AMA Journal of Ethics^®

How Can Medical Students be Prepared for International Rotations?

Medical students seeking information about the feasibility of an international experience contact us regularly with questions about initiating the process. We encourage their interest because of the global perspective they will gain from interacting with diverse and often underserved populations. Added benefits include enhanced cultural sensitivity toward patients and professional coworkers in a field that is increasingly international. Many students also find they’ve broadened their career options as a result of global health service. The first meeting or correspondence with students, often before they have settled on a particular nation or continent, involves getting acquainted and asking several questions: Why do you want to go? What do you want to accomplish? How much time can you commit?

Students are motivated by a combination of the desire to serve, interest in academic research, curiosity about non-Western medical education and training and a wish for personal enrichment. Those who express humanitarian or faith-based ideals usually seek to be useful in whatever way an institution can employ a person with limited medical skills. Some hope to design a research project, while others desire to experience an exotic environment, with medical practice being only one aspect of the cultural enrichment they seek. The opportunity to interact with local medical students or residents might determine the choice. Any research project requires institutional review board approval or exemption from approval on the part of the home and the host institutions. The length of time a student can commit affects both the possibility of school credit for the rotation and the availability of funding sources. The specific requirements for credit and funding should be explored carefully. Longer stays may benefit the host because the student becomes more productive after learning the system. Settling on a mutually compatible time frame is often surprisingly complex, thus necessitating an early start when planning.

Advice for the Medical Student Seeking an International Rotation

Groundwork for an international experience must begin a minimum of 6 months before the proposed visit; a year ahead is not too early to begin gathering information: how much time the school will allow a student to be away from campus and how many weeks are required for an accredited rotation, for example. Networking begins by identifying individuals in the home institution with international experience and contacting several sending agencies and institutions about available openings. One source is International Health Opportunities, which can be found on the Web site of AMSA, the American Medical Student Association [1]. The Journal of the American Medical Association Volunteer Opportunities feature provides an alphabetical list with contact information for numerous agencies and institutions [2]. A third source is the American College of Surgeons’ Operation Giving Back Web site, which allows physicians to combine “location” choices and “specialty” in searching for global service opportunities. One eligible “practice category” in this online search system is “medical student” [3].

Considerations essential to each student’s decision include cost, language and culture, visas, skills, health and safety issues and the educational benefits. Airfare is usually the single greatest expense. Sources of support are rare, although some medical schools provide limited assistance. International institutions almost never offer funding but may assist with housing.

If English or another language in which the student is conversant is not the dominant language of the area, he or she must make certain that adequate translation services are available. Language difficulties compound adjustment frustrations and reduce a student’s usefulness. Likewise, students should examine their other skills and assets. In addition to the knowledge and skills acquired in the first years of medical school, some institutions may value computer expertise, English language teaching aptitude or a knack for simple repairs.

Suggestions for Students Overseas

Other suggestions for the student who has arranged an international rotation:

• Acquire some knowledge of the history and culture of the area from books, articles or the Internet, bearing in mind the reality may be different than expected.
• If a research project is anticipated, contact your home institutional review board as well as the institutional review board equivalent (e.g., ethics committee, board of directors) of the host institution to gather all the data required for project approval before you travel.
• Ask about visa requirements, which vary widely. Travel agents can be helpful, but visa assistance may not be automatic.
• Visit your local travel clinic if there is one. Get all recommended immunizations and follow prophylactic malaria medicine guidelines.
• Road traffic events are likely to be the greatest injury risk, so employ sensible transportation strategies.
• Once the arrangements have been established among you, your school and your international host, stick with your original travel plans.
• Luggage allowances vary with stopovers, so if you are carrying supplies, additional charges might be levied.
• Ask about appropriate clothing and suitability of items such as shorts or running attire. Slacks for women may be frowned on in some locales and acceptable in others. Comfortable shoes are always correct.

As you begin working, remember that you are a guest; be respectful and polite. Treat host physicians with the same respect shown to physicians in the U.S. Do not use first names with any hospital personnel unless they insist upon it. Titles such as doctor, mister, professor or madam are always correct. Offering gratuitous advice on how to improve procedures or infrastructure will be received politely but will be neither appreciated nor acted upon. “Now in Nashville, we do it this way,” is as annoying in an international setting as it would be in Dallas or Milwaukee. Water and electricity are often precious and intermittent, so practice economy in their use and have a good attitude towards conditions that are the norm for your hosts.

Culture Shock is Normal and Rarely Fatal

Cultural sensitivity—largely respect and humility—involves being cautious about what you say and do. Find a “consultant” early on and ask about the appropriateness of certain words or behaviors. In many cultures touching is not as commonplace as among Americans, especially touching between members of opposite sexes, and eye contact is not universally acceptable. Dress modestly; speak in a moderate tone. Be flexible regarding accommodations, food, communications and other arrangements. Most visitors are afforded the best available, so try to express gratitude even when accommodations appear less than optimum. Time, relationships and a positive outlook go far toward mitigating the effects of culture shock. Keep a journal and take photographs—but only after seeking permission from the subjects.

Appreciate the value of a “high touch, low tech” medical practice by observing that health professionals take careful histories and perform thorough physical exams when MRIs and sophisticated lab tests are unavailable. Emphasize the positive aspects of the experience. Honesty is in order, but focusing on problems may be viewed as culturally insensitive and hamper other students from obtaining an invitation from that medical center.

As the experience draws to a close, make certain you take away more than souvenirs. Perhaps you might learn a greeting (Africans often ask, “How is your family?” rather than “How are you?”) or adopt a procedure (Nigerian pediatricians have the mother hold the child during a routine well-baby check-up) or request a recipe. The international experience is a two-way street. What is acquired frequently outweighs what is given if a person is open and intent on gaining new insights and strategies.