McKinley, Danette W.; Williams, Shirley R.; Norcini, John J.; Anderson, M Brownell
Predicted physician shortages in the United States have led to recommendations for medical school expansion,1 although studies have suggested that this may not increase the number of physicians choosing primary care specialties.2 Primary care physicians are likely needed to reduce health care disparities among the underserved.3,4 With increased global mobility and the accompanying threats of increased incidence of communicable diseases, physicians will be expected to be familiar with a wider range of illnesses. Research indicates that international health experiences have positive educational effects, including increasing the likelihood of the selection of a primary care career and improving interest in serving underserved populations.5–7 The offering of such experiences can be attractive to applicants and can provide a wider range of clinical experiences for students and residents. In their literature review of eight articles that evaluated international medical education opportunities during medical school or residency, Thompson et al.7 found that these opportunities were positively associated with choosing careers in primary care specialties. These experiences have also been shown to increase interest in serving the underserved in this country and abroad.8
Medical school students have shown an increasing interest in participation in such experiences,8–10 suggesting that international opportunities can be a powerful recruiting tool for both undergraduate and graduate medical school programs. In 2007, 43% of respondents to the Association of American Medical Colleges’ (AAMC’s) Medical School Graduation Questionnaire rated their instruction in global health issues in the medical school curriculum as “inadequate.”11 Discovering opportunities and available funding sources may not be easy for trainees. Providing a resource that describes the programs offered at individual schools may facilitate students’ and residents’ pursuit of international medical education opportunities.
In 1988, the Educational Commission for Foreign Medical Graduates (ECFMG) published survey results providing detailed information on overseas activities of schools of medicine, dentistry, pharmacy, and public health12 based on collaboration with the AAMC, the American Association of Dental Schools, the American Association of Colleges of Pharmacy, and the Association of Schools of Public Health. At that time, two instruments were developed: one for deans or other administrators regarding policies and information about the students participating in the programs, and the other for faculty who directed international activities.
Beginning in 2005, the AAMC, the Foundation for Advancement of International Medical Education and Research (FAIMER), and the Global Health Education Consortium (GHEC, formerly the International Health Medical Education Consortium) joined together to collect information about international activities at U.S. allopathic medical schools. The ECFMG surveys provided a basis for updating the information available on international opportunities for faculty, students, and residents. The intention of these efforts was to distribute more current information about international opportunities for students, residents, and faculty. Based on the survey responses, an electronic resource was made available on the FAIMER Web site in March 2007. This resource includes information about the extent and nature of international opportunities for medical students, residents, and faculty. It also provides information about which schools offer programs, their funding sources, and in which geographical regions these experiences are offered.
The purpose of the current study is to describe the experiences available to students and residents at U.S. allopathic medical schools on the basis of survey results. We examined whether there were differences in available opportunities between public and private schools.
The survey instruments used by the ECFMG in their 1988 study of medical schools served as the basis for the current investigation. In May 2005, staff from the AAMC, FAIMER, and GHEC met to review content and develop the survey. The survey was designed to collect information about the types of international opportunities in medical education provided to faculty, students, and residents at U.S. allopathic medical schools. Categories of opportunities included research, electives, and global health. Respondents were also asked to provide information on experiences offered separately to faculty, students, and residents from outside the United States. The survey was piloted with 41 medical schools deans and faculty directly involved with international programs between May and August of 2005. Invitations were sent to medical school deans and faculty at the remaining 79 schools in January of 2006. As of February 5, 2008, survey results were available for 111 respondents from medical schools in the United States. Descriptive statistics (number, percent) of respondents reporting the availability of various opportunities to students and residents from their own schools and abroad as well as funding sources are presented. The percentage of private school respondents indicating opportunities was compared with the percentage of public school respondents indicating availability at their institutions. Schools were classified on the basis of data from the AAMC Medical School Tuition and Fee Survey.13,14
Reponses were received from 111 respondents representing 99 U.S. allopathic medical schools. Of the 111 respondents, 55 (50%) were in the dean’s office at the medical school (i.e., assistant or associate dean, dean), 38 (34%) were international program administrators (directors or coordinators), and 14 (13%) were faculty members in charge of international programs. Two respondents did not specify their title, and one respondent was a student. A total of eight respondents were eliminated from the analyses because their responses could not be verified or were incomplete. The results presented are based on responses from the remaining 103 respondents from 96 medical schools. Of the 96 schools in the study, 37 are private (41 respondents) and 59 are public (62 respondents). The number (and percentage) of respondents indicating opportunities offered at their respective schools are provided in Table 1. The percentage of private school respondents indicating availability of international opportunities is contrasted with the percentage of public school respondents reporting such opportunities. Responses are summarized for U.S. medical students, medical students from abroad, U.S. residents, and residents from abroad.
Of the 103 respondents, 46 (45%) indicated that preclinical research opportunities are available. International opportunities over the summer and break periods were offered by 63 (61%) of the schools, 90 (87%) reported that international clinical electives were offered, and 59 schools (57%) reported offering clinical research opportunities. Only five schools (5%) reported that no international opportunities were available to medical students.
Respondents were asked to indicate which opportunities were offered at their schools to medical students from abroad (preclinical research, language/cultural immersion, break/summer activities, clinical activities, and clinical research). Twenty-three (22%) respondents reported that international students were involved in preclinical research, 59 (57%) responded that they arranged clinical activities for medical students from abroad, and 27 (26%) indicated that students from abroad participate in clinical research activities. Respondents were given the option to expand on their responses by providing free-text explanations. Some reported that it was difficult for students from abroad to have contact with patients because of insurance and institutional constraints. Despite these challenges, observership opportunities were reported by three schools.
International opportunities offered to residents included global health tracks (n = 11; 11%), elective international rotations (n = 61; 59%), and clinical opportunities (n = 46; 45%). Three respondents noted that residents could pursue international opportunities on their own with the approval of the school of medicine. About one quarter of those responding reported research opportunities for residents from abroad (n = 25; 24%), and 29 reported clinical opportunities for international residents (28%). Forty-two respondents (41%) reported that there were no formal opportunities offered to residents from abroad. Some respondents noted difficulties in obtaining funding for residents from abroad, and others cited challenges in meeting licensure requirements in clinical settings with patient contact.
Among respondents representing private schools, only 10 (24% of private school respondents) indicated that pretravel preparatory courses were offered to students in their institutions, whereas 22 (36%) respondents at public schools reported such courses. Of the 41 respondents from private schools, 28 (68%) reported that clinical research opportunities were offered to students, compared with 51% of those respondents from public schools. Four respondents (10%) from private schools indicated that there were no international opportunities offered to students at their schools, whereas only 1 of the 62 respondents (2%) from public schools indicated an absence of opportunities. Regarding data on students from abroad, 37% of the 41 respondents from private schools reported clinical research opportunities compared with 19% of the 62 representatives of public schools. Both respondents who indicated that international rotations for residents were required at their institutions were from public schools. Only 51% of the private schools representatives indicated that elective clinical rotations were available for residents from their schools, whereas 65% of those from public schools stated that international clinical rotations were offered. Half of the private school respondents reported no opportunities for residents from abroad (n = 21), whereas 34% of the public school respondents indicated that no opportunities were offered to residents from abroad.
The survey included questions on collaboration and funding available for international opportunities. Table 2 provides the number and percentage of responding schools and reports collaborative efforts as well as funding sources. Medical school respondents stated that the international opportunities they offered frequently involved collaboration with other medical schools (n = 51; 50%) and health professions schools within their respective universities (n = 44; 41%). Three of the respondents cited cooperative efforts with schools of public health or tropical medicine in development of international opportunities. Collaborations with nongovernment organizations were more frequently reported than those with government organizations (37% versus 21%). Respondents were questioned about external as well as internal sources of funding. By far, individual donors were the most common source of external funding (n = 48; 47%), followed by foundations (n = 37; 36%). In addition to these sources of external funding, respondents noted grants, alumni association funding, and endowments targeted for international study. Internal sources of funding were deans (n = 49; 48%) and individual departments (n = 40; 39%). Some respondents reported university resources (n = 4, 4%) as sources of internal funding. Some cited that research funds for the medical school had been allocated for international opportunities in the past, but these funds had decreased over the last few years.
International opportunities have been shown to “restore medical students’ idealism”3 and to improve the likelihood that they are subsequently involved in provision of care for underserved communities.6–9 As medical schools in the United States expand, and as global health is an increasing concern, it is not surprising that students’ interest in international opportunities is escalating. Funding of such opportunities may be challenging, but collaborations with schools of public health and international schools hold some promise.8 Respondents in this study reported endowments specifically targeted toward the provision of international opportunities. Most of the respondents reported on activities for medical students. International opportunities for residents are more difficult, given the restrictions (e.g., financial and legal constraints) associated with graduate medical education in the United States. Residents from their own institutions often pursued international opportunities as part of elective clinical rotations. Clinical research and observership opportunities for residents from abroad were reported by a number of respondents, with a higher percentage of private school representatives indicating the availability of international research opportunities for these residents.
It may be possible to provide valuable clinical experiences for U.S. medical students and residents through placement in international settings where their skills are needed. Partnerships with public health programs, international medical schools, community health centers, and religious organizations will be necessary to ensure adequate educational support for these programs. Funding sources for such efforts may be expanding as well (e.g., Johnson & Johnson’s partnership with Yale Medical School, the Bill & Melinda Gates Foundation, and the University of Washington). Several schools have developed structured guidelines to ensure consistency in the quality of the international program offerings,15–17 and investigators have noted improvement in the diversity of diagnoses observed,15 along with improved examination performance.7
Although the current investigation provides some information on international opportunities in medical education in U.S. allopathic medical schools, it is not without its limitations. Although most respondents were from the dean’s office, some were more familiar with opportunities provided for medical students, and others were more familiar with residents’ activities. Because students and residents could pursue these opportunities during school vacation periods, it may be useful to survey the participants directly to determine the nature and duration of their experiences. Details on the length and content of the opportunities have not been collected from faculty advisors, and the addition of such data to the resource would be invaluable. We categorized responses on the basis of whether the school was public or private, but additional information on school characteristics may have been valuable in identifying factors related to the availability and diversity of international opportunities offered. Though we reported only on U.S. allopathic schools, experiences offered by international schools are also of interest and provide an area for additional research. FAIMER is in the process of developing a survey tool to assess international opportunities available during medical school as well as those available as part of graduate medical education.
Although not discussed here, the survey included questions on opportunities for faculty at U.S. allopathic schools and those from abroad. This paper specifically focused on medical students and residents because of research findings suggesting that these experiences affect career specialty choices. Whereas the students choosing to pursue these opportunities may have been more likely to choose primary care or to serve underserved populations, such experiences may improve the distribution of physicians (i.e., choosing primary care specialty or working in underserved areas). Physicians provided with international opportunities are afforded exposure to a wider range of illnesses. These experiences may improve cultural competence through exposure to patients in other countries with different health care systems and views of medicine.
This collaboration has resulted in the development of an online resource summarizing the opportunities available at U.S. allopathic schools which is freely available at (www.faimer.org/resources/opportunities). Medical school faculty and/or program directors are invited to contribute to this resource, and information is updated as new responses are received. With additional data collected from international medical schools, we anticipate that this will become a more comprehensive source of information on the assorted opportunities available globally. Combining these data with those from other sources (residency training, board certification, licensure, etc.) would supplement research conducted to show the long-term effects of these opportunities.
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