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Dealing With Patient Death on International Health Electives: A Qualitative Study of Residents’ Experiences

Bashir, M. Usmaan MD; Nordhues, Hannah C. MD; Merry, Stephen P. MD, MPH; Sawatsky, Adam P. MD, MS

doi: 10.1097/ACM.0000000000002763
Research Reports

Purpose International health electives (IHEs) provide numerous educational benefits; potential harms are less well understood. One potential harm is trainee distress associated with increased patient death during IHEs. The purpose of this study was to explore residents’ and fellows’ IHE experiences with patient death.

Method The authors used applied thematic analysis to explore residents’ and fellows’ IHE experiences with patient death. The Mayo International Health Program supports IHEs from all specialties across three Mayo Clinic sites. Data were collected and analyzed in two steps. First the authors collected, coded, and analyzed narrative reflections from 43 postrotation reports gathered in 2001–2017 and identified themes relating to experiences with patient death. Second, in 2016–2017 the authors conducted semistructured interviews with six previous participants to refine thematic analysis.

Results Participants described impacts of experiencing increased patient death and identified themes in two domains: difficult experiences with patient death and potential interventions to help residents process their experiences. They identified four themes illustrating why these experiences were difficult: lack of preparation for increased exposure to death, lack of closure, consequences of limited resources, and differences in cultural beliefs regarding death. While pretrip preparation for dealing with death was viewed as important, trainees identified support during and debriefing after IHEs as additional important interventions.

Conclusions Given the popularity of IHEs, residency programs should consider the effect on trainees of increased exposure to patient death. Study findings can inform IHE preparation, support, and debriefing to minimize distress associated with witnessing patient deaths on IHEs.

M.U. Bashir is associate consultant, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota.

H.C. Nordhues is chief resident, Internal Medicine Residency Program, and instructor of medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota.

S.P. Merry is assistant professor of family medicine, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota.

A.P. Sawatsky is assistant professor of medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID:

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: This study was deemed exempt by the Mayo Clinic Institutional Review Board (IRB ID 14-004305).

Previous presentations: This study was presented at the Society of General Internal Medicine 2016 Annual Meeting, Hollywood, Florida, May 11, 2016.

Supplemental digital content for this article is available at

Correspondence should be addressed to Adam P. Sawatsky, Mayo Clinic, Division of General Internal Medicine, Gonda 17, Rochester, MN 55905; telephone: (507) 284-8913; email:

Copyright © 2019 by the Association of American Medical Colleges