Loss of international medical experiences: knowledge, attitudes and skills at risk
TL;DR: It is time for the leaders in graduate medical education to prioritize international health opportunities and press for changes in reimbursement patterns at the national level or special funds for international electives.
Abstract: Background
Despite the great influence International Medical Experiences (IMs) can have on young physicians and their impact on patients and communities, they are not offered in all training programs and are at risk of being reduced in some due to stringent guidelines for funding of graduate medical education.
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Journal Article•
TL;DR: Findings suggest that having IHE experiences contributed to a more well-rounded training for medical students; students reported being more culturally competent and were more likely to choose a primary care specialty and/or a public service career.
Abstract: Background and objectives The present study reviewed the published literature to examine the effects of international health electives (IHEs) on medical student learning and career choice. Methods A systematic literature review was conducted to identify key English-language articles on IHEs, using PubMed journal databases for the period 1990--2009. Article inclusion for this review was vetted by a rigorous evaluation of each article's study methods, content, and data quality. Pooled or aggregate information from 11 key articles, including information on type and duration of IHE, study and comparison group characteristics, and measured outcomes such as self-reported changes in cultural competency, clinical skills, and specialty choice, were extracted and summarized. Results Findings suggest that having IHE experiences contributed to a more well-rounded training for medical students; students reported being more culturally competent and were more likely to choose a primary care specialty and/or a public service career. Conclusions Although IHE experiences appear to have educational benefits, the quality and availability of these electives vary by institution. Barriers to ensuring that students attain a safe and rich experience include the lack of consistent categorical funding, safety concerns when traveling, and limited faculty experience and resources to support and guide students during their rotations abroad.
133 citations
TL;DR: Demographic and attitudinal characteristics at entry into medical school predicted whether students chose a career in family medicine, and entry characteristics that predicted a student’s ultimate career choice in family Medicine.
Abstract: Background Student choice is an important determinant of the distribution of specialties of practising physicians in many countries. Understanding characteristics at entry into medical school that are associated with the choice of residency in family medicine can assist medical schools in admitting an appropriate mix of students to serve the health care needs of their regions. Methods From 2002 to 2004, we collected data from students in 15 classes at 8 of 16 Canadian medical schools at entry. Surveys included questions on career choice, attitudes to practice and socio-demographic characteristics. We followed students prospectively with these data linked to their residency choice. We used multiple logistic regression analysis to identify entry characteristics that predicted a student’s ultimate career choice in family medicine. Results Of 1941 eligible students in the participating classes, 1542 (79.4%) contributed data to the final analyses. The following 11 entry variables predicted whether a student named family medicine as his or her top residency choice: being older, being engaged or in a long-term relationship, not having parents with postgraduate university education nor having family or close friends practicing medicine, having undertaken voluntary work in a developing nation, not volunteering with elderly people, desire for varied scope of practice, a societal orientation, a lower interest in research, desire for short postgraduate training, and lower preference for medical versus social problems. Interpretation Demographic and attitudinal characteristics at entry into medical school predicted whether students chose a career in family medicine.
109 citations
Cites background from "Loss of international medical exper..."
...These include age,(13) marital status,(13) having a societal orientation and volunteering in a developing country.(14,26) Rural origin, which has been shown by others to be predictive,(27,28) was not associated with a career choice of family medicine in our study; however, it was associated with a decreased likelihood of switching career interests away from family medicine during medical school....
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TL;DR: Global health training and exposure for residents can be effectively integrated into an academic surgical residency program through relationships with training programs in low-income countries.
Abstract: Hypothesis Surgical trainees in the United States have a growing interest in both clinical experiences and structured training opportunities in global health. Global health training and exposure can be integrated into a surgical residency program. Design The global health activities of surgical residents and faculty in 1 department were evaluated from January 1, 1998, to June 1, 2008, using a survey and personal interviews. Results From January 1, 1998, to December 31, 2002, 4 faculty members made more than 20 overseas volunteer medical expeditions, but only 1 resident participated in global health activities. In 2003, a relationship with a surgical training program in a developing country was established. Ten residents and 12 faculty members have made overseas trips during the last 5 years, and 1 international surgeon has visited the United States. During their research block, 4 residents completed 1- to 3-month clinical rotations and contributed to mentored research projects. Three residents completed a university-based Global Health Clinical Scholars Program, and 3 obtained master's degrees in public health. A joint conference in injury-trauma research was also conducted. A faculty member is based overseas with clinical and research responsibilities, and another is completing a master's degree in public health. Conclusions Global health training and exposure for residents can be effectively integrated into an academic surgical residency program through relationships with training programs in low-income countries. Legitimate academic experiences improve the success of these programs. Reciprocity with collaborative partners must be ensured, and sustained commitment and funding remain a great challenge to such programs. The long-term effect on the development of global health careers is yet to be determined.
104 citations
TL;DR: The greatest barriers to establishing these activities were time constraints for faculty and residents, lack of approval from the Accreditation Council for Graduate Medical Education and Residency Review Committee, and funding concerns.
Abstract: Background Interest in global health during postgraduate training is increasing across disciplines. There are limited data from surgery residency programs on their attitudes and scope of activities in this area. This study aims to understand how global health education fits into postgraduate surgical training in the US. Study Design In 2007 to 2008, we conducted a nationwide survey of program directors at all 253 US general surgery residencies using a Web-based questionnaire modified from a previously published survey. The goals of global health activities, type of activity (ie, clinical versus research), and challenges to establishing these programs were analyzed. Results Seventy-three programs responded to the survey (29%). Of the respondents, 23 (33%) offered educational activities in global health and 86% (n = 18) of these offered clinical rotations abroad. The primary goals of these activities were to prepare residents for a career in global health and to improve resident recruitment. The greatest barriers to establishing these activities were time constraints for faculty and residents, lack of approval from the Accreditation Council for Graduate Medical Education and Residency Review Committee, and funding concerns. Lack of interest at the institution level was listed by only 5% of program directors. Of the 47 programs not offering such activities, 57% (n = 27) were interested in establishing them. Conclusions Few general surgery residency programs currently offer clinical or other educational opportunities in global health. Most residencies that responded to our survey are interested in such activities but face many barriers, including time constraints, Residency Review Committee restrictions, and funding.
94 citations
Cites background from "Loss of international medical exper..."
...xposure to a broad spectrum of illnesses, and increased ultural sensitivity.(3,4) Potential reciprocal benefits to host...
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...Clinical global health opportuities in postgraduate training have typically been offered n nonsurgical disciplines, partly because of the traditional ocus of public health on infectious diseases and maternal nd child health.(1,4,14,18,19) Recently, the substantial burden igure 2....
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TL;DR: The international experiences available to students and residents at U.S. allopathic medical schools are described to increase students’ and residents’ interest in public health, their likelihood of choosing a career in primary care, and their commitment to serving the underserved.
Abstract: Danette W. McKinley, Shirley R. Williams, John J. Norcini, and M. Brownell AndersonAbstractBackgroundInternational health experiences have beenshown to increase students’ and residents’interest in public health, their likelihood ofchoosing a career in primary care, and theircommitment to serving the underserved.The purpose of the current study is todescribe the international experiencesavailable to students and residents at U.S.allopathic medical schools.MethodAn online survey was conducted tocollect information about the types ofinternational opportunities in medicaleducation provided to faculty, students,and residents at U.S. allopathic medicalschools.ResultsReponses from 103 representatives of96 U.S. allopathic medical schools wereincluded in the analysis. A varietyof opportunities for students andresidents was reported, with 59% ofthe respondents reporting electiverotations for residents, 11% reportinga global health track for students, and45% reporting opportunities toperform preclinical research abroad.ConclusionsDespite associated costs and risks,U.S. medical schools are developingand refining international healthexperiences for medical students andresidents.
80 citations
References
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TL;DR: Despite uncertainties about mortality and burden of disease estimates, the findings suggest that substantial gains in health have been achieved in most populations, countered by the HIV/AIDS epidemic in Sub-Saharan Africa and setbacks in adult mortality in countries of the former Soviet Union.
5,168 citations
"Loss of international medical exper..." refers background in this paper
...Though some medical students and residents are exposed to poor patients within the US, not all training programs include such patients and the level of poverty is less extreme than in developing countries where many still die of hunger and curable communicable diseases [7]....
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TL;DR: IHEs appear to have positive educational influences on participants' knowledge, skills, and attitudes, and may play some role both in recruiting residents and in their choices of careers in primary care and underserved settings.
Abstract: PURPOSE: To evaluate the educational effects of international health electives (IHEs) on participants. IHEs are a popular component of many medical school and residency program curricula, and are reported to provide benefits in knowledge, skills, and attitudes.
METHOD: The authors reviewed all studies reported in Medline and ERIC databases that have assessed the educational effects of IHEs on U.S. and Canadian medical students and residents. Data extracted from eligible studies included type and duration of IHE, details of survey instrument, response rate, comparison group, and outcomes. Seven of the eight eligible studies assessed educational effects on participants using self-reported questionnaires; a single study used an objective measurement of knowledge.
RESULTS: Eight studies involving 522 medical students and 166 residents met inclusion criteria. IHEs appear to be associated with career choices in underserved or primary care settings and recruitment to residency programs. They also appear to have positive effects on participants' clinical skills, certain attitudes, and knowledge of tropical medicine.
CONCLUSION: IHEs appear to have positive educational influences on participants' knowledge, skills, and attitudes. Furthermore, IHEs may play some role both in recruiting residents and in their choices of careers in primary care and underserved settings. Future directions for research in this field are discussed.
359 citations
TL;DR: There is a paucity of longitudinal research reports on the extent to which students' attitude scores shift as they progress through medical school, and this work aims to address this issue.
Abstract: Background Attitudes influence behaviour. Developing and maintaining proper attitudes by medical students can impact on the quality of health care delivered to their patients as they assume the role of doctors. There is a paucity of longitudinal research reports on the extent to which students' attitude scores shift as they progress through medical school.
Objective This study examined the change in attitude scores of a large student cohort as they progressed through medical school. Whether student gender is related to attitude change was also investigated.
Method Medical students from 3 consecutive classes (1999–2001) participated in this study. Students completed 2 instruments that included the Attitudes Toward Social Issues in Medicine and an in-house tool referred to as the Medical Skills Questionnaire. The instruments were administered at 3 milestones during the course of medical school training (entry, end of preclinical training and end of clerkship).
Results Reliability estimates for total (0.82–0.91) and subscale (0.41–0.81) attitudinal scores were in the acceptable range. Multivariate analyses of variance of mean attitudinal scores indicated a persistent decline in several attitude scores as students progressed through the medical educational programme. Females demonstrated higher attitude scores than males.
Conclusions As students progress through medical school their attitude scores decline. The reasons for the shift in attitude scores are not clear but they may relate to a ceiling of high attitude scores at entry, loss of idealism and the impact of the unintended curriculum. Further study of the impact of medical education on student attitudes is warranted.
322 citations
"Loss of international medical exper..." refers background in this paper
...Following the traditional trajectory, students' idealism and desire to work with underserved populations has been shown to decline as they progress from preclinical training through residency [8]....
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Journal Article•
TL;DR: This study of IHFP fellows demonstrates multiple significant impacts of international health experiences on US medical students in training, and suggests medical schools should increase the availability of high-quality international experiences.
Abstract: BACKGROUND AND OBJECTIVES To determine the impact of international health experiences on physicians in training, we studied 60 US medical students who participated in an International Health Fellowship Program (IHFP). METHODS In 1995 and 1996, US medical students were selected to participate in the IHFP, which included training at three US medical schools and at seven medical schools in developing countries. The program included a 2-week preparatory course at a US school and a 6- to 8-week field experience. Evaluative data were collected prior to the course, after the course, after the field experience, and 1-2 years later. RESULTS A total of 60 students were selected from 145 applicants. At the end of the fellowship, a majority of participants noted that the exposure affected them in the following ways: changed world views; increased cultural sensitivity; enhanced community, social, and public health awareness; enhanced clinical and communication skills; more appropriate resource utilization; changes in career plans; and a greater understanding of the challenges of working in areas with scarce resources. After the international field experience, students more strongly agreed with the importance of oral rehydration, communication skills, and patient education. According to student self-assessments, the IHFP significantly improved core medical skills. Ninety-six percent of participants recommended international health experiences for other students. CONCLUSIONS This study of IHFP fellows demonstrates multiple significant impacts of international health experiences on US medical students in training. The knowledge, attitudes, and skills gained through international health experiences are important for medical practice in the United States and abroad. Given the high interest of medical students in international health and the potential for positive educational impacts, medical schools should increase the availability of high-quality international experiences.
218 citations
"Loss of international medical exper..." refers background in this paper
...They also chose to practice in more culturally diverse and underserved areas, and the majority choose careers in primary care [10,19,20]....
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TL;DR: International health experiences appeared to have an important impact on the decisions and attitudes of residents.
Abstract: The purpose of this study was to assess the impact of international health electives on physicians-in-training. A retrospective study was conducted using an anonymous, self-administered mailed survey to internal medicine residents who trained at Yale from 1982 to 1996 based on their experience with our International Health Program (IHP). The response rate was 61%, with 96 completed surveys in the participant group and 96 completed surveys in the nonparticipant group. Participants were more likely than nonparticipants to care for patients on public assistance (77 versus 49; P < 0.001) and immigrant patients (41 versus 23; P = 0.006). Among residents who changed their career plans, participants (22) were more likely than nonparticipants (14) to switch from subspecialty medicine to general medicine (P = 0.02). Participants were significantly more likely to have a positive view of health care delivery in developing countries. Compared with nonparticipants (64), IHP participants (74) believed that the physical examination is under-used by physicians from the United States as a diagnostic skill (P = 0.03). International health experiences appeared to have an important impact on the decisions and attitudes of residents.
201 citations
"Loss of international medical exper..." refers background in this paper
...Residents in an international health track often switched from subspecialty to general medicine during residency [21]....
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