AMA Journal of Ethics^®

Case

State Medical University is working to design and implement an updated version of its curriculum. As part of this new curriculum, the university would like to establish a policy for student engagement in the community. The dean, Dr. Grant, suggests that students need to be active in serving the larger community in which they live and study during their medical training. He emphasizes that this would be an excellent learning experience for the students, inasmuch as he views the urban community where the university is located as a different world from that which the majority of the medical students have previously experienced. Several other faculty members agree with Dr. Grant’s opinion.

Ramona, the medical student representative to the committee, agrees that that many of her classmates entered medical school wanting to make a difference and improve the lives of others. She suggests to the committee that both local and international experiences could enhance the new curriculum and students’ education. She is intrigued by the opportunity to visit a foreign country for an elective. She suggests to the committee that prospective students look for global health experiences when choosing a medical school. She stresses that she believes that experiences in developing nations provide unique educational opportunities that students cannot get in their local surroundings.

Several of the faculty members express concern over the idea of the university’s devoting resources to international electives. They suggest implementing a policy which would not permit students to go on international rotations for academic credit, preferring that they work to address the local need that surrounds them.

Commentary 2

Like Ramona, many students enter medical school with the desire to make a difference, relieve suffering, and improve quality of life for others. Many argue that the qualities of altruism, idealism, and service are essential in physicians. Students must be taught these qualities to meet the needs of their patients [1-3]. Medical students also commonly yearn for more clinical responsibility and ways to use their new knowledge. Academic centers often pair their university’s resources and eager medical students with communities in need [3, 4] in the hopes of both engaging students and caring for underserved communities—not only within our inner cities, but also within our medical school neighborhoods and around the world.

In this case, the faculty at State Medical University suggest implementing a policy that would not permit students to go on international rotations for academic credit, preferring that they work to address local health care needs. The impact of globalization, however, has expanded the roles and responsibilities of health professionals, and future physicians will have the responsibility to address inequities in health throughout the world. Thus, medical training cannot be biased toward domestic problems to the exclusion of international experiences but should incorporate a global perspective. Medical schools that have the requisite faculty expertise, resources, and well-established partnerships should offer such training.

“Global health” as a concept emphasizes the notion that the most pressing health issues facing humankind are not bound by international borders and are best addressed from a global (and not from the U.S. or any individual country) perspective. It is distinct from the disciplines of public health and international health in that it not only emphasizes the prevention of illness, underserved communities, and the health of populations, but also “refers to the scope of the problems, not their locations… global health can focus on domestic health disparities as well as cross-border issues” [5]. Moreover, the global health perspective prioritizes partnership, cooperation, and solidarity among nations in tackling health disparities and needs. These experiences, either local or international, are necessary in medical training, and medical schools must provide thoughtful curricular opportunities to foster the values of altruism, humanitarianism, and social service. In this paper, the term “global health” is used to refer to both local and international experiences undertaken within this larger framework. The term “international” is used to designate activities outside of the United States [5]. International health experiences, when applied within the context of a larger global health framework, provide students with perspectives and skills not otherwise obtained in medical school.

Benefits of Global Health Programs

As discussed in the case, significant health disparities can be found near academic medical centers, presenting important opportunities for learning and service. Students who work in local student-run clinics or homeless shelters “gain firsthand experience about the impact of poverty and homelessness on one’s health and well-being” [4]. Prior research has shown that these local community experiences also influence students’ perceptions of community health [6], residency program selection, and professional responsibility [7]. As further explained by Buchanan:

The extreme poverty and need students are likely to encounter in this setting and the opportunity for meaningful interaction with the community make the SRC [student-run clinic] an ideal place to role-model ethical behavior and professionalism, including altruism and respect for all patients [3].

Indeed, the perspectives and skills learned working within local communities are core competencies of medical education.

International health experiences further promote compassion, volunteerism, and dedication to the underserved in low-resource settings [2, 8, 9]. As the world becomes increasingly interconnected, familiarity with different cultures, fluency in different languages, and international health experiences become increasingly constructive. As Shaywitz and Ausiello suggest:

[S]ince one of the most essential qualities of being a doctor is an interest in helping those who are in greatest need, teaching physicians about the medical problems faced by people in LMICs [low and middle income countries] should be a priority of medical education” [1].

International health experiences increase student awareness of the social, economic, and political determinants of health and interdisciplinary models of health care [2, 8, 10]. One study found that physicians who had an international health experience during medical school were more likely than their physician colleagues to practice primary care, to obtain public health degrees, to work with underserved populations, and to participate in community health activities [11]. A study comparing residents who participated in an international health elective to those who did not found that, after residency, elective participants were significantly more likely to work with immigrant patients and patients receiving public assistance [12]. International health experiences not only teach medical students more about medicine in another culture, but also show them how to be advocates for different communities in need.

Unlike low-resource settings in the U.S., international health sites often lack basic infrastructure, including access to clean water, sanitation, food, transportation, and routine health services. These settings present unique challenges not otherwise seen by students, including barriers to care, a high prevalence of tropical diseases, and advanced disease states. Without the ability to rely on diagnostic tests, students gain the opportunity to strengthen their clinical and physical examination skills [9].

International experiences further spur activism and outreach within local communities when students return home, encompassing the values of a global health perspective. Clinical models or research learned internationally can inform program development or research in other geographic settings [13]. As the faculty who designed UCSF’s Global Health Sciences initiative have written,

Taking the global health perspective, we are able to draw on similar transnational experiences elsewhere in the world to design and implement studies locally, while intending that what we learn in California will contribute to global thinking on this issue of increasing global importance [14].

Program Development

As there is growing interest in programs with both international and local experiences, medical schools can expect that curricula that incorporate a global health perspective and that value community outreach will attract students with similar goals. When developing such curricula, however, medical schools must establish thoughtful and cohesive partnerships for local and international collaborations. Community perspectives are frequently overlooked in program and research development, but true collaborations provide underserved patients and organizations a way to inform health care initiatives to reflect the needs of their community. Partnerships between U.S.-based universities and collaborating international institutions should be responsive to the competing needs and interests of multiple parties, including students and faculty from both institutions and the larger communities that the institutions serve. Further, the institutions and hospitals that host rotating students often bear a heavy burden in orienting students and attending to their day to day needs, including the time investment of clinical tutors, language translation, housing, and travel arrangements. Appropriate compensation for these efforts is essential to ensure that the partnerships are equitable and remain sustainable [18-19]. Although student rotations per se do not have a significant impact on the care of patients, the institutional partnerships that share the goals of mutual education, training, and capacity building can produce thoughtful programming that benefits both the larger host community and the students on rotation. In addition such partnerships can lead to other mutually beneficial inter-institutional activities such as research collaboration and program development. Continuity of these partnerships enables long-term sustainability and provides mutually beneficial global health experiences for students and the larger community [18-20].

Students must be prepared for the ethical and clinical challenges specific to working in low-resource settings both in the U.S. and abroad. Because many global health electives are unstructured and poorly supervised, students struggle to determine what role and level of responsibility they should assume. Much of the learning on such rotations occurs through experience rather than self-directed or guided learning [21]. Medical students commonly face ethical challenges when on international rotations, but institutional partnerships can help anticipate and mitigate these conflicts. Students selected to participate in the activities should demonstrate a commitment to careers working with the underserved, and be prepared to undertake the necessary pre-departure training to make such experiences meaningful and mutually beneficial for all parties involved.

Medical school curricula that foster and promote humanitarian and social services within the framework of global health, either locally or internationally, create physicians that share these values. Moreover, student interest in international health experiences is especially encouraging and needed to prepare physicians for careers that address the gross inequities in health care and resources in an increasingly interconnected world.