As a medical student I spent a month in Tanzania at a teaching hospital. I encountered problems and learned procedures that I never would have seen or done in the United States. The experience gave me the ability and confidence to handle problems in an emergency that few of my colleagues would attempt and probably saved several lives. I also learned about cultural beliefs that affected health care and observed the impact of a variety of social programs upon public health and access to care. I have applied these lessons at home. As a medical student, I was sometimes amazed at the level of authority and responsibility given to me in Tanzania, but I usually did not question it or seek more supervision. While many years have passed since then, U.S. medical students’ desire for international experiences has not diminished. However, we now know much more about the potential contributions and unintended consequences of students’ global health experiences both for the students and the communities that host them.
In our November issue of Academic Medicine we feature four articles on the topic of global health and medical education. Rassiwala et al describe two different models for medical student engagement in international health and Scott provides a commentary about these programs. These short visits by students with or without faculty can provide temporary boosts to the health care of a community while exposing students to experiences that can change their lives. Cherniak reviews published literature on objectives for international medical electives and provides guidance for future programs. Dacso and colleagues describe an international collaboration between University of Pennsylvania and Botswana to improve medical education and clinical care through exchanges of faculty and students. Taken together these articles provide a window on to a major area of interest for U.S. medical students and medical schools. What can we learn from these articles? I will share some of my conclusions tempered by my own experience.
Although short term visits by medical students provide an introduction to the health care problems and culture of another country they also can create expectations for longer term commitments that may not always be met. There are also risks that students may be called upon to function in roles for which they are not prepared. Additionally, there could be health risks and larger risks to the students related to political and cultural unfamiliarity. We need to be asking ourselves whether the benefits exceed the risks for each of these programs.
Longer electives for students should have clear educational objectives for the pre-elective, intra-elective and post-elective periods. If one of the goals will be to enhance clinical skills, there should be adequate supervision of the students so that they are not placed into situations above their skill levels. Since educational approaches differ from country to country and the medical needs in developing countries often exceed the available resources, there are numerous opportunities for confusion of visiting students’ roles. We need to proactively investigate what the goals are for these electives and how the experiences will meet these goals.
The development of a long term collaboration between a U.S. medical school and one in a developing country offers the advantage of long term commitments and supervision of students, but even in these situations the differences in resources between the two collaborators creates a power differential that can lead to misunderstandings and confusion of roles. As more medical schools seek relationships with international partners the experience described by Dacso et al should be a helpful model with valuable lessons.
As we continue to develop international programs the experiences of colleagues that are presented in the pages of Academic Medicine will be helpful road maps. We have the opportunity to do enormous good for people in great need, and I encourage anyone who is interested to pursue this opportunity, but we must also be cognizant of the harms that unprepared visitors can cause a fragile community. The four articles that I highlight present a balanced view that should be reviewed by all who are considering such experience.