Bringing global issues to medical teaching

Global Health in Undergraduate Education: Knowledge, Attitude, and Practice of Sudanese Medical Students towards Global Health Education: a cross-sectional study

INTRODUCTION

Globalization and other relevant phenomena such as healthcare workforce, ageing of the population, brain drain etc. all necessitate medical curricula to transcend national medicine and encompass a more global approach. This is especially true in the context of developing countries which currently act as passive recipients of ongoing global decisions, health inequities or pandemics. The aim of this research was to study the Knowledge, Attitude, and Practice of Sudanese medical students towards global health education and the impact of extra-curricular activities on their knowledge and attitudes.

METHODS

This was a descriptive cross-sectional institutional based study. The study was conducted in five Sudanese Universities and participants were selected using systematic random sampling. An online-based, self-administered questionnaire was used, samples were collected between November 2019 until April 2020 and data was analyzed using SPSS version 25.

RESULTS

1176 medical students were involved. The study revealed a poor level of knowledge among 72.4%, and only 2.3% of respondents revealed a good level of knowledge. Mean knowledge scores between Universities slightly vary and have shown positive correlation according to the grade of the medical student. Regarding attitude, the results demonstrated the high level of interest of medical students in global health, their agreement in including global health in their official medical education curriculum (64.8%) and their consideration of including global health as part of their future career (46.8%).

CONCLUSION

The study concluded that there is a knowledge gap among Sudanese medical students regarding global health education, although students showed good attitudes and willingness to include global health in their official curriculum.

RECOMMENDATIONS

Global health education should be implemented in the official curriculums of Sudanese Universities, and Universities should do global partnerships and increase the learning and teaching opportunities in this interesting field.

Implementation and evaluation of crowdsourcing in global health education

BACKGROUND

Current global health course is most set as elective course taught in traditional teacher-taught model with low credit and short term. Innovate teaching models are required. Crowdsourcing characterized by high flexibility and strong application-orientation holds its potential to enhance global health education. We applied crowdsourcing to global health teaching for undergraduates, aiming to develop and evaluate a new teaching model for global health education.

METHODS

Crowdsourcing was implemented into traditional course-based teaching via introducing five COVID-19 related global health debates. Undergraduate students majoring in preventative medicine and nursing grouped in teams of 5-8, were asked to resolve these debates in reference to main content of the course and with manner they thought most effective to deliver the messages. Students' experience and teaching effect, were evaluated by questionnaires and teachers' ratings, respectively. McNemar's test was used to compare the difference in students' experience before and after the course, and regression models were used to explore the influencing factors of the teaching effect.

RESULTS

A total of 172 undergraduates were included, of which 122 (71%) were females. Students' evaluation of the new teaching model improved after the course, but were polarized. Students' self-reported teaching effect averaged 67.53 ± 16.8 and the teachers' rating score averaged 90.84 ± 4.9. Students majoring in preventive medicine, participated in student union, spent more time on revision, and had positive feedback on the new teaching model tended to perform better.

CONCLUSION

We innovatively implemented crowdsourcing into global health teaching, and found this new teaching model was positively received by undergraduate students with improved teaching effects. More studies are needed to optimize the implementation of crowdsourcing alike new methods into global health education, to enrich global health teaching models.

Decolonising the global to local movement: Time for a new paradigm

Mama Amaan Project (MAP) delivered perinatal education and doula services to underserved refugee and immigrant communities in Seattle, Washington. MAP presented at a 'global to local (glocal)' workshop for US-based global health agencies redirecting their experience and resources to address domestic health crises. Glocal models reference Global South anti-colonial social transformations through Primary Health Care (PHC) - 'health for all as a right' and investment in strong public sectors. As Black women working in our communities, we resisted labelling MAP glocal. Western donors and NGOs appropriate PHC's community participation narratives, meanwhile implementing World Bank/IMF economic structural adjustment health system cuts - thereby shifting austerity-related resource shortfalls to communities. In US contexts of neoliberal shrinking social safety nets and workers' rights, similar strategies to address austerity-related health disparities are promoted as 'global to local'. Projects like MAP cannot substitute quality public services. They expose gaps and build community empowerment to demand quality healthcare. Drawing on MAP and 'global health' experience in Mozambique, we call for re-embracing PHC's activist values - agitating for health as a universal human right for all, rather than putting the burden and blame on underserved communities. We propose decolonising the 'glocal' paradigm by embracing 'transnationality', 'relationality' and 'mutuality'.

Hyperglobalist, sceptical, and transformationalist perspectives on globalization in medical education

PURPOSE

Globalisation has been hotly debated in recent decades and has seemingly had a profound impact on medical education. This review synthesises the medical education literature using key perspectives from globalisation theory by Holton (Making globalisation).

METHODS

Holton (Making globalisation) recognised three key perspectives in globalisation theory-hyperglobalist, sceptical, and transformationalist. This article critically reviews the literature on globalisation in the field of medical education using this theoretical framework.

RESULTS

Hyperglobalist and sceptical perspectives dominated early periods of medical education literature on globalisation, projecting it either as a mainly positive or mainly negative force, respectively. Most forecasts grounded in these perspectives have not materialised in medical education policy and practice. Since 2010, the volume of scholarship about globalisation has increased and has been predominantly transformationalist in perspective, recognising a reality that has both positive and negative consequences.

CONCLUSIONS

The medical education literature has mirrored the broader social science literature, in moving over time from hyperglobalist and sceptical positions, towards a 'third wave' of globalisation thinking that is transformationalist. Medical education practitioners and policymakers should be mindful of these perspectives and trends as they navigate the opportunities and challenges presented by globalisation.

Going Global: Interest in Global Health Among US Otolaryngology Residents

Background:

To meet the rising interest in surgical global health, some surgical residency programs offer global health experiences. The level of interest in these programs, however, and their role in residency recruitment and career planning has not been systematically evaluated.

Objective:

(1) Define interest in global health among Otolaryngology residents in the USA. (2) Assess engagement of Otolaryngology residencies in global health training. (3) Determine barriers to global health training in residency.

Methods:

A survey questionnaire was developed and sent to all Otolaryngology Residency Program Directors for distribution to all current Otolaryngology residents in the US.

Results:

A total of 91 complete surveys were collected. A majority of respondents felt that global health was either “very important” or “extremely important” (67%). Two-thirds of respondents had prior global health experience (68%). While 56% of respondents would definitely participate in a global health elective and 78% would likely or definitely participate, only 37% of residency programs offered a global health experience. The availability of a global health elective significantly correlated with residency match choice in respondents with previous global health experience. The three most common barriers to participation were insufficient time, insufficient funding, and lack of program.

Conclusion:

Participation in bilateral and equitable international electives is a unique experience of personal and professional growth. There is an interest in these opportunities during residency training among Otolaryngology residents that is not reflected in availability within training programs. This suggests the need for development of humanitarian outreach exposure through global health experiences during surgical residency training.

Field Research Experience of Medical Students: Learning and Translation from Global to Underserved US Settings

While most medical schools in the USA provide opportunities for global health experiences, global health education is not included consistently or emphasized adequately in many medical school curricula. The City University of New York Medical School (CSOM) has a mission to educate and train students who are traditionally underrepresented in medicine to practice primary care in medically underserved communities in New York. This manuscript documents the experience of the CSOM in expanding global health education by introducing a new global health cancer training program, partnering with clinicians at the Ocean Road Cancer Institute (ORCI) in Tanzania. This manuscript illustrates the following points: (1) the CSOM curriculum that focuses on community health and social medicine; (2) the process by which students learn by developing research proposals for global cancer; (3) the field research experience and lessons learned; (4) learning about cancer and medicine in a developing country; and (5) lessons learned for translation from global to domestic underserved populations. We also suggest a checklist for future students interested in pursuing global cancer education and research, and recommendations for maximizing learning and career development of students interested in global cancer research and its application to underserved populations in the USA.

Global health education for medical students in Italy

BACKGROUND

Global health education (GHE) in Italy has spread since the first decade of 21st century. The presence of global health (GH) courses in Italy was monitored from 2007 to 2013. In 2019, a new survey was proposed to assess the availability of educational opportunities in Italian medical schools.

METHODS

An online survey was carried out using a questionnaire administered to a network of interested individuals with different roles in the academic world: students, professors, and members of the Italian Network for Global Health Education. The features of courses were analysed through a score.

RESULTS

A total of 61 responses were received from affiliates of 33 out of the 44 medical schools in Italy. The national mean of GH courses for each faculty was 1.2, reflecting an increase from 2007. The courses increased nationwide, resulting in a dispersed GHE presence in northern, central and southern Italy. One of the most critical points was related to the nature of "elective" courses, which were not mandatory in the curricula. Enrollees tended to be students genuinely interested in GH issues. Some community and service-learning experiences, referred to as GH gyms, were also detected at national and international levels.

CONCLUSIONS

GHE has spreading in Italy in line with the vision of the Italian Network for Global Health Education. Although progress has been made to disperse GH courses around the country, more academic commitment is needed to include GH in the mandatory curricula of medical schools and other health faculties.

Global health education in UK medical schools: a review of undergraduate university curricula

INTRODUCTION

In recognition of our increasingly globalised world, global health is now a required component of the medical school curriculum in the UK. We review the current provision of global health education (GHE) in UK medical schools to identify gaps in compulsory teaching.

METHODS

We conducted a review of the literature to inform a two-part electronic survey of global health compulsory teaching, optional teaching and pre-elective training. Surveys were sent to all 33 UK medical schools for completion by the faculty lead on global health and the nominated final year student representative.

RESULTS

Surveys were returned by 29 (88%) medical school faculty and 15 (45%) medical student representatives; 24 (83%) faculty and 10 (67%) students reported including GHE in the core curriculum; however, there was wide variation in the learning outcomes covered. On average 75% of faculty and 82% of students reported covering recommended global health themes 'global burden of disease', 'socioeconomic and environmental determinants of health', 'human rights and ethics', and 'cultural diversity and health', while only 48% of faculty and 33% of students reported teaching on 'health systems' and 'global health governance'. Almost all institutions offered optional global health programmes and most offered some form of pre-elective training, although content and delivery were variable.

CONCLUSION

Over the last decade, the inclusion of global health in the core curriculum of UK medical schools has increased dramatically. Yet, despite interest among students, significant gaps are apparent in current GHE. Governing bodies in medical education should establish a comprehensive national strategy to help improve access to fundamental GHE for all medical students.

Developing Global Health Diplomacy-related Skills Using a COVID-19-like Epidemic Simulation as a Learning Strategy

Public health and global health practitioners need to develop global health diplomacy (GHD) skills to efficiently work within complex global health scenarios, such as the current coronavirus disease (COVID-19) pandemic. Problem-based learning was used as a framework to create a scenario-based activity designed to develop GHD-related skills. The application and effectiveness of this scenario-based activity to develop GHD-related skills were assessed. A mixed-methods approach involving a self-administered survey and one focus group discussion was used. The survey collected baseline participant characteristics as well as understanding and improvements in GHD-related skills using a 5-point Likert scale. The focus group was audio-recorded and thematically analyzed using both inductive and deductive codes. Data integration was achieved by connecting and weaving. Method and investigator triangulation techniques were used. Participants self-reported significantly better postscenario-based activity responses when asked about their understanding of diplomacy, negotiation, communication, and how to address public health emergencies (P < 0.01, Wilcoxon signed rank test). Most participants either agreed or strongly agreed that their GHD-related skills improved with participation in the scenario-based activity (diplomacy = 55.6%; negotiation = 66.5%; communication = 72.2%; addressing public health emergencies = 72.1%). Overall, qualitative data were consistent with results obtained using quantitative methods. The scenario-based activity was effective for improving the self-reported understanding of GHD-related skills. The scenario-based activity was also effective for developing the selected GHD-related skills (as self-reported). This scenario-based activity is likely to reduce cognitive load and avoid participant overload, thereby facilitating learning. Further research is required to elucidate its long-term impact on skills development.

Long-term impact of Global Health educational experiences in Rome: an attempt of measurement

Background

Global health education (GHE) is spreading in Europe and in other parts of the world. Since 2008, Sapienza University of Rome has offered activities to medical and other health profession students related to global health (GH), which is grounded in the theory of social determinants of health and inspired by social justice. The educational activities included elective courses as well as community and service-learning experiences, referred to as GH gyms. This study attempts to measure the long-term impact of these educational experiences, especially to demonstrate their influence on the perceived social responsibility of future health professionals.

Methods

A questionnaire was elaborated and tested on a small sample of participants. It was sent to participants by e-mail. Quantitative results were analysed through descriptive statistics and qualitative answers were carefully read and classified.

Results

A total of 758 students from different faculties took part to the educational experiences. Only 488 e-mail addresses were available. One hundred and five (21.5%) questionnaires were returned. Participation in GH gyms was perceived to have had a higher influence on future professional and personal choices, when compared to participation in elective GH courses.

Conclusions

The study shows that consideration of health and social issues related with inequities in health and the use of interactive teaching methodologies had important effects on social responsibility of a large number of students. As there could be a selection bias among respondents, more research is needed to understand the impact of GH educational experiences. The inclusion of global health education in health and social curricula and the use of interactive methodologies with a correct evaluation of results are the indications that emerge from this research, together with the necessity of a strong involvement of students, professors and the whole academic reality.

The DISCuSS model: Creating connections between community and curriculum - A new lens for curricular development in support of social accountability

Medicine's social mandate recognizes the importance of introducing changes to systems and practices to meet the healthcare needs of marginalized populations. Social accountability efforts encompass a wide array of actions, including equity, diversity and inclusion initiatives, and adapting knowledge relevant to practice across education, research, and clinical domains. To influence change in education, ongoing structures and processes are needed to ensure adequacy, relevance, and effectiveness of curricular coverage. In support of this, we created an innovative and creative approach to developing curricular modules to prepare medical students to provide care that is responsive to the cultural, economic, and psychosocial realities of diverse patient populations. The DISCuSS model (Diversity, Identify, Search, Create module (with community engagement), Sustainability, Social accountability) provides a community-engaged, iterative approach to curriculum development relevant to social accountability. Over the past 5 years, we have created nine curricular modules focused on health-related inequities and social concerns, including modules on Indigenous and refugee health, sexual and gender minority health, human trafficking, and addiction. AFMC Graduation Questionnaire results have shown a statistically significant increase in our students 'preparedness to provide care to diverse populations.' The DISCuSS model, which continues to evolve, can be adapted and used in other settings.

International health experiences in postgraduate medical education: A meta-analysis of their effect on graduates' clinical practice among underserved populationsExpériences internationales de soins de santé en formation médicale post-doctorale : une méta-analyse des effets sur la pratique clinique des diplômés au sein des populations mal desservies

BACKGROUND

International health experiences (IHEs) are popular among medical learners and provide a valuable learning experience. IHE participants have demonstrated an increased intention to care for underserved populations in the future, but what is its actual impact on practice? This study evaluates the effect of postgraduate IHE participation on the future careers of clinicians regarding their work among underserved populations.

METHODS

We conducted a systematic review and meta-analysis of peer-reviewed articles comparing the populations served by physicians who had participated in an IHE with those of physicians who had not participated in an IHE.

RESULTS

764 titles were scanned, 28 articles were reviewed, with an eventual 3 studies of fair-good or good quality identified. These addressed physicians' service to domestic underserved populations, and also addressed future service in a low- or middle-income country (LMIC). Meta-analysis demonstrated a statistically-significant increase in service by IHE graduates to domestic underserved populations (OR = 2.12; CI = 95%; P = 0.03). The certainty of the evidence was low due to limitations in study design (non-randomised studies) and inconsistency in effects.

CONCLUSION

Participation in an IHE may cause an increase in care for domestic underserved populations in future clinical practice, though further research from high quality randomised trials is needed to increase the certainty of the effect. Further study is needed to establish whether there is a similar effect with increased future service in a LMIC setting.

A Global Veterinary Education Program for North American Veterinary Students: A Description of Purdue University Best Practices

Worldwide growth in global mobility has transformed the way we communicate, trade, and approach global issues. The rise of global migration and distribution comes with a higher probability of transmitted disease, human-wildlife conflict, and food safety issues. No longer viewed as isolated incidents, the occurrence of global health threats in one part of the globe is now a concern throughout the world. Our society needs globally conscious veterinarians who are dedicated to affecting world change through the improvement of animal and human health; veterinarians who are prepared to collaborate, exchange, and engage with the world around them. Higher education institutions for veterinary medicine have the responsibility to prepare their students to become agents of change within society and rewrite the narrative on global health. This article highlights the intentional approach that Purdue University College of Veterinary Medicine took to address the need for more globally conscious veterinarians. The article provides examples of administrative structures, funding sources, global engagement opportunities, methods to increase student awareness of opportunities, and student support. Finally, we describe the impact of this approach in increasing student participation in global engagement.

Medical education: an Italian contribution to the discussion on global health education

BACKGROUND

In Italy an important contribution to the spread of global health education (GHE) grew from the establishment and work of the Italian Network for Global Health Education (INGHE). INGHE gave a national shared definition of global health (GH), grounded in the theory of determinants of health, inspired by a vision of social justice, and committed to reduce health inequities. The aim of this article is to share with the international community INGHE's point of view on Medical Education.

METHODS

To express its view of medical education at the national level, INGHE established a dedicated commission, which elaborated a first draft of the document and then shared and discussed it with all other members.

RESULTS

INGHE elaborated a paper where it explained the need to change medical education in order to prepare future health professionals for the challenges of the globalized and unequal world. In this article the authors summarize the experience of INGHE and share with the international community its document.

CONCLUSIONS

The authors believe it is necessary now, more than ever, to insert this new approach to health at social and academic levels. Students should play a fundamental role in the spread of GHE, and activities related with GHE could be considered an important part of the third mission of universities to promote social justice.

Integrating Competency-Based Didactic and Experiential Global Health Learning for Dental Students: The Global Health Learning Helix Model

The aim of this study was to evaluate the feasibility and preliminary outcomes of immersive integrated experiential and didactic courses in strengthening competency-based global health learning in dental education. To address global inequities in oral health and student interest in global health, the Harvard School of Dental Medicine introduced two global health courses in 2017-18. The first was a didactic course in the core predoctoral curriculum, and the second, in collaboration with the Inter-American Center for Global Health, was a five-day elective experiential learning course in rural Costa Rica. The experiential course was an extension of the didactic course. All 33 second-year dental students completed the didactic course, and three of those students completed the experiential course. A pre-post survey and a six-month follow-up survey on self-reported knowledge based on course learning objectives were administered. The experiential course students also completed journals and interviews for qualitative analysis. Thirty-two students completed the pre-post didactic course surveys, for a response rate of 94%. There was a 100% response rate on the pre-post didactic surveys by those students who participated in the experiential learning course. While the experiential learning group scored similarly to the class average before the didactic course, they had higher scores than the class averages both immediately after and at the six-month follow-up. All three students reported that the experiential learning course was "extremely effective" in building on what they learned in the didactic course. Qualitative analysis of the journals and interviews suggested enhanced learning from the combination of didactic and experiential methods. These preliminary results support the Global Health Learning Helix Model, a theoretical competency-based teaching model for ethical student global health engagement to better prepare the future generation in tackling oral health disparities both locally and worldwide.

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

BACKGROUND

Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs.

METHODS

We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries.

RESULTS

Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education.

CONCLUSIONS

In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.

Motives, experiences and psychological strain in medical students engaged in refugee care in a reception center- a mixed-methods approach

BACKGROUND

The UN Refugee Agency has reported that an increasing number of people are being forcibly displaced worldwide. Despite this, global health issues, especially initiatives focusing on physical and psychological conditions of refugees, are still rarely considered in medical curricula. Furthermore, there is little evidence regarding the experiences and possible related psychological strain of medical students who work with refugees. Therefore, the present study aimed to investigate motivations, learning achievements and experiences, as well as psychological strain and possible protective factors, in medical students volunteering in a reception center for refugees.

METHODS

In this prospective study using a mixed-methods approach, we applied (1) qualitative content analysis of semi-standardized interviews in a pre-post design in a subsample of n = 16 students. The aims were to analyze (1a) the students' motivations and experiences in the reception center, and (1b) the students' perceived learning achievement. We further administered (2) psychometric questionnaires using a cross-sectional approach to n = 62 students in order to examine (2a) the students' psychological strain, in terms of secondary traumatization, depression, anxiety and health-related quality of life, and (2b) possible protective factors such as attachment style and sense of coherence.

RESULTS

The content analysis of the students' interviews revealed three main categories before the assignment and four main categories subsequently, displaying a broad variety of perspectives. Quantitative analysis identified that 3.2% of the students showed moderate secondary traumatization, and a correlation emerged between the number of shifts and symptom severity of secondary traumatization. The students displayed significantly reduced scores for depression and anxiety, when compared to a sample of first-year medical students. Sense of coherence was identified as a protective factor concerning secondary traumatization.

CONCLUSION

A rather small proportion of the medical students working in the reception center displayed explicit symptoms of psychological strain in terms of secondary traumatic stress. Due to their assignments, students were able to improve their cultural awareness, which they reported to be highly relevant for their future occupation. In view of increasing globalization, theoretical and practical courses on issues of flight and global health might therefore be implemented as an obligatory part of medical curricula.

Internationalization of Medical Education-Building a Program to Prepare Future Leaders in Healthcare

In a globally interconnected world, internationalization of medical education has become increasingly important. While many programs focus on international programs for clinical students, the number of programs for preclinical medical and dental students is small. Based in the Anatomy course, the program presented here involves early international collaborations between preclinical students from six countries. Our work involves small-group video sessions and a large international student videoconference (including cultural and didactic components). The online connections progress with in-person basic sciences summer internships undertaken at the international partner institutions. This collaborative program features unique elements that facilitate cultural exchange and help develop leadership skills in healthcare early in a student's career. We present recommendations for international program implementation.

Medical Clerkship in a State Registration and Reception Center for Forced Migrants in Germany: Students' Experiences, Teachable Moments, and Psychological Burden

Aspects of global health are becoming increasingly relevant for doctors of future generations. However, medical curricula rarely include courses which focus on global health or forced migration. Furthermore, it remains unclear whether students are at risk to develop psychological strain, after being confronted with highly burdened or even traumatized asylum seekers. This is a prospective study using a mixed-methods approach. We included n = 22 medical students performing a medical clerkship in a state registration and reception center for refugees. By applying (1) qualitative interviews, (2) reflective diaries, and (3) psychometric questionnaires, we examined the students’ experiences, teachable moments, and potential psychological burdens. In the interviews, the students emphasized the importance of cultural sensitivity during their clerkship. However, they also reported cognitive changes concerning their views of themselves and the world in general; this could indicate vicarious traumatization. The reflective diaries displayed high learning achievements. According to the psychometric questionnaires, the assignment in the reception center had not caused any significant psychological strain for the students. By completing their medical clerkship in a reception center, students were able to improve their medical, organizational, and interactional knowledge and skills. Furthermore, they reported that they had broadened their personal and cultural horizons.

Impact of Global Health Electives on US Medical Residents: A Systematic Review

BACKGROUND

The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes.

OBJECTIVES

The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature.

METHODS

An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents.

FINDINGS

Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks.

CONCLUSIONS

Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.

Impact of Global Health Electives on US Medical Residents: A Systematic Review

Background:

The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes.

Objectives:

The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature.

Methods:

An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents.

Findings:

Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks.

Conclusions:

Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.

Interprofessional education between medical students and nurse practitioner students in a Global Health course

BACKGROUND

Few global health experiences include intentionally-directed interprofessional training. We aim to prospectively evaluate the impact of a global health elective in facilitating interprofessional education (IPE) and promoting cultural sensitivity.

METHODS

We included in our study, medical and nursing students who participated in the 2015 and 2016 cohorts of the Nicaragua Global Health course. The course consisted of a 12-week curriculum, and included an in-country immersion where students were organized into small-groups that participated in a variety of interprofessional activities. Students filled out pre- and post-course surveys. We performed quantitative analysis on numeric data and qualitative analysis on open-ended questions.

RESULTS

Of 39 total students enrolled in the course, 26 (18 medical and 8 nursing students) participated in the study and filled out the pre- and post-course surveys. Mean competency scores increased for all questions between pre- and post-course surveys, and of these, 5 of 7 reached statistical significance. Qualitative themes identified included: 1) the importance of understanding other team member's roles and relative strengths; 2) the value provided by the breaking down of traditional power dynamics between clinicians.

CONCLUSIONS

Global health experiences represent a unique and under-utilized opportunity for facilitating IPE.

Recommendations for undergraduate medical electives: a UK consensus statement

INTRODUCTION

Many doctors, across grades and specialities, supervise or advise students and juniors undertaking elective placements. Electives form part of medical curricula on a worldwide scale. The Medical Schools Council (MSC) Electives Committee in the UK identified a gap in the current literature in relation to provision of comprehensive recommendations for the design and management of undergraduate elective programmes. Electives afford many known benefits for medical and other health care students, but the context, and risks (impacting potentially on patient, public and student well-being) are usually different from those associated with 'home' clinical placements.

AIM

The aim is to share experiences and good practice within UK Medical Schools, and inform and inspire others involved with similar programmes across the globe.

METHOD

This paper reports the results of the formation of a sub-group to draft a set of recommendations, drawing on the reported experiences of academic elective leads across all UK schools, and including input from the MSC, and the student group Medsin (to capture the learner voice). The final document was the result of a national consultative process of four iterations. The end document was approved at school level, e.g. by curriculum committee, by each of the participating schools.

RECOMMENDATIONS

The recommendations consolidate the experiences of 30 participating UK medical schools. The consultation process generated 17 pre-departure recommendations, seven during elective recommendations, 11 post elective recommendations and a further four recommendations relating to infectious disease.

CONCLUSION

We believe developing elective programmes using collective recommendations will provide a basis for a safer and more structured approach to a medical elective without losing the uniqueness and creative experiences valued by participants. Issues relating to undergraduates leaving their home school to experience medicine in a new context or country replicate across sites, so many recommendations will be transferable internationally.

Global Health Teaching in India: A Curricular Landscape

Today, health has transcended national boundaries and become more multifaceted. Global health has evolved as a new paradigm and is recently being identified as a thrust area now in India. Despite an existing need for a standardized global health curriculum, there is little information available on its education and curriculum in medical and health education space. In the Indian context, we are yet to have a fuller picture of the current status, including, content, structure, selection, teaching methods of global health, and how students are evaluated in India. The objective of this study was to map courses relating to studies on global health in India and analyze its mode of delivery. A detailed Internet search was carried out to identify global health courses and analyzed for: (i) whether global health is a part of the teaching curriculum, (ii) mode of teaching, (iii) broad contents, (iv) instructional formats, (v) assessment, and (vi) selection process. It was found that delivery of global health education in India was fragmented with limited focus at the undergraduate and postgraduate levels. Global health teaching was largely based on certificate courses or online courses, with hardly any institutions imparting a distinct global health education program. There is also no definite specification as to which institutes can impart teaching on global health education and what the specific eligibility requirements are. Our analysis suggests that efforts should be directed toward integrating global health education into broader public health curriculum. At the same time, the need for generation of global health leaders, creation of a common forum for addressing merits and demerits of global health issues, as well as creation of more opportunities for placements are recognized.

Global health education in Swedish medical schools

AIMS

Global health education is increasingly acknowledged as an opportunity for medical schools to prepare future practitioners for the broad health challenges of our time. The purpose of this study was to describe the evolution of global health education in Swedish medical schools and to assess students' perceived needs for such education.

METHODS

Data on global health education were collected from all medical faculties in Sweden for the years 2000-2013. In addition, 76% (439/577) of all Swedish medical students in their final semester answered a structured questionnaire.

RESULTS

Global health education is offered at four of Sweden's seven medical schools, and most medical students have had no global health education. Medical students in their final semester consider themselves to lack knowledge and skills in areas such as the global burden of disease (51%), social determinants of health (52%), culture and health (60%), climate and health (62%), health promotion and disease prevention (66%), strategies for equal access to health care (69%) and global health care systems (72%). A significant association was found between self-assessed competence and the amount of global health education received (p<0.001). A majority of Swedish medical students (83%) wished to have more global health education added to the curriculum.

CONCLUSIONS

Most Swedish medical students have had no global health education as part of their medical school curriculum. Expanded education in global health is sought after by medical students and could strengthen the professional development of future medical doctors in a wide range of topics important for practitioners in the global world of the twenty-first century.

Global health education in the United Kingdom: a review of university undergraduate and postgraduate programmes and courses

OBJECTIVES

This study reviews the current state of global health education (GHE) in the United Kingdom (UK) through the collation and synthesis of data on undergraduate and postgraduate global health degree programmes. It examines both the curriculum provided and profile of the student currently studying global health in the UK.

STUDY DESIGN

Descriptive, case study design.

METHODS

A systematic review of the literature identified a set of global health 'core competencies' that students could acquire through their chosen programme of study. Those competencies were synthesized and then compared to core and elective courses currently offered by global health degree programmes at UK universities. A questionnaire was designed and sent electronically to all global health Programme Directors requesting generic information regarding the profile of their global health students.

RESULTS

Fifteen universities in the UK, based in England and Scotland, offered twenty-five postgraduate and six undergraduate global health degree programmes in 2012-13. Two Universities were developing a full, three-year, undergraduate degree programme in global health. Sixteen core competencies for a medical and non-medical student constituency were identified. Of these, just three 'core competencies' - epidemiology of tropical diseases, health systems (including health system management), and health care services - corresponded directly to core and elective courses offered by >50% of UK universities. The five most frequently offered subjects were: health systems (including health system management), research methods, public health (including specialisations in prevention, treatment and care), epidemiology, and health economics.

CONCLUSIONS

GHE in UK universities has seen comparable growth to North American institutions, becoming Europe's regional hub for undergraduate and postgraduate courses and programmes. As with the US and Canadian experience, GHE at the undergraduate level is offered primarily to medical students through intercalated degree programmes. At the postgraduate level, there is more innovation in content and mode of delivery, with a small number of UK universities providing students from a diversity of backgrounds the opportunity to study global health from multidisciplinary perspectives. Distance learning is also seeking to make the delivery of GHE truly global, with a growing number of universities recognizing its potential to further innovate in global health pedagogy. While demand for GHE is predicted to remain robust, to ensure the needs of students and practitioners are met, more critical reflection on global health curricula, the desired profile of graduates, and equity of access is required.

Teaching corner: "first do no harm": teaching global health ethics to medical trainees through experiential learning

Recent studies show that returning global health trainees often report having felt inadequately prepared to deal with ethical dilemmas they encountered during outreach clinical work. While global health training guidelines emphasize the importance of developing ethical and cultural competencies before embarking on fieldwork, their practical implementation is often lacking and consists mainly of recommendations regarding professional behavior and discussions of case studies. Evidence suggests that one of the most effective ways to teach certain skills in global health, including ethical and cultural competencies, is through service learning. This approach combines community service with experiential learning. Unfortunately, this approach to global health ethics training is often unattainable due to a lack of supervision and resources available at host locations. This often means that trainees enter global health initiatives unprepared to deal with ethical dilemmas, which has the potential for adverse consequences for patients and host institutions, thus contributing to growing concerns about exploitation and "medical tourism." From an educational perspective, exposure alone to such ethical dilemmas does not contribute to learning, due to lack of proper guidance. We propose that the tension between the benefits of service learning on the one hand and the respect for patients' rights and well-being on the other could be resolved by the application of a simulation-based approach to global health ethics education.

Impact of international experience on research capacity of Chinese health professionals

Context

It is common practice worldwide for health professionals to study abroad. However, the outcome of such experience has not been rigorously evaluated in China. Our current study aimed to quantify the impact on research of studying abroad among Chinese health professionals.

Methods

A self-administered structured questionnaire was developed among health professionals in Harbin Medical University and its affiliated hospitals who had studied abroad (‘returning’ professionals) and health professionals who did not have experience abroad (‘resident’ professionals). 166 ‘returning’ professionals (Group A) and 166 age-, sex- and specialty-matched ‘resident’ professionals (Group B) were included in the study. SPSS software was used for data entry and analysis.

Results

The total IF of papers published by Group A and Group B was, respectively, 1933.52 and 629.23 (P < 0.01) and the number of NSFC was 154 and 34 (P < 0.01), respectively. The total IF of papers published abroad was associated with the duration abroad (P < 0.01) and not with the age of going abroad (P > 0.05). The total IF of papers published at home, and the number of NSFC had no relationship with the duration abroad (both P > 0.05) nor the age of going abroad (both P > 0.05). The total IF of papers published at home and the number of NSFC were positively correlated with the total IF of papers published abroad (both P < 0.01).

Conclusions

This study reflects the beneficial experience of working overseas. The opportunity for overseas experience should not be limited by age. Overseas study should be prolonged.

Sustained impact of short-term international medical mission trips: resident perspectives

PURPOSE

To assess perspectives of residents: (1) who participated in short-term international medical mission trips (STIMMTs) as medical students regarding impact of the experiences on their professional development; and (2) who did not participate in STIMMTs regarding barriers to participation.

METHODS

Three hundred seventy-nine residents from 16 programs at two Florida institutions completed surveys requesting Participant and Trip Details and Impact of Participation (including items rating learning, cultural competency, and social responsibility).

RESULTS

One hundred thirty-one residents participated in at least one STIMMT. They identified improved adaptability to new healthcare settings, communication with patients and professionals from different backgrounds, and appreciation for the impact of culture on health as positive outcomes. Leading barriers to STIMMT participation included cost, timing, and lack of availability.

CONCLUSIONS

Years after participation in STIMMTs, residents perceived sustained benefits in cultural competency, communication skills, adaptability, and desire for service. Institutions may consider facilitating STIMMTs as one way to address standards specified by accrediting authorities to provide training in cultural competency, social responsibility, altruism, and understanding the importance of caring for underserved populations. Barriers to STIMMT participation may be reduced through availability of institution-sponsored scholarships, identification of external grant and scholarship opportunities, and coordination of fund-raising activities.

Maximising the value from the elective experience: post-elective workshops

BACKGROUND

Medical electives are important facets of Global Health education of UK medical students, preparing them for work in an increasingly globalised world. However, their explicit educational value is unclear, and is often lost because of inadequate preparation and review procedures.

METHOD

Aiming to capitalise on this unique personal and professional development opportunity, which Newcastle University students undertake in their fourth year, a pilot feedback workshop was designed in which 42 final-year students gave 10-15-minute reflective presentations to subgroups of between six and eight peers, followed by an opportunity for questions, discussion and feedback. Feedback was sought from individual questionnaires and then there was open discussion with the whole group.

RESULTS

Despite the participants' variable satisfaction with the pre-elective procedures, all felt that the elective itself was valuable and enjoyable, and, moreover, all enjoyed and benefited from debriefing in this workshop format.

DISCUSSION

This pilot was successful. Simple, inexpensive workshops are to be recommended for overcoming perceived staffing and timetabling barriers to Global Health education, and affording students the maximum personal and professional benefit from their own, and each others' medical electives.

To the point: obstetrics and gynecology global health experiences for medical students

This article, from the To the Point series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides educators with an overview of considerations for obstetrics and gynecology global health experiences for the medical student. Options for integration of obstetrics and gynecology global health into undergraduate medical curricula are discussed. Specific considerations for global health clinical experiences for medical students, including choosing a clinical location, oversight and mentorship, goals and objectives, predeparture preparation, and evaluation, are reviewed.

Fostering reciprocity in global health partnerships through a structured, hands-on experience for visiting postgraduate medical trainees

BACKGROUND

Global health programs that allow international experiences for US learners should also enable reciprocal learning experiences for international learners, particularly if that is a need identified by the partner institution.

METHODS

A partnership between Indiana University and Moi University, Kenya, has successfully hosted 41 visiting Kenyan internal medicine and pediatrics registrars at Indiana University since 2006. The program's logistics, curriculum, and evaluation are described.

RESULTS

The registrars rotated through nephrology, cardiology, hematology and oncology, infectious diseases, and intensive care, as well as related ambulatory experiences, functioning on a level comparable to fourth-year medical students. They showed significant improvement in pretest and posttest scores on a standardized National Board of Medical Examiners examination (P  =  .048). International learners experienced culture shock, yet they felt the Indiana University elective was helpful and would recommend it to future participants.

CONCLUSIONS

Global health programs can reciprocate the benefits derived for US students and residents by offering learning experiences to international learners if that is an expressed need from the international partner. Barriers to those experiences can be overcome, and the hands-on, elective experience has the potential to positively affect the knowledge and attitudes of participants as well as the home nation.

A research-based narrative assignment for global health education

There is a paucity of research on novel approaches to classroom-based global health education despite the growing popularity of this topic in health professional curricula. The purpose of the following paper is to (1) describe the rationale underlying the use of a research-based narrative assignment for global health education, and (2) describe the results from an evaluation of this assignment with undergraduate public health students, including its strengths and limitations. The research-based narrative assignment was implemented during an introductory global health course for third and fourth year undergraduate public health students. The students (n = 20) completed the assignment and then wrote a two-page reflection about their experience. The author analyzed these student reflections using open coding and thematic analysis. Four salient themes were identified from the written reflections including (1) the challenge of representing persons, (2) the opportunity to develop an engaged understanding of the chosen issue, (3) seeing the bigger picture or integrating the various determinants into a coherence story, and finally (4) the struggle to create a compelling story that was based on accurate information. The analysis of the students' reflections provides important insights into their experience conducting this assignment, particularly in highlighting key strengths and challenges of this approach. These strengths and challenges are discussed.

International child health elective for pediatric residents

BACKGROUND

There are increasing evidence highlighting the importance of incorporating issues of global health into pre- and post-graduate medical curricula. Medical international cooperation is a fundamental component of strategies to include global health issues in post-graduate medical curricula.

METHODS

Here we describe a seven-year cooperation between the Non Governmental Organization (NGO) "Doctors for Africa CUAMM" and the Pediatric Residency Program (PRP) of the University of Padua (Italy) that offers residents a well-articulated personalized international child's health (ICH) elective in Africa, called "Junior Project Officer". The elective includes: a careful candidate selection process; pre-departure educational course; preceptorship in Padua and Africa, personalized learning objectives, a personalized job description, a six-month hands-on learning experience in Africa, evaluation of the experience, and formal private and open feed-backs/reports.

RESULTS

Between 2006 and 2012, 14 residents aged from 27 to 31 years, six attending the III, nine the IV and two the V year of residency completed the six-month stage in Africa. All worked in pediatric in-patient units; seven also worked in out-patient clinics, six in emergency rooms and seven in community health centers. Eleven were involved in teaching activities and four in clinical research projects. All residents claimed to have achieved their learning objectives.

CONCLUSIONS

A strong partnership between the NGO and the PRP, and well-articulated personalized learning objectives and job description contributed to a successful ICH elective.

Child health in low-resource settings: pathways through UK paediatric training

UK doctors training in paediatrics benefit from experience of child health in low-resource settings. Institutions in low-resource settings reciprocally benefit from hosting UK trainees. A wide variety of opportunities exist for trainees working in low-resource settings including clinical work, research and the development of transferable skills in management, education and training. This article explores a range of pathways for UK trainees to develop experience in low-resource settings. It is important for trainees to start planning a robust rationale early for global child health activities via established pathways, in the interests of their own professional development as well as UK service provision. In the future, run-through paediatric training may include core elements of global child health, as well as designated 'tracks' for those wishing to develop their career in global child health further. Hands-on experience in low-resource settings is a critical component of these training initiatives.

Factors associated with pharmacy student interest in international study

OBJECTIVES. To examine the interest of pharmacy students in international study, the demographic factors and involvement characteristics associated with that interest, and the perceived advantages and barriers of engaging in international opportunities during pharmacy school. METHODS. A self-administered electronic survey instrument was distributed to first-, second-, and third-year pharmacy students at the University of Kentucky College of Pharmacy. RESULTS. There were 192 total respondents, for a response rate of 50.9%. Seventy-two percent reported interest in international study. Previous international study experience (p=0.001), previous international travel experience (p=0.002), year in pharmacy school (p=0.03), level of academic involvement (p<0.001), and level of diversity involvement (p<0.001) were associated with international study interest. Positive influences to international study included desire to travel and availability of scholarships. Perceived barriers included an inability to pay expenses and lack of foreign language knowledge. CONCLUSIONS. The needs and interests of pharmacy students should be considered in the development and expansion of internationalization programs in order to effectively optimize global partnerships and available international experiences. Colleges and schools of pharmacy should engage students early in the curriculum when interest in study-abroad opportunities is highest and seek to alleviate concerns about expenses as a primary influence on study-abroad decisions through provision of financial assistance.

Student objectives and learning experiences in a global health elective

International health electives offer unique experiences for medical students to develop clinical skills and cultural competencies in unique and diverse environments. Medical students have been increasingly pursuing these learning opportunities despite the challenges. However, their goals in pursuing these opportunities and the relation between their learning objectives and actual experiences have not been studied adequately. It is important to assess these programs based on student objectives and whether those objectives are met. Thirty-seven medical students from five cohorts at a US medical school completed pre-post questionnaires regarding their global health elective objectives and learning experiences. The questionnaires included mostly open-ended questions and a Likert-scale rating of their overall experience. Qualitative thematic analysis involved inductive coding and followed a content-driven immersion-crystallization approach. Quantitative program evaluation measures yielded descriptive statistics. Five general objectives and four types of learning experiences were identified. Student objectives were: (1) to observe the practice and organization of health care in another country; (2) improve medical/surgical skills; (3) improve language skills; (4) learn about another culture; and (5) deepen knowledge of infectious diseases. All of their objectives were achieved. Moreover, one learning theme, "self-reflection and personal growth," was not a student objective. Quantitative assessment showed that most students had a favorable elective experience. Program challenges were also identified. Students in a global health elective were able to fulfill self-identified learning objectives, while also gaining other unexpected yet important lessons. Students' learning objectives also should be considered in evaluating learning experiences in international health electives.

A case for an international health elective training program during residency: a four-points call for action

BACKGROUND

International Health Electives (IHE) are becoming more popular among graduate training programs. This is likely due to the high demands from graduating medical students who are seeking to have an international health experience during their post-graduate training. Despite the important educational experiences associated with an IHE, this opportunity does not exist in all graduate medical programs and fewer have formal established programs.

SUMMARY

We are suggesting that graduate training programs are in a unique position to provide such experiences to our future physicians, in turn creating immediate benefits to host nations as well as long-term impacts on our society in the United States. We are proposing Four Points for stakeholders involved in training future physicians to use as they consider designing such opportunities for future trainees. The four points include: residents are capable of providing service to host nations, improve the quality of care to communities in the U.S., foster graduating medical students' global health interests and increase global health mentorship.

CONCLUSIONS

We hope that addressing these four points will reemphasize the importance of establishing an IHE in all graduate training programs.

The evolution of global health teaching in undergraduate medical curricula

BACKGROUND

Since the early 1990s there has been a burgeoning interest in global health teaching in undergraduate medical curricula. In this article we trace the evolution of this teaching and present recommendations for how the discipline might develop in future years.

DISCUSSION

Undergraduate global health teaching has seen a marked growth over the past ten years, partly as a response to student demand and partly due to increasing globalization, cross-border movement of pathogens and international migration of health care workers. This teaching has many different strands and types in terms of topic focus, disciplinary background, the point in medical studies in which it is taught and whether it is compulsory or optional. We carried out a survey of medical schools across the world in an effort to analyse their teaching of global health. Results indicate that this teaching is rising in prominence, particularly through global health elective/exchange programmes and increasing teaching of subjects such as globalization and health and international comparison of health systems. Our findings indicate that global health teaching is moving away from its previous focus on tropical medicine towards issues of more global relevance. We suggest that there are three types of doctor who may wish to work in global health - the 'globalised doctor', 'humanitarian doctor' and 'policy doctor' - and that each of these three types will require different teaching in order to meet the required competencies. This teaching needs to be inserted into medical curricula in different ways, notably into core curricula, a special overseas doctor track, optional student selected components, elective programmes, optional intercalated degrees and postgraduate study.

SUMMARY

We argue that teaching of global health in undergraduate medical curricula must respond to changing understandings of the term global health. In particular it must be taught from the perspective of more disciplines than just biomedicine, in order to reflect the social, political and economic causes of ill health. In this way global health can provide valuable training for all doctors, whether they choose to remain in their countries of origin or work abroad.

Knowledge and interests of Romanian medical students in parasitology, tropical and travel medicine

As travel has become easier and faster, the rate of tropical infections across the world is expected to increase; more students working abroad are going to encounter these diseases more often. Disorders of parasitic etiology play an important role in travel and tropical medicine. The aim of our study was to assess the preclinical students' knowledge regarding parasitic diseases, tropical and travel medicine in the broad context of their professional background. A total of 346 Romanian medical students completed a 13-item questionnaire on the above-mentioned topics. In order to allow for complex evaluation, the questionnaire also included items related to their extracurricular training as well as their future perspectives. The majority of the students (97.7%) declared they had prior knowledge (before studying parasitology) of malaria. Most of the responders (90.2%) knew that a journey in (sub)tropical regions requires adequate prophylactic measures. About a quarter of those interviewed (26.4%) would agree to practice tropical medicine after graduation. They were mainly interested in helping people from underdeveloped countries regardless of remuneration (52.7%). The majority of students (59.8%) wished to practice clinical medicine. It has been observed that fewer than 5% of the questioned students had ever read a scientific paper or book in the field of tropical medicine. English was the most commonly spoken foreign language (92.8%), and 99.1% of students had at least intermediate computer skills. Finally, 71.6% of students would choose to practice the specialty of travel medicine if it were available in Romania. The implementation of appropriate measures towards the globalization of medical teaching in Romanian universities should represent an important issue in this new millennium, in which borders between various nations are starting to fade; otherwise the next generations of physicians will lose the chance to gain wider experiences and share the international influences on health.

Ethical issues encountered by medical students during international health electives

CONTEXT

Medical students increasingly wish to participate in international health electives (IHEs). The authors undertook to understand from the students' perspective the ethical challenges encountered on IHEs in low-resource settings and how students respond to these issues.

METHODS

Semi-structured interviews were conducted with 12 medical students upon their return from an IHE. A purposive sampling strategy was used. Inductive data analysis using a constant comparative technique generated initial codes which were later organised into higher-order themes.

RESULTS

Five themes relating to ethical issues were identified: (i) uncertainty about how best to help; (ii) perceptions of Western medical students as different; (iii) moving beyond one's scope of practice; (iv) navigating different cultures of medicine, and (v) unilateral capacity building.

CONCLUSIONS

International health electives are associated with a range of ethical issues for students. Students would benefit from formal pre-departure training, which should include an evaluation of their expectations of and motivations for participating in an IHE, careful selection of the IHE from amongst the opportunities available, learning about the local context of the IHE prior to departure, and the exploration and discussion of ethical and professionalism issues. Other factors that would benefit students include having an invested onsite colleague or supervisor, maintaining an ongoing connection with the home institution, and formal debriefing on conclusion of the IHE.

Integrating CanMEDS competencies into global health electives: an innovative elective program

Globalization has opened the doors for medical students to undertake international health electives, providing an opportunity for them to gain valuable competencies and skills outside their formal curriculum. As the number of medical students embarking on these electives increases, there is a need to structure the electives with specific learning objectives and to ensure adequate educational outcomes.We describe the International Pediatric Emergency Medicine Elective (IPEME), which is a novel global health elective that brings together students from Canada and the Middle East who are selected on the basis of a competitive application process and brought to Toronto for a 4-week living and studying experience. The program was introduced in 2004 and uses four specific areas to provide its structure: pediatric emergency medicine, global health, leadership, and peace building. The elective uses core CanMEDS competencies to foster cross-cultural dialogue, networking, and cooperation and fulfills the program's aim of using health as a bridge to peace.The lessons learned from the curriculum planning and implementation process are highlighted and the impact of the program explored to help provide a framework for developing similar international electives.