Changes within and outside the medical profession necessitate expanding global health training for medical students so that they may meet their professional and societal obligations as physicians. Externally, challenges arise from an interconnected world where people, animals, food products, technologies, and pathogens move seamlessly across national boundaries. Internally, there is a large and growing demand for access to global health training by medical students and residents, with the availability of this training a factor in medical school and residency selection.1 Moreover, extreme disparities in health and access to health care within and among countries confront the medical profession, which must be more responsive to the needs of all persons, especially those who typically have been underserved. Major medical organizations, including the American Board of Internal Medicine, the American College of Physicians–American Society of Internal Medicine, the European Federation of Internal Medicine, and the Canadian Medical Association have stated, through specific learning objectives, that addressing health care inequalities both within and beyond our borders is a fundamental principle of physician professionalism.2,3 For medical schools to prepare students to fulfill the roles demanded of today’s physicians, these promulgated objectives must be translated into components of the medical education curriculum.
Though there exist compelling moral, ethical, professional, pedagogical, and economic reasons to include global health training in undergraduate medical education, there are few data available concerning current practices for teaching global health issues in Canadian medical schools. Data from non-Canadian medical schools are also scarce, but medical student surveys conducted in the United States and the United Kingdom indicate an increased, yet unmet, demand for global health training and opportunities.4,5 Anecdotal information from Canadian medical schools suggests wide variation in the amount of time devoted to global health issues, materials covered, format of presentation, and whether relevant courses are required or elective. Understanding current global health practices in medical schools is an important step in improving and standardizing education in this area. This process is further complicated by the lack of consensus on the knowledge and skills that constitute necessary global health education in medical schools, though one set of recommendations has been recently published.6
To understand better the quality and quantity of global health educational activities currently available at Canadian medical schools, we conducted a survey of existing global health offerings.
Before we undertook this study, we sent a letter to the deans at each medical school, notifying them of the goals of the survey and inviting each school to participate. We solicited information about international and global health activities and courses from all 17 Canadian medical schools, using a 14-point questionnaire developed for this purpose (see Appendix). To complement the questionnaire, we also consulted representatives identified by each institution as being involved in global-health-related activities as well as publicly available medical school Web sites, other faculty interested in global or international health, international health student liaisons, and personal contacts at each school. To assess Canadian medical school curricula as broadly as possible and to identify any and all relevant information about global-health-related topics, we asked about both global and community health programs as part of the data collection because some medical schools offer global health topics through their community health, infectious disease, or public health modules. We did not define global health in the questionnaire; instead, we allowed all respondents to determine which curricular elements and activities at their institution were related to global health. This approach had the important advantage of making it more likely that we identified all relevant global health activities and course offerings, though we recognized that it might affect our ability to compare responses across medical schools. To further enhance our ability to identify all possible global health offerings, we contacted the Canadian Federation of Medical Students’ International Health student liaison at each medical school and asked him or her to review and verify collected information for his or her medical school.
We standardized responses from each medical school by placing them in the following predefined categories: global health courses, global health lectures or modules, and lectures/modules that included global health topics. Courses and lectures were further divided into mandatory or elective. Global health courses/modules were defined as courses or modules identified and designed specifically to teach global or international health topics. Lectures and modules that included global health topics were defined as presentations that included global health issues, even though the primary focus was a disease or another topic. Presentations on malaria, poverty, community health, and health care disparities are examples of modules or lectures that might include global health topics.
In deciding whether to consider a course, lecture, or module as either a global health course/lecture/module or a course/lecture/module with global health topics, we assessed the overall intent of the class, presentation, or unit using course syllabi and survey information. For example, a lecture on malaria that discussed parasitic life cycles, pathogenesis, prevention, treatment, and global burden of disease would be defined as a lecture that included global health topics, but not a global health lecture.
Some medical schools use the terms global health and international health interchangeably. We combined information on global and international health activities from each school and refer to both as global health.
Other than allocating responses into the previously defined categories, we did not combine individual school responses using descriptive or other statistical methods. We did not feel that further aggregating the data would be useful in understanding differences across medical schools; moreover, we felt that the number of schools involved (17) and the qualitative nature of the responses did not require further statistical analysis.
Results and Conclusions
Current opportunities in Canada
Thirteen (76%) of 17 medical schools responded to the questionnaire within the time frame provided. Information for the remaining four medical schools was obtained by directly contacting faculty and/or medical student liaisons identified through the Association of Faculties of Medicine of Canada Resource Group on Global Health. Information obtained from designated institutional representatives was more complete and comprehensive than that from other sources.
As of now, there is no uniform approach to curriculum content or educational opportunities in global health across Canadian medical schools (Table 1). At the time of the survey, no undergraduate medicine program provided a mandatory, stand-alone credit course in global health. Dalhousie University Faculty of Medicine was the only medical school planning to start a mandatory, stand-alone global health course within the coming academic year. At four medical schools, neither mandatory nor elective global health courses or lectures were reported. Nine medical schools (53%) reported having either specific global health lectures or modules as part of mandatory courses. Among medical schools that provided additional information, the time devoted to global health lectures or modules in mandatory courses ranged from 2 to 22 hours across four years (Table 1). There was no consistency in the year of medical school that global health material was offered, the topics covered, or the amount of information provided.
Ten medical schools (59%) stated that global health topics were presented as components of mandatory modules such as community medicine, tropical medicine, or infectious diseases; schools responding that global health topics were integrated into lectures also tended to have specific sessions on global health (Table 1). As noted, the definition of what constituted global health topics was left to each respondent, and presentations on subjects such as AIDS, parasitic diseases, or malnutrition were considered by a number of respondents as teaching global health topics.
Seven medical schools (41%) offered global health elective courses. Elective opportunities to learn about global health ranged from, on one end of the spectrum, two-year programs at the University of Saskatchewan and Laval University Faculty of Medicine with courses that include both a didactic component at the medical school and time at an elective site in a developing country to, on the other end, as little as two to three hours of lectures on global-health-related issues nested into other elective units during the course of four years. Though the programs offered by the University of Saskatchewan and Laval University are quite comprehensive, they are available only to a select group of students; interest in these programs reportedly far exceeds available spaces. Some medical schools offer elective sessions on global health topics outside of regularly scheduled class times. The University of Alberta Faculty of Medicine and Dentistry offers Saturday sessions on global health issues, and the University of Ottawa Faculty of Medicine has a 13-week seminar and problem-based learning elective course that is offered during lunchtimes. At Queen’s Medical School, the global health elective is run by students.
All 17 medical schools allow their students the opportunity to participate in international electives (overseas activities recognized for academic credits), though Northern Ontario School of Medicine encourages students to take Canadian-based rather than internationally based electives. However, there is no uniformity in prerequisites required for going on an overseas elective, supervision of the experience, or financial support provided to participate in international electives (Table 2). At 7 of the 16 medical schools (44%) from which students went on international electives, the electives were arranged and supported by medical students without clear faculty support or supervision. Only Dalhousie University Faculty of Medicine, Queen’s Medical School, the University of Saskatchewan Faculty of Medicine, and the University of Toronto Faculty of Medicine (25%) could be clearly identified as requiring or providing predeparture training before students could participate in an overseas elective. The amount of preparation required ranged from a two-hour session given at the University of Toronto Faculty of Medicine to 20 hours of mandatory lectures and 23 hours of mandatory language lessons at Dalhousie University Faculty of Medicine. The University of Alberta Faculty of Medicine and Dentistry and McMaster University Faculty of Health Sciences did not require any specific predeparture training for their students; however, they did make students aware of training programs or manuals offered by other institutions.
Not surprisingly, given the strong interest in global health issues, students at many Canadian medical schools have established active global health groups which serve to facilitate student exposure to global health topics and to support summer internships and research electives in developing countries. Examples of such student groups include
* Queen’s Medical School’s Medical Outreach,
* University of British Columbia’s Medical Overseas and student electives,
* University of Toronto’s International Health Program,
* Dalhousie’s Global Health Initiative, and
* The Université de Montréal’s Comité d’Action Sociale et Internationale.
The number of students engaged in these programs varies across universities and was outside of the scope of this survey. Anecdotally, larger schools with greater access to funding were able to provide a greater range of opportunities for their students than were smaller medical schools.
During the past 20 years, U.S. and Canadian medical student participation in international electives has doubled to roughly one in five students.7 In addition, medical students support greater exposure to global health issues in undergraduate medical school curricula.7 As research has shown, the opportunity to participate in a global health experience during medical school is associated with a number of benefits, including greater cultural understanding, stronger motivation to pursue either primary care or future international health work, better understanding of socioeconomic influences on health and illness, greater appreciation for public health, and improved foreign language proficiency (Table 3).8,9 However, despite the increased demand for global health training, information to date suggests that medical schools’ responses to this need have been fragmented and insufficient.1,10 Much of the existing literature on global health in medical schools focuses on international electives. International electives are often the only exposure medical students may have to global health issues, yet among the students who participate in international electives, fewer than 30% have participated in programs to prepare them for their overseas experience.11 As of 2001, only 26% of medical schools in developed countries offer a separate global health component in their curricula.4
The results of our survey demonstrate that global health training in Canadian medical schools is haphazard and without uniform guidelines or objectives. Despite the lack of consensus among Canadian medical schools for global health training, medical students are seeking global health opportunities in increasing numbers.1 Often with little or no faculty oversight, medical students are filling the vacuum in medical curricula by developing their own programs and electives. This situation may lead to medical students who are practicing beyond their competence level, to the detriment of patients, themselves, and their medical schools and affiliated hospitals.12
This study has a number of limitations. It is possible that we did not identify all global-health-related activities at Canadian medical schools. We occasionally had to rely on designated medical student liaisons for information about global health curricula at their schools, and it is possible that these students were not aware of the complete range and scope of global health programs at their schools; thus, we may be underreporting the available programs at Canadian medical schools. However, one could question the effectiveness of any global health module that interested medical students do not recognize as being related to global health.
The term global health has been described as referring to “health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.”13 Though there may be a general consensus of what is or is not global health, this definition is open to a wide range of interpretations, thus complicating attempts to make comparisons across medical schools. Because the definition of global health was left to respondents, it is also possible that some courses or lectures self-identified as relating to global health might not be considered so by an independent observer.
Much of the literature to date has focused on U.S. medical schools and students,7,8,14 and there could be important differences in attitudes and interests between Canadian and U.S. medical students. However, given the number of active global health student groups we identified at Canadian medical schools, Canadian medical students are at least as likely to be interested in global health issues as their U.S. counterparts are. Furthermore, whereas 11.1% of the total U.S. population was foreign born in 2000, 18.4% of the total Canadian population was foreign born in 2001, the closest year for which data are available.15,16 Global health training for Canadian physicians is as relevant as, if not more relevant than, global health training for U.S. physicians.
In examining career choices of and personal changes in students after global health experiences, ascertaining causality can be difficult. Possibly, students who are already predisposed to community involvement and primary care elect to pursue international electives, rather than the international electives influencing students. However, given the widespread interest amongst medical students for more global health training and opportunities, it is reasonable to postulate that expanding global health components in medical school core curricula might have the benefit of inspiring more students to pursue primary care and community-based careers.
This possible benefit is especially relevant given that Canada has a growing immigrant population, and increased skills in cultural competence and primary care are needed. Furthermore, the obligation to better serve disadvantaged populations regardless of geographic location has been defined as a fundamental component of medical professionalism. Global health programs provide a way to address these needs and to develop required skills.
A substantial challenge facing the expansion of global health training within medical school curricula is the lack of consensus among schools about the necessary information and skills that need to be taught.6 The lack of agreement among Canadian medical schools has led to a patchwork of programs ranging widely from nothing to two-year electives with combined didactic and overseas components. Medical students and Canadian health care at large would benefit from a systematic approach to global health training supported by organizations such as the Association of Faculties of Medicine of Canada and accreditation bodies. Without this leadership, it is probable that global health training will continue to vary widely among schools. Such an inconsistent, haphazard approach means that many of Canada’s future physicians are likely to be ill-prepared to face the global changes altering health and health care around the world.
This project was conceived and supervised by Dr. Brewer as part of a report on global health training for the Global Health Resource Group of the Association of Faculties of Medicine of Canada. Anne Fanning was instrumental in the formation of the resource group that led to this project. The following McGill University medical students contributed to collecting the data and information necessary to complete the survey: Jonathan Ailon, Tadeu Fantaneanu, Louise-Helene Gagnon, Rajesh Girdhari, Euna Hwang, David Kaiser, Charles Leduc, Marie-Josee Lynch, David Mackenzie, Elizabeth Mindorff, Lee Mozessohn, Nadia Primiani, Ngoc Han Quang Le, Anais Rameau, Gabriel Rebick, Genevieve Smith, Patrick Weldon, and Mei-ling Wiedmeyer.
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