Interest in global health among medical students, residents, and faculty has dramatically increased over the last decade, but training is often unidirectional, with inequity benefiting high-income countries (HICs) instead of the intended beneficiaries in low and middle-income countries (LMICs). We describe the process of changing the state law in Tennessee (TN) to create a medical license category intended to improve equity in global health education through bidirectional training.

Many residency programs across specialties offer international electives to introduce residents to health care in LMICs, and the pairing of academic institutions in HICs with those in LMICs, known as “twinning,” is a common model in academic global health.1 These global health opportunities have multiple benefits for trainees from HICs, including cross-cultural experiences, exposure to advanced disease and disease processes, infrequently encountered in high-resource settings, and increased autonomy.2 However, there is growing concern that such “partnerships” are fraught with power imbalances, in which partners do not benefit equally from the relationship and may even represent a modern form of colonialism in which stakeholders from HICs engage in partnerships with those in LMICs without prioritizing the identified needs or goals of the LMIC partner.3 Examples of unequal global health partnerships span the spectrum of medical practice, including clinical care, medical education, and research.4

Global health proponents frequently discuss “bidirectional partnerships,” implying equity and equality in such collaborations. In many cases, however, neither is given more than the passing nod when there continue to be publications reporting results of research conducted in an LMIC without an LMIC author, a disconnect in priorities of funding agencies that continue to fund the initiatives of HIC researchers rather than the diseases with the highest mortality in LMICs, and a lack of access to clinical trials of new therapeutics in LMICs.5 Perhaps this is most obvious in the unidirectional travel of trainees from HIC to health care institutions in LMICs without reciprocal opportunity for students, trainees, and faculty from LMICs to spend time in educational rotations in HICs for purposes of expanding surgical capacity and care in their home country.

This concept of a “one-way street” in global health is a particular problem for institutions within the United States, where state licensing laws and, to a lesser degree, federal visa restrictions block the pathway for bidirectional exchange in most settings.6 Our institution has a long-standing partnership with a teaching hospital in Kijabe, Kenya, and has sent more than 100 medical students and residents across disciplines to that location over the last 15 years. However, there have only been a handful of reciprocal visitors from Kenya, with those individuals only able to observe clinical care. This inequity has not gone unnoticed by our partners and is mentioned in the conversation about our otherwise robust and mutually beneficial collaboration. In response, we set out to create a pathway for bidirectional global health education within our state.

We queried the TN Medical Board website to determine whether an existing state licensure category would allow a foreign medical graduate (FMG) to spend time at a medical institution for supervised clinical care and graduate medical education. Finding none, we contacted the medical director of the board and spoke with their legal counsel. Both parties confirmed that no existing licensure category existed that would accomplish our goal of bringing a Kenyan resident or faculty member to our institution for supervised medical education. Furthermore, they explained that any new licensure category within the state must be created by the passage of legislation at the state level. Therefore, we wrote a proposal for new legislation to create such a licensure category and secured sponsorship for the bill within the TN House of Representatives and TN Senate (SB1902/HB2849).7 Of importance in our proposal was the requirement that FMGs under this licensure category be supervised by a licensed physician (much like residents in training) as the US health care system differs from their home country, applicants must show proof of malpractice coverage, and rotations at institutions within TN under this bill are limited to 90 days to protect against “brain drain” of well-trained physicians from LMICs to institutions within HICs. Furthermore, the proposed bill posed a no-risk financial burden to the state. During the 2022 legislative session, the authors met with the Director of the State Medical Board to secure support, the Community Advocacy Office at our institution, and multiple state representatives and senators to lobby for the support of this bill, dubbed the “Visiting Fellows Act.” The bill progressed through pertinent sub-committees of the 2 branches of the Legislature and was ultimately passed through both the House and the Senate with bipartisan support before being signed into law by the Governor of TN.7 A flowsheet outlining the legislative process utilized is shown in Table 1.

Table 1 - Creating a New “Short-Term Visitor Clinical Training License” Category via State Legislature: The “Visiting Fellows Act” Stakeholder engagement  State medical board   Legal counsel  Secure legislator sponsors in House and Senate   Meet with representatives 2 months prior to legislative session   Target physician legislators   Present current evidence: literature and other states with similar legislation6,8-10   Present benefits to state including improved medical training, increased temporary capacity, stronger global health systems   Helpful to present the bill as a bipartisan effort Policy document drafting  By legislature legal counsel, edits as needed Bill introduction by sponsors Costing and budgeting  Application fee gives the bill a positive financial note  No cost burden to state Committees  Health   Meet with chairs of health committees  Finance, Ways, and Means Lobby legislators for support of bill  Request local societies and physicians to lobby in support Bill will be voted on floor, then sent to governor for signature Implementation  Meet with interested local institutions and generative internal policies for Visiting Fellows

The passage of legislation to create a short-term license for clinical medical education of FMGs is a necessary step to address inequity in global medical education. However, additional barriers must also be addressed. States who have created such licenses appropriately require proof of medical malpractice for individuals applying for licensure. Options for fulfilling this requirement include purchasing malpractice coverage on the free market (as some physicians do for locum tenens jobs) or the host institution extending their medical malpractice coverage to include these visiting clinicians. Such a strategy requires careful discussion with the institution’s risk management team, legal counsel, and executive medical board to garner their support and approval. Challenges in obtaining federal visas to enter the United States remain a significant hurdle. The J-1 visa is specifically for medical training for FMGs but requires acceptance into a formal accredited training program and passage of the USMLE board examinations. This is not realistic for short-term medical education experiences. Advocacy at the federal level is ongoing to address this challenge. Institutions creating bidirectional medical education programs are encouraged to carefully construct the curriculum for visiting clinicians to address the specific training needs required by their home institution to maximize capacity building in surgical care in their home region.

As interest in involvement in global health increases and academic institutions in the US partner with those in LMICs to provide global health training for US-based trainees and faculty, it is imperative that great care is taken to ensure equity in collaborative partnerships between health care institutions in HICs and LMICs. Equity in professional health education supports international health goals, improves the long-term stability of global health training, and strengthens health care systems worldwide. Providing opportunities for true bidirectional exchange includes facilitating a pathway for FMGs to participate in medical education within HICs for the acquisition of specific skills that will increase their capacity in their home institutions. While this commitment necessitates concerted effort, this report illustrates the feasibility of creating such a pathway. Medical licensure in the United States is regulated at the state level, requiring champions in individual states to take the necessary steps to create similar programs within their own states that would benefit their LMIC partners (Supplemental Digital Content Appendix 1, https://links.lww.com/SLA/E697). The specific structure and format can be adapted to the needs of the state, academic institutions within that state, and LMIC partners as applicable. We strongly encourage global health leaders in academic institutions across the United States to pursue similar efforts to increase the intellectual exchange of medical training globally, thus improving care for all.

1. Abraham PJ, Abraham MN, Corey BL, et al. Cross-sectional analysis of global surgery opportunities among general surgery residency programs. JSR. 2020;77:1179–1185. 2. LeCompte MT, Goldman C, Tarpley JL, et al. Incorporation of a global surgery rotation into an academic general surgery residency program: impact and perceptions. World J Surg. 2018;42:2715–2724. 3. Ameh E, Narayanan PV, Maya J. Opinion: it’s time to end neocolonialism in global surgery. Global Views, DEVEX. WORLD. 2020. 4. Sayegh H, Harden C, Khan H, et al. Global health education in high-income countries: confronting coloniality and power asymmetry. BMJ Glob Health. 2022;7:3008501. 5. Taylor-Robinson SD, Spearman CW, Suliman AAA. Why is there a paucity of clinical trials in Africa? QJM. 2021;114:357–358. 6. Hudspeth JC, Rabin TL, Dreifuss BA, et al. Reconfiguring a one-way street: A position paper on why and how to improve equity in global physician training. Acad Med. 2019;94:482–489.