruments capable of this assessment.

Acknowledgments

I would like to thank Mary K. Zimmerman, PhD, Sarah Finocchario-Kessler, PhD, MPH, and Robert H. Lee, PhD, for reviewing the draft of the article and making helpful suggestions.

Human Participant Protection

No protocol approval was needed for this study as it is a review of previously published research.

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Short-term medical service trips: a systematic review of the evidence.

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10 Best Medical Mission Trips 2023 & 2024: Make a Difference

Medical mission trips present a fantastic opportunity for individuals, particularly those in the healthcare sector, to utilize their skills and expertise for the betterment of the world. Even for those who aren’t healthcare professionals, there’s still a vast array of volunteering opportunities in developing nations.

This blog post will serve as a guide, highlighting 10 notable medical mission trips taking place in 2023 and 2024. We will delve into the various types of mission trips, and the advantages of being a volunteer, and provide insights on how you can select a trip that matches your interests and skills.

Exploring the Diversity of Medical Mission Trips

A medical mission trip is essentially a short-term volunteer program enabling you to extend healthcare services to those in need in underprivileged nations. These trips are orchestrated by various entities such as churches, hospitals, and non-governmental organizations (NGOs).

The nature of these medical mission trips can be diverse. Some are aimed at providing essential healthcare services like vaccinations, treatment of common diseases, and wound care. In contrast, others are centered on more specialized care like surgeries, dental services, or mental healthcare.

Benefits of Volunteering

There are many benefits to volunteering on a medical mission trip. These benefits include:

• Making a difference in the world. Medical mission trips are a great way to use your skills and experience to help people in need. You can make a real difference in the lives of people who would not otherwise have access to healthcare.
• Gaining new skills and experience. These trips can be a great way to gain new skills and experience in the medical field. You will have the opportunity to work with experienced healthcare professionals and learn new techniques.
• Experiencing a new culture.  Medical mission trips are a great way to experience a new culture and learn about different ways of life. You will have the opportunity to meet new people and learn about their customs and traditions.
• Growing personally and spiritually. Healthcare mission trips can be a great way to grow personally and spiritually. You will have the opportunity to reflect on your own life and values, and you will learn about the importance of compassion and service.

How to Find the Right Mission Trip for You

There are a few things to consider when choosing a medical mission trip. These include:

• Your skills and experience. What are your skills and experience in the healthcare field? If you’re a doctor, you’ll need to find a trip that offers clinical opportunities. If you’re a nurse, you might be interested in a trip that focuses on providing basic medical care.
• Your interests.  What are your interests in the medical field? Are you interested in working with children, women, or the elderly? Are you interested in providing specialized care, such as surgery or dentistry?
• Your budget. Mission trips can vary in price. Some trips are very affordable, while others can be quite expensive.
• Your schedule.  How much time do you have to commit to a medical mission trip? Some trips are only a few days long, while others can last several weeks.

Once you’ve considered these factors, you can start your search for the right medical mission trip. There are a number of resources available to help you find a trip that’s right for you. You can search online, talk to your church or hospital, or contact an NGO that organizes these trips.

10 Best Medical Mission Trips 2023 & 2024

Here are 10 of the best medical mission trips in 2023 & 2024:

1. Project Medishare: Haiti

Project Medishare is a non-profit organization dedicated to providing healthcare services to the underserved population of Haiti. The organization conducts various medical mission trips, opening opportunities for doctors, nurses, and other healthcare professionals to volunteer their services.

You can participate in tasks ranging from basic healthcare provision to specialized care, depending on your expertise.

2. Global Brigades: Guatemala

Global Brigades organizes health, dental, and engineering brigades to serve in developing countries. For those interested in medical volunteer work, they offer numerous mission trips to Guatemala.

These trips are tailored for different healthcare professionals, including doctors, nurses, and other healthcare staff, and they focus on improving local healthcare infrastructure and providing necessary medical services.

3. AmeriCares: Kenya

AmeriCares, a global non-profit, extends medical care and relief services to needy populations worldwide. They coordinate a variety of mission trips to Kenya , allowing doctors, nurses, and other healthcare professionals to provide vital healthcare services in underserved regions.

Their work often involves treating common illnesses, conducting health education, and improving local healthcare facilities.

4. Doctors Without Borders: Sierra Leone

Doctors Without Borders is an international medical humanitarian organization renowned for providing healthcare assistance to people affected by conflict, epidemics, disasters, or exclusion from healthcare. Among their numerous programs, they organize medical mission trips to Sierra Leone, creating opportunities for healthcare professionals to provide critical care in a country still recovering from a prolonged civil war and an Ebola outbreak.

5. Children’s Heart Foundation: Honduras

The Children’s Heart Foundation is a non-profit that focuses on providing cardiac care to children in developing countries. They run several medical mission trips to Honduras.

These trips are ideal for doctors, nurses, and other healthcare professionals specializing in cardiac care, as they will be directly involved in providing life-saving treatments to children with heart conditions.

6. Project Hope: Tanzania

Project Hope is another global non-profit that extends medical assistance to those in need. They organize a variety of mission trips to Tanzania , offering opportunities for healthcare professionals to volunteer their services.

The range of healthcare services provided during these trips depends on the needs of the communities served and the expertise of the volunteers.

7. Partners in Health: Peru

Partners in Health is a non-profit that focuses on providing medical services to people in need in developing countries. Their mission trips to Peru allow healthcare professionals to volunteer their services and provide much-needed healthcare to underserved communities.

8. Habitat for Humanity: Nepal

While known for building homes, Habitat for Humanity also organizes medical mission trips to Nepal. These trips provide volunteers with an opportunity to offer care to individuals in need while contributing to the construction and improvement of homes and community facilities.

9. Smile Train: Peru

Smile Train is a non-profit dedicated to providing cleft lip and palate surgery to children in developing countries. They organize medical mission trips to Peru, where healthcare professionals can volunteer to provide surgical services and other healthcare to children affected by cleft lip and palate conditions.

10. International Medical Corps: Rwanda

International Medical Corps is a global non-profit that provides to people in need in developing countries. They offer a range of mission trips to Rwanda, creating opportunities for healthcare professionals to volunteer their services in communities that lack sufficient healthcare infrastructure and resources.

Additional Tips

Planning and participating in a medical mission trip is a substantial commitment. Here are some additional tips to consider as you embark on this journey.

Commence Your Research Early

Medical mission trips are diverse and numerous. Starting your research early gives you ample time to identify a trip that aligns with your skills, interests, and schedule.

Evaluating multiple options will also allow you to find a mission trip that meets your budget and other personal needs.

Consult Your Doctor

If you have any health concerns, it’s essential to discuss them with your doctor before committing to a medical mission trip. Such trips often involve physically strenuous activities and exposure to different climates and environments, which may pose health risks.

Obtain Necessary Training

Depending on the nature of the medical mission trip, you might require specific training. For instance, if your trip involves surgical procedures, you may need certification in basic life support (BLS). Other specialized healthcare areas may also require additional training or certification. Be proactive in understanding and acquiring these prerequisites.

Prepare for Challenges

Embarking on a medical mission trip means stepping out of your comfort zone. Be ready for long working hours, limited resources, and encountering cultural differences. While these aspects can be challenging, they also offer profound opportunities for growth and learning.

Embrace Learning Opportunities

Medical mission trips provide a unique platform to learn from other healthcare professionals and the community you serve. Be open to absorbing new information and techniques, and respect the local customs and traditions. This openness to learning will not only enrich your professional skills but will also contribute significantly to your personal development.

How can I apply for these medical mission trips?

You can apply for these medical mission trips by visiting the respective organization’s website and filling out the application form. Make sure to submit all necessary documents and meet the application deadline.

What qualifications do I need to join a medical mission trip?

The qualifications vary depending on the specific mission trip. Generally, you should be a healthcare professional or a student in a healthcare-related field. Some trips may also accept non-medical volunteers.

What is the duration of these medical mission trips?

The duration of the medical mission trips can range from a few days to several months, depending on the specific program and the needs of the community being served.

Are these medical mission trips safe?

Yes, the safety of volunteers is a top priority for all of these programs. However, as with any travel, there are inherent risks. It’s important to follow all safety guidelines provided by the organization.

Do I need to speak the local language?

While knowing the local language can be beneficial, it is not always a requirement. Many mission trips provide translators. However, learning basic phrases can enhance your experience and interaction with the local community.

Can I earn continuing education credits (CECs) or units (CEUs) by participating in these trips?

Some medical mission trips offer the opportunity to earn CECs or CEUs. You should check with the specific program or your professional licensing board for more information.

Medical mission trips are a great way to make a difference in the world. They offer the opportunity to use your skills and experience to help people in need, gain new skills and experience in the medical field, experience a new culture, and grow personally and spiritually.

I believe that everyone has the potential to make a difference in the world. If you’re looking for a way to use your skills and experience to help others, I encourage you to consider volunteering on a medical mission trip. It’s a truly rewarding experience that can change your life.

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• How to Apply to A Medical Mission? - Step-by-Step Guide 2023
• What Are the Best Specialties for Medical Missions?…
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$15M settlement reached after doctors allegedly left heart surgeries to perform other operations

HOUSTON, Texas (KTRK) -- The Federal Bureau of Investigation is investigating three Texas Medical Center institutions after a whistleblower came forward accusing three heart surgeons of violating regulations during complicated operations.

On Monday, the FBI posted on X, formerly known as Twitter, saying that the doctors had "gambled with their patients' care during complicated open-heart-surgeries no less, compromising quality care over quantity and then falsely billed Medicare for reimbursement of services they improperly delegated."

According to U.S. Attorney Alamdar S. Hamdani, Baylor St. Luke's Medical Center (BSLMC), Baylor College of Medicine (BCM), and Surgical Associates of Texas P.A. (SAT) have jointly agreed to pay $15 million to resolve the claims.

The settlement resolved allegations from June 3, 2013, to Dec. 21, 2020. The civil lawsuit alleges three surgeons, 71-year-old Dr. Joseph Coselli, 63-year-old Dr. Joseph Lamelas, and 77-year-old Dr. David Ott, violated Medicare teaching physician and informed consent regulations.

According to the U.S. Attorney's Office, the investigation began on Aug. 7, 2019, when the whistleblower alleged that Coselli, Lamelas, and Ott regularly ran two operating rooms at once and delegated key aspects of extremely complicated heart surgeries to unqualified medical residents at St. Luke's.

The sealed qui tam lawsuit alleges that the heart surgeries at hand are some of the most complicated operations performed at any hospital, including coronary artery bypass grafts, valve repairs, and aortic repair procedures.

The U.S. Attorney's Office said these surgeries typically involve opening a patients' chest and placing the patient on the bypass machine for some portion of time.

The lawsuit alleges that the surgeons ran two operating rooms at once and failed to attend the surgical timeout, which is a critical moment when the entire team would pause and identify key risks to prevent surgical errors.

"Patients entrusted these surgeons with their lives - submitting to operations where one missed cut is the difference between life and death," said Hamdani. "Allegedly, the patients were unaware their doctor was leaving for another operating room. This settlement reaffirms the importance of Medicare requirements governing surgeon presence and ensuring that no physician - no matter how prominent or successful - can skirt around the rules."

The doctors are accused of hiding this information by falsely attesting on medical records they were physically present for the "entire" operation.

"The complete disregard for patient safety exhibited by these three doctors put patients at risk and violated Medicare regulations for their own convenience and greed," said Special Agent in Charge Jason E. Meadows of the Department of Health and Human Services Office of Inspector General. "This record settlement demonstrates our steadfast commitment to protecting Medicare beneficiaries and working with our law enforcement partners to utilize all the tools in our arsenal to hold accountable those who steal from Medicare and other federal health care programs."

Baylor St. Luke's Medical Center sent Eyewitness News the following statement:

Baylor St. Luke's Medical Center has reached an agreement with the Department of Justice (DOJ) to resolve a documentation and billing matter involving compliance and billing requirements set forth by the Centers for Medicare and Medicaid Services (CMS). The DOJ claims are strictly allegations and the settlement by Baylor St. Luke's is not an admission of liability. Baylor St. Luke's remains committed to complying with all CMS regulations. Baylor St. Luke's is a world-renowned academic medical center that cares for patients from throughout the world with the most complex conditions. The hospital provides its patients with safe, high-quality care and remains committed to compliance with all applicable regulations.

The $15 million recovery is the largest settlement to date involving concurrent surgeries. The whistleblower will receive $3,075,000 due to the False Claims Act, which entitles the private whistleblower who commences the suit to a portion of the recovery.

For updates on this story, follow Alex Bozarjian on Facebook , X and Instagram .

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Service mesh technology revolutionizes 6G core network signal processing

by National Research Council of Science and Technology

Korean researchers are strengthening South Korea's leadership in the global market through the development of 6G, the next-generation mobile communication technology.

Electronics and Telecommunications Research Institute (ETRI) announced that they showcased their latest research results at the " 6G Symposium Spring 2024 " held in Oulu, Finland, from April 9 to 11, drawing the attention of attendees.

At this symposium, ETRI particularly showcased its "service mesh" technology. This technology is a key 6G technology that addresses complex communication issues among numerous cloud-native mobile network functions that are dynamically created or terminated in a cloud environment.

6G mobile networks are moving away from the dedicated hardware equipment structure of existing 4G/5G networks. They are evolving into a cloud-native architecture where mobile network functions are virtualized into software services that are developed, deployed, executed, and managed in a cloud environment.

Accordingly, network functions developed in the form of microservices in various languages and environments are deployed and operated on the cloud. To provide smooth mobile services to users, these microservices need to exchange complex control signals rapidly. However, the existing structure posed issues such as communication delays due to inefficient communication methods.

ETRI's newly developed service mesh architecture has significantly improved communication delay by reducing existing networking procedures by more than 80%. It reduced the number of networking stack that a packet passes, which used to be 24 round trips, to just 4.

By completely separating the business logic and communication logic that were mixed within existing network functions, and adopting an agent that can selectively use high-speed communication methods such as gRPC, an open-source Remote Procedure Call (RPC) framework, ETRI has enhanced the mobile core network signal processing performance.

Additionally, it provides a 6G development environment where network function developers can focus solely on developing core mobile service functions. Developers no longer need to worry about the communication logic such as network service registration, discovery, connection, and authentication.

Namseok Ko, the head of ETRI's Mobile Core Network Research Section, said, "ETRI's service mesh technology can be adopted as a core technology for cloud-native 6G mobile networks . This technological development is expected to enable faster and more efficient 6G communication services and contribute to the advancement of global communication technology."

The research team stated that this symposium, held as a part of the EU 6G Flagship project, provided an opportunity to solidify South Korea's position as a global leader in the field of communication technology.

ETRI also announced plans to further expand and commercialize this technology through the next-generation communication industry technology development project promoted by the Ministry of Science and ICT.

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