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Expanding the Boundaries of Medical Education: Evidence for Cross-Cultural Exchanges

Mutchnick, Ian S.; Moyer, Cheryl A.; Stern, David T.

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Washington, DC, November 9-12, 2003

Moderator: Amy Blue, PhD

Correspondence: David T. Stern, MD, PhD, Division of General Medicine, 300 North Ingalls, 7E10 NIB, Ann Arbor, MI 48109-0429; e-mail: 〈dstern@umich.edu〉.

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Abstract

Problem Statement and Background. Cross-cultural experiences are in increasing demand by both graduate and undergraduate medical students, yet the benefits of these experiences are not clearly established.

Method. A review of the literature was conducted to identify articles on the outcomes of cross-cultural experiences. Themes were identified and categorized into domains.

Results. Forty-two studies were found; 27 articles used qualitative methods, nine used quantitative methods, and six used both. Most (24) were from the nursing literature, 18 were from the medical literature. All studies reported positive outcomes along four domains: students’ professional development, students’ personal development, medical school benefits, and host population benefits.

Conclusions. Studies reviewed were primarily case controlled or case series. Future research is needed that more clearly defines outcome measures and uses more rigorous methods. Although results suggest positive outcomes in all domains, additional research is needed before cross-cultural rotations can be supported based on evidence.

We now live in a global society, and globalization is here to stay. It affects our economies, the way we exchange information, our language use, and the way we travel. Medicine has also become a global enterprise. Infectious diseases such as HIV, West Nile Virus, and hepatitis have spread globally. Yet mainstream medical education remains largely focused on national—as opposed to global—health issues.

Demand for cross-cultural experiences within medical schools is on the rise. The term “cross-cultural experience” most often refers to an elective completed outside the student’s home country during medical school or residency, yet it may also refer to experiences in communities populated by continental natives (i.e., Native Americans in the United States or the Maori of New Zealand). In 1982, only 6% of U.S. medical students participated in a foreign elective; from 2000 to 2002 the proportion was 20% to 38.6%.1,2 Some data also indicate a rise in the number of graduate medical students interested in cross-cultural experiences.3 Although the number of medical schools offering these types of experiences to their students has also increased in the last decade, the costs—in financial terms as well as in time away from their home institution—make a stronger commitment to these types of opportunities difficult in the face of limited data.

Much of the published literature surrounding cross-cultural exchanges describes anecdotal experiences of an individual health professional, often relating positive experiences both personally and professionally.4–6 Yet these thought-provoking pieces are largely unsubstantiated by systematic research.

The purpose of this review is to identify and analyze the available research literature on cross-cultural experiences to address the following questions:

1. What are the outcomes of cross-cultural experiences relevant to students, the medical school and/or the host country?

2. What is the evidence supporting those outcomes, and is the evidence compelling?

3. What are the areas in need of future research regarding cross-cultural experiences during medical training?

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Method

We define “cross-cultural experiences” as periods of time when participants visit a community with cultural and societal norms different from those of their home without any intercessionary return to their home environment. Although most cross-cultural experiences occur internationally, experiences in communities populated by continental natives (i.e., Native Americans in the United States or the Maori of New Zealand) are included in this definition.

A systematic literature search of indexed, English-language journals using Ovid Medline (National Library of Medicine (NLM), 1966–2003) and other electronic databases was performed using major Medical Subject Headings (MeSH) and text words. A Medline search using the MeSH “International Educational Exchange” yielded 1,822 citations. Of these, 94 citations were identified based on titles and abstracts as appearing relevant. Of these 94, 13 were found to contain data on the outcomes of cross-cultural experiences. Additional articles were gathered through individual journal searches and by evaluating selected references cited in articles.

Only those articles including qualitative or quantitative data on the outcomes of cross-cultural experiences on groups of health care professionals were included for the analysis. Opinion pieces and articles describing anecdotal reports were excluded.

Reported outcomes were examined collectively and coded for recurrent themes. Each of 17 identified themes was categorized into one of the following domains: professional development; personal development; medical school benefits; and host population benefits. For data to be included in this analysis as supportive of the identified themes, it had to meet two criteria. First, if statistical significance was reported, the data must have been significant. Second, the conclusions drawn by the authors on outcomes needed to be reasonably related to the data provided. No data reporting negative effects were excluded from this analysis—there were none.

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Results

Forty-two journal articles met the inclusion criteria.3,7–47 Most were qualitative in nature (64%), very few compared students who participated in a cross-cultural experience with those who did not (24%), and less than half of the articles (43%) were found in the medical literature. Of the 18 articles from the medical literature, the majority (61%) reported data collected from medical students, as opposed to residents. Of the 24 articles from the nursing literature (53%), all but 2 used either graduate or undergraduate/preregistration (UK) nursing students. The two additional articles related the cross-cultural experiences of practicing health services professionals. Of those articles not relying solely on qualitative data, nine (21%) used quantitative data and six (14%) used both qualitative and quantitative data. The majority of the articles were case series (27 or 64%), whereas one article was a cross-sectional study (2%) and four did not describe their methods (10%).

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Professional Development

The domain of professional development contains eight themes: increased cultural competence, deeper understanding of professional practice issues through comparative experience, increased compassion toward patients, increased communication skills, increased appreciation for and/or knowledge of public health, increased appreciation for and confidence in clinical skills, effect on public service career orientation, and increased awareness of resource use. Table 1 illustrates that all eight dimensions are supported by both qualitative and quantitative data.

Table 1
Table 1
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Increased cultural competence8,10,12,13,15,16,19,22,24,25,27–31,33,36,38,40,41 is the most frequently reported outcome of international experiences. Authors reported that students and residents who participated in cross-cultural experiences (“cross-cultural participants,” or CCPs) tended to think more positively about people from different cultures, as well as practicing with greater insight and empathy with cross-cultural patients. Barry and Bia “found that a short-term elective... stimulated residents to become... more respectful of cultural differences.”8 St. Clair and McKenry used the “Cultural Self-Efficacy Scale” which measures general and specific cultural skills on a scale of 1 = little skill to 5 = much skill. The average score of all students at the beginning of the year (before any students went on exchange) was 2.8, whereas at the end of the year the average CCP score was 3.75 and the non-CCP score 3.3 (p = .007).41

Students reported a deeper understanding of professional practice issues through comparative experience.7,10–13,15–17,22,24,29,33–34,36,38 Most frequently, authors reported CCPs returned home with greater understanding of health care systems, both at home and in the country they visited. Bissonette (1991 and 1994) reported that CCPs “developed a wider palate from which to handle” death and dying and came to appreciate the potential for the family’s role in patient care.11,12 Despite the wealth of qualitative data supporting this claim, only two quantitative studies address the issue.7,22

Studies suggested that students return from cross-cultural experiences with an increased appreciation for and knowledge about public health.12,17,19,22,24,25,28,45 These data relate mostly to CCPs having visited underserved populations; many returned with a greater appreciation for the importance and impact of public health issues on populations. Waddell and colleagues found that while non-CCP controls (made up of those students who applied to be part of the cross-cultural experience described, but were not accepted) scored 504 on the Preventive Medicine/Preventive Health portion of the National Board of Medical Examiners (NBME) part II, Israel-bound CCPs scored 536 (p = .01) and Yugoslavia-bound CCPs scored 533 (p = .05).45

CCPs were also reported to have both an increased awareness of the importance of and an increased skill in communication with other colleagues and with patients.10,22,24,25,29,39–41 Skills included greater understanding of cognitive assumptions in communication, better understanding and use of nonverbal communication, and simply being better able to speak with non-English-speaking individuals regardless of their ability to speak the relevant foreign language. “Accent, affect, and culture meant that although words were recognized, their meaning remained unclear. This caused the student to stop and consider the meaning of every communication, which in turn caused them to reflect upon everything and every action – nothing could be taken for granted and everything needed to be verified. This process of itself caused the students to carefully consider what was happening around them, ask questions and seek clarification.”40 Comparing pre- and postexperience data from CCPs, where 1 = strongly agree and 5 = strongly disagree, Haq et al. report that after their cross-cultural experience, CCPs agreed more strongly with the importance of nonverbal communication in physician–patient interactions (pre = 1.32, post = 1.21, p = .006) and that patients may often undermine their own treatment due to miscommunication with the physician (pre = 1.73, post = 1.64 (p = .02).25

Increased compassion toward patients8,11,22,24–25,40–41 is another outcome frequently associated with cross-cultural experiences during training. CCPs appear to have a greater ability to connect with their patients and feel compassion with what their patients were experiencing after rotating cross-culturally. In one study, CCPs discussed the long-term effects the international experiences had on the development of nurse-patient relationships, emphasizing the deepening of their relationships with patients. Non-CCPs did not mention these things.41

CCPs reported an increased appreciation for and confidence in their clinical skills.12,15,20,23,25,37 “[The students] return with the concept that the foundation of the art of medicine is a complete and detailed history and the performance of a thorough physical examination followed by a thoughtful assessment of the problem, rather than examining computerized print-outs of laboratory tests.”20 On a seven-point scale, with −3 = strongest negative effect and +3 = strongest positive effect, internal medicine (IM) residents assessed the improvement of their clinical skills to a median score of 1 after a recent cross-cultural experience.37

Cross-cultural experiences appeared to affect students’ career orientation, increasing interest in public service.12,14,20,22,23,25,31 CCPs were more likely to plan for and engage in careers that emphasized assisting underserved populations both domestically and abroad. Gupta and colleagues surveyed 317 graduates of the Yale Internal Medicine residency program (125 were CCPs). They found CCPs were more likely to have a substantial portion (>20%) of their current patient population include patients on public assistance (77 versus 49), immigrant patients (41 versus 23), patients who are substance abusers (42 versus 21) and patients infected with HIV (30 versus 13); all of these difference were statistically significant (p values not reported).23

Students reported an increased awareness of resource use,8,12,20,25,37 an outcome most noticeable in CCPs who went to developing countries. “There is no health insurance, so you need to be very careful about what tests you order, because all the costs have to come out of the patient’s pocket.”12 Quantitative data suggest a small decrease in the use of resources for the care of patients but do not compare their results with non-CCPs.

Articles also include data that did not fall into any of the domains described above.37,42,46 Miller and Corey report that the median score of a CCP self-assessment on the impact of an immersion experience on their professional lives was two (-3 strongest negative effect and 3 strongest positive effect).37 Thompson et al. report that the average CCP rating for the long-term impact of immersion on intellectual development was significantly greater for CCPs traveling to developing countries compared with students traveling to a developed country (5.8 v 5.3, p < .01, 1 = small impact and 7 = large impact).42

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Personal Development

The domain of personal development includes the following themes: broadened perspective, value of experiential learning, increased sense of independence and confidence, general personal growth, and ability to set realistic goals. Four themes are supported by qualitative data; general personal growth is supported by quantitative data.

The most frequently cited outcome in this domain is a broadened perspective.13,24,25,30,31,35,39–41,44 “The complete cultural immersion was an ‘eye opener’ for the majority of [CCPs] who indicated that their world view had been broadened and their personal lives enriched by this short experience.”13 CCPs came away from their immersion experience with greater appreciation of their chosen occupation. “I regained the sense that being a doctor is a wonderful privilege.”25

Several articles describe the value of experiential learning as a benefit of cross-cultural exchanges.19,24,30,31,40,41,44 “[It was] the most valuable experience I have had so far at medical school,” wrote one student. The authors note, “Although the students had received classroom input on many aspects of [Maori culture] in previous years, there was a strong feeling that this ‘field experience’ was a more effective way to learn.”19 CCPs also reported a greater sense of self-confidence in their interactions with others and in their struggles with skill development.24,27,33,38,40,41 “CCPs no longer shied away from [cultural self-efficacy and competence] but reached out to meet new people, learn new skills, and experience new things.”41

CCPs, confronting an underserved population with numerous problems, overcame both an initial pessimism and a sense of hopelessness and focused on setting realistic goals.24,25,40 “Crucial to the outcomes [of the student’s experience] was setting realistic expectations; an optimistic outlook and a determination to see the potential for learning out of any situation. They became more aware of their limitations but used this to consider how this might affect future interactions with patients.”40

Several authors commented on the cognitive growth of CCPs.21,37,42,46,47 Thompson et al. found that those CCPs who visited a developing (versus developed) country reported a greater sense of intellectual development (4.1 for developing country CCPs and 3.4 for developed country CCPs; 1 = small impact, 7 = large impact; p <.05).42 Using a validated measure of cognitive development based on Perry’s scale of young adult cognitive development, both Frisch and Zorn (1995) report that CCPs were more likely to advance along Perry’s scale of development over the course of a year than non-CCPs (CCPs 3.5 and 3.125 times more likely to advance cognitively versus non-CCPs, respectively; p = .018 and .044).21,47,48

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Medical Schools

Four themes comprise the domain of medical school benefits: increased attractiveness for incoming students, the overall value of an international program, development of new curricular materials, and exposure to a wider range of clinical experience per unit time. All four themes are supported by qualitative data; two are supported by quantitative data as well.

The data suggest that programs offering international health field electives are increasingly attractive to incoming students, potentially providing a strong tool for recruitment.9,18,20,22,23,37,43 Some evidence indicates that students looking for a place to train will preferentially pick a program offering a cross-cultural experience. Forty percent of the 281 students surveyed by Miller and colleagues indicated that the presence of a cross-cultural experience had a significant impact on their choice to attend the Duke University residency in IM; interestingly, 61% of the 101 residents who had not yet participated in the experience said that this was a significant factor in their choice to attend Duke.37

Several articles suggest that participants value cross-cultural experiences very highly.14,19,25,28,34,37,38 Miller et al. report that 99% of 281 individuals, whether CCPs or non-CCPs, felt the international program should be continued. The median score for the CCPs in this group regarding the impact of their cross-cultural experience on their medical training was 3 (-3 = strongest negative effect and + 3 = strongest positive effect).37 Chiller and colleagues report similar data: responding to a survey three years after graduation from medical school, 100% of 39 CCPs felt their international experience (which fulfilled their Community Health requirement) was valuable, compared with .8% of 36 students fulfilling their Community Health requirement through coursework.14

Another benefit for medical schools is the development of new curricular materials.7,32 Korthuis et al. describe the creation and execution of an evidence-based medicine (EBM) curriculum at a Russian medical school to good effect.32 Armstrong and colleagues write about their experiences creating a comparative health systems curriculum as part of an immersion experience.7 Finally, cross-cultural experiences may provide students with a wider range of clinical experiences per unit time.12,20 “In one month’s time in the emergency department/holding area in Tegucigalpa, residents are exposed to a greater variety of acute and serious illnesses than they may see in an entire year in many pediatric programs in the United States.”20

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Host Populations

Given the importance of the host population, there has been surprisingly little attention paid to formal evaluation of this aspect of the cross-cultural experience.15,19,28,32 Dowell et al. state that “the local communities were unanimous in their positive support for the project. Initial feelings about its success were reaffirmed at a debriefing with the chief executive and staff held at [a local town] four months afterwards.”19 Cohen echoes this sentiment and adds that as a result of donations brought by successive students, libraries are slowly being created for the host population.15 Korthuis and colleagues state that after the delivery of a series of lectures at a Russian medical school, “several [Russian] faculty members have incorporated EBM concepts into their own lesson plans. One now writes articles about EBM for the local medical newsletter. There are plans for a more in-depth, [Russian] faculty-led EBM seminar.”32 In addition, the visiting residents brought with them a computer with both medical text and EBM software. Finally, Jamrozik writes that not only did the host community enjoy the visit from medical students but that neighboring communities have expressed interest in being the location for future visits.28

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Discussion

In today’s world, the distinction between “domestic” and “foreign” has lost some of its clarity. At home, more of our patients belong to different cultures, requiring physicians to have a broader perspective on patient care and cross-cultural communication. By increasing social and economic integration and the ability to travel great distances quickly, we now have, in the words of Dr. Gro Harlem Brundtland, “a single microbial sea [that] washes all of humankind.” Health and economies are interdependent; according to the Committee on Macroeconomics and Health, “improving the health and longevity of the poor is an end in itself... but it is also a means to achieving the other development goals relating to poverty reduction.”49 In short, “they” are not “they” anymore; “they” are, in fact, “we.”

In this context, medical students and educators have started to “think globally.” The purpose of this review is to clarify the benefits and limitations of cross-cultural exchanges for health professions students. This manuscript expands upon an earlier review of international health electives50 by broadening the search to include non-U.S. institutions and other allied health professions. Not surprisingly, increased cultural competence and a deeper understanding of professional practice through comparative experience appear to be the most frequently cited professional outcomes. Most authors note the idea that these experiences could be used to achieve the desired educational goals of cultural competence. A broadened perspective about the world appears to be the most frequently cited personal development outcome of cross-cultural experiences. Living in alternative social environments creates an educational experience unmatched in any textbook or classroom exercise. In addition, these experiences appear to positively effect the sponsoring institutions, most importantly by increasing the attractiveness of their programs to new applicants.

The evidence supporting the outcomes described above is both qualitative and quantitative in nature, but is admittedly not overwhelming. There are no randomized trials to determine effects. These outcomes are measured primarily by self-report, with a few studies evaluating change in knowledge. Few have taken the challenge of evaluating behavioral change at the level of patient outcomes.

This review illustrates a gap in the current research literature regarding cross-cultural experiences for medical students. While a few papers had quite sophisticated methods of data collection and analysis,21,22,25,26,30,39,41 most studies fell short of demonstrating a clear benefit to participating in a cross-cultural experience over not participating. Articles in this review were limited to those concerning members of the health professions. Future research may benefit from an exploration of the literature on study abroad programs among undergraduate students for insights on both outcomes and research methods. Future reviews might also be improved by the inclusion of non-English-language journals.

Future research should also include clearly defined outcomes that are directly attributable to participating in a cross-cultural experience. Comparison groups are one means to that end. Without them it is difficult to determine which outcomes, if any, can only be replicated by training outside of one’s own culture. And without random assignment to participation or nonparticipation, selection biases associated with those students who choose to participate in cross-cultural experiences are likely to influence the results. Although it may be difficult to conduct randomized controlled trials (RCTs), one could compare CCP students, as Waddell et al. did, to a control group made up of individuals who applied to join the cross-cultural experience program but were not accepted.

It is also worth exploring whether there are differing degrees of cross-cultural exposure by comparing students who rotated in developing versus developed nations. Another option might be comparing the impact of rotating internationally with the impact of rotating cross-culturally in one’s own country. For example, for some students, spending time in an urban, inner-city environment might be comparable with spending time abroad.

Next, the research literature to date has made little use of validated instruments to assess the impact of international rotations. Only three articles stated the validity of the instrument used;22,25,39 several others referenced the source of their instrument, but failed to state whether or not it was validated.21,26,32,40,41 Without evidence from validated instruments it will be difficult to convince physicians, administrators, and policy makers of the merit of these experiences. In addition, most instruments use self-reported outcomes. Additional studies of behavior-based outcomes, including standardized patient evaluations and patient satisfaction scales of cross-cultural competency, are needed. In addition, none of the research published to date has reported on the potential negative effects of cross-cultural experiences, aside from the cost. Of the 42 articles reviewed, only one had an equivocal result. In this study, Inglis et al. found that the “impact of participation in the program was less than expected.” However, the authors note that “nevertheless participants reported they had learnt much from their experiences.”26 Future research needs to take an honest look at the potentially deleterious effects on students, medical schools, and host populations.

This also raises the issue of the dearth of evidence regarding the impact of these experiences on host populations. Only four of 42 articles addressed the host population’s response to cross-cultural experiences by health care professionals. More research is warranted that elucidates the impact on host populations. This is a first and critical step in establishing a nonexploitative relationship and better assessing how to meet both student and host national needs.

Finally, future research should include an assessment of what type of program structure provides the best educational outcomes. For instance, what kind of pretrip preparation should be included? What kind of mentoring both during and after a cross-cultural experience is optimal? Research into types of educational goals, and how best to reach them, will be extremely valuable in designing future cross-cultural programs.

Although no single article in this review provided strong evidence for the benefit of cross-cultural experiences, taken together they suggest benefit for those involved. Future research should more clearly describe the nature of these benefits, illuminate their connection to specific types of programs, and create specific programs to meet the needs of individual programs. The evidence presented here suggests that cross-cultural experiences are of benefit across a multitude of dimensions, for not only the student but for the medical school and the host populations as well.

The mission of the medical school is not only to train excellent clinicians, but also to prepare individuals to explore the limits of current assumptions and serve the patients of the future. The model of medical education that creates only clinicians and scientists no longer does justice to the complex and pressing issues facing our society. Tomorrow’s students ought to be given the chance to learn about and engage the broader issues of health care while in training. Cross-cultural exchanges have the potential to help our students become culturally-aware and globally-competent physicians.

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