AMA Journal of Ethics^®

Abstract

Almost all allopathic medical schools in the United States allow students to participate in global health immersion experiences. The Liaison Committee on Medical Education accreditation requirements specify that students’ home institutions are responsible for overseeing learning experiences, assessing and mitigating risk, ensuring appropriate supervision, and offering instruction about what to expect, ethically and culturally, in a learning setting. Students should also have opportunities to debrief about their experiences.

Global Health Experiences

In a survey of MD-granting medical schools during the 2016-2017 academic year administered by the Liaison Committee on Medical Education (LCME), 140 of the 145 surveyed schools offered international experiences.¹ These most commonly occurred in the fourth (and final) year of the curriculum but could also have been available earlier.¹ Medical students choose global health immersion experiences for a number of reasons, including an altruistic desire to serve those with poor access to health care or a desire to practice and expand their clinical skills, expand their understanding of global health challenges and issues, gain exposure to the diagnosis and treatment of diseases uncommon in the United States or to advanced states of disease, or gain experience in cultures and with languages different from their own. International and global health experiences have been shown to positively influence cultural awareness, intention to work with underserved populations, and consideration of primary care specialty choice among participating students.² While there are many educational benefits associated with international rotations, there can be risks to both students and patients. For example, students might wish to visit locations that pose dangers to their health and safety. They also might be asked to provide care and perform procedures beyond their level of experience and competence.

MD-granting medical schools typically support student engagement in global health immersion experiences by helping students find an experience, providing financial and administrative support, and granting academic credit for such experiences. In so doing, schools bear ultimate responsibility for meeting LCME accreditation requirements: taking reasonable steps to ensure students’ adequate preparation and supervision, ensuring students’ participation is appropriate to their level of training, ensuring students’ safety, and ensuring appropriate clinical oversight, among others.

LCME Accreditation Requirements

To be eligible for postgraduate (residency) training in the United States, physicians must have graduated from MD-granting medical schools in the United States and Canada whose medical education programs are accredited by the LCME. LCME accreditation is assessed by peers who determine whether a medical education program has achieved an acceptable level of quality. In reviewing a program, the LCME assesses the program’s performance on 93 elements organized under 12 standards.³ Four elements apply directly to schools’ global health immersion offerings.

1. The LCME does not require schools to provide international or global health experiences. However, Element 6.6 (service-learning) requires schools to “provide sufficient opportunities … in service-learning and community service activities.”³ We are aware that many schools include elective international or global health immersion activities in their list of service-learning and community service curricular activities.
2. Element 7.7 (ethics) states that schools must “ensure that the medical curriculum includes instruction for medical students in medical ethics and human values both prior to and during their participation in patient care activities and requires its medical students to behave ethically in caring for patients.”³ Although not explicitly stated, the LCME expects that students will receive appropriate instruction in ethics relevant to patient care activities.
3. Element 9.3 (clinical supervision of students) states that the school “ensures that medical students in clinical learning situations involving patient care are appropriately supervised at all times in order to ensure patient and student safety, [and] that the level of responsibility delegated to the student is appropriate to his or her level of training.”³ The LCME’s intent and expectation for this element, as applied to global health experiences, is that students will provide appropriate care and services under direct supervision of appropriately credentialed health care practitioners who practice within the scope of their training.³ In global health experiences involving patient contact, supervising practitioners must be both licensed to provide the expected level of patient care and educationally prepared to supervise medical students. The LCME does not stratify this expectation based on location of the learning experience, domestic or international.
4. Element 11.3 (oversight of extramural electives) lists the oversight responsibilities of the school. These responsibilities include assessment of (1) “potential risks to the health and safety of patients, students, and the community”; (2) “the availability of emergency care” for students on the elective; (3) risk assessment for the possibility of “natural disasters, political instability, and exposure to disease”; (4) “the need for additional preparation prior to, support during, and follow-up after the elective”; (5) “the level and quality of supervision”; and (6) “any potential challenges to the code of medical ethics adopted by the home school.”³ Many of these expectations are addressed through LCME requirements for all accredited medical education programs, regardless of where students take the elective. For international experiences, a school would have to ensure that these expectations are met on site prior to approving that site for offering an elective. This element also requires that “a centralized system exists in the dean’s office at the home school to review the proposed extramural elective prior to approval.”³ This statement unequivocally places responsibility on schools for ensuring students’ safety, appropriate training for the experience, and quality of supervision.

Applying LCME Requirements

The LCME judges programs’ performance on each of the above-listed elements individually for the purpose of accreditation. Beyond being the basis of accreditation decisions, accreditation requirements collectively create a larger framework of responsibilities for schools for clinical oversight, ethical behavior, personal safety, and health needs of students participating in global health immersion experiences.

In any clinical setting, there is a natural tension between providing oversight of student activities and permitting students to practice their developing skills. This tension is often amplified in global health immersion experiences in regions that are resource poor and among populations with poor access to health care services. Health care professionals in such situations are often stretched beyond their capacity, and students can be viewed as adequately prepared to provide some services independently or with minimal supervision, thereby creating a fertile environment for students to potentially practice beyond their level of experience and expertise. Similarly, students might feel pressured to provide services beyond their scope and without adequate supervision.⁴ Host needs and patient expectations can sometimes lead to students feeling conflicted about—or overwhelmed by their knowledge of—their own limitations. This disconnect can pose ethical dilemmas for students in resource-poor clinical settings.⁵ For example, a student could be asked to attend patients unsupervised or be expected to perform unsupervised deliveries of newborns. In either case, a student could be faced with a dilemma that may be characterized as “no care vs care by a somewhat trained but unlicensed student.” LCME Element 9.3 is intended to prevent students from being put in this situation.³

Students engaging in global health immersion experiences in resource-poor regions face potential physical and mental health hazards including infectious diseases, vehicular trauma, personal violence, food and water contamination, environmental hazards, emotional stress, cultural dissonance and cultural shock, fatigue, sleep deprivation, and a sense of isolation and helplessness.^6,7,8 Compliance with LCME accreditation standards and elements requires that schools, at a minimum, assess these risks, counsel students on risks and prevention strategies prior to international experiences, and provide physical and emotional support services and resources to students as needed when they return home.⁹

LCME standards and elements are for the most part nonprescriptive. They generally do not describe how schools should address requirements but rather require that student preparation, curricular content, and program responses to problems be sufficient to meet students’ needs and LCME expectations for acceptable practice. Current literature suggests that preparing students for global health immersion electives could include their reviewing reports from prior students, becoming familiar with resource disparities they are likely to observe among patients and communities, anticipating the need to develop responses to ethical questions and to various cross-cultural influences on health belief systems they are likely to encounter, and considering how these factors might influence how they cope in their international environments.^6,7,10,11

The LCME does not prescribe the content or amount of ethics training required for global health immersion programming.³ At a minimum, the LCME expects that a school’s ethical standards will be followed regardless of educational setting. Experts suggest that additional training could include helping students consider their host communities’ influences—both positive and negative—on their understandings of ethics, social determinants of health, origins of global health inequity, and the nature and scope of their ethical responsibilities to practice medicine in ways that are culturally appropriate and within their level of expertise.^12,13,14,15 Postexperience debriefing has also been emphasized as a valuable ethical component of global health immersion experiences^16,17 that allows students to discuss what they encountered during their learning experiences.

Conclusion

MD-granting US medical schools that support curricular offerings and electives in global health immersion experiences have responsibilities to ensure that those experiences conform to LCME accreditation standards and elements and, as such, are comprehensively designed to protect both students and patients. Schools should consider consulting the current literature and subject matter experts to determine best practices for preparing students for and supporting them throughout these experiences.