Editor’s Note: This is a commentary on Rassiwala J, Vaduganathan M, Kupershtok M, Castillo FM, Evert J. Global health educational engagement—a tale of two models. Acad Med. 2013;88:1651–1657.
In the current issue of Academic Medicine, Rassiwala and colleagues1 correctly point out that the interest in global health activities by students in all of higher education—including, specifically, medical students—has increased dramatically in the last few years. Almost every day faculty who are in a position to facilitate these experiences, deans, and offices of international programs are asked by students to arrange an overseas experience of one kind or another. The hope of all of us is that these experiences will open the minds of our students to the challenges of global health in a larger context and inspire them to serve in communities that are medically underserved—whether in the developing world or in the United States. It is a constant challenge, however, to balance the educational and personal needs of these students with the resources of the medical school, and most importantly, the best interests of the population and medical practitioners in the countries to which they travel.
In their article, Rassiwala and colleagues describe two different Northwestern University Feinberg School of Medicine programs that provide these experiences to medical students. The first model involves students travelling to Nicaragua for a one-week, intensive experience accompanied by two physicians from Northwestern. This model provides the students with a high volume clinical experience and a large amount of patient care under the direct supervision of their U.S. faculty. The alternative experience is a four-week-long program in Mexico through which students work with a local health care practitioner and live with host families. This experience is coordinated by Child Family Health International, an outside, nonprofit organization that has existing relationships with that Mexican community and substantial expertise in arranging these visits. Child Family Health International charges medical students from the United States a fee for its role in coordinating these global health experiences.
The advantage to the first model is that, while very brief, it provides an intense clinical experience through which students can practice their clinical skills under the supervision of physicians who understand their level of training and can supervise them appropriately. Further, being accompanied by U.S. physicians is a comfort for the students. The high level of expertise of the U.S. physicians who make these trips usually draws many, many patients who want to be seen and treated, resulting in a high-volume, often high-acuity experience for the students. One disadvantage to the first model is that because it is so brief and because the students are completely under the supervision of the U.S. faculty, they are insulated. The brevity and the supervision of U.S. physicians keep them from experiencing all aspects of local (in this case, Nicaraguan) culture, and certainly from fully understanding the health care difficulties in that nation. In addition, as Rassiwala and colleagues correctly point out, this model has the potential disadvantage of setting patient expectations that cannot be met on a regular basis once the Americans leave—and more concerning is the possibility that some patients may start therapies that cannot be sustained once the brief visit concludes.
One of the advantages to the second model is that the students get more of an immersion into the culture of the country that they visit and a better understanding of the workings of the health care system by working side-by-side with a local health care practitioner. While the volume of patient care may be lower and the opportunities to practice clinical skills may be fewer, students do have a wonderful opportunity to be a part of the many successes and frustrations that come from work in the developing world. The disadvantages of the second model are that while the students work side-by-side with a local practitioner, there is no guarantee of the quality of the care provided, and, as mentioned, most times the number of patient interactions is much smaller. Additionally medical students, especially those in the early years of medical school, may be ill equipped to deal with the clinical and health system issues that may arise.
Much has been written about the ethics of U.S. physicians and students providing care to patients in the developing world.2 The success of these programs—much like the success of the Northwestern programs—depends on a full appreciation of not only the ethical dilemmas of health care in these countries but also the dilemmas of the faculty and students who participate. One strategy for understanding and addressing these dilemmas is to create larger global health curricula within the medical school. These programs—usually directed at students in a global health “track”3—have grown exponentially in the last few years and have the advantage of providing a longitudinal curriculum for students that prepares them for the experience, exposes them to the ethical issues that they will encounter, and helps them understand health services strengthening in a larger context before they travel. Some of the best of these programs or tracks also provide intense preparation in tropical medicine, cultural humility, and resiliency strategies.
Sustainability and a Larger Commitment
A larger criticism of medical school programs, such as the two described by Rassiwala and colleagues, and of other similar programs provided by so many U.S. medical schools, is the concern for sustainability. When U.S. physicians and students, albeit well-meaning, bring the resources and expertise of their home institutions without some plan for sustaining change in the local environment they visit, their interventions can certainly lead to distrust and potentially to resentment of the U.S. presence. The two models Rassiwala and colleagues describe, and the model most medical schools adopt, is usually to run international medical visits from a global health office or an international programs office within the institution and to allow interested students and connected faculty to participate. While this is a good start, certainly a more sustainable model would involve U.S. medical schools participating in long-term projects within these countries in conjunction with the health delivery systems that are already in place. The schools that work within this more collaborative model have found opportunities for their students to participate over a longer period of time in projects that are fully integrated into the needs of the country. This model also addresses concerns about the students who visit bringing value (rather than simply gaining clinical and international experience) to the international site. With a more sustained presence, led by dedicated and talented faculty, U.S. medical schools have the opportunity to provide expertise that is of great value in exchange for the educational opportunities afforded to the students they send.
In the end, any attempt to expand the horizons of U.S. medical students so that they gain a desire to care for medically underserved populations and communities, including those abroad, should be applauded. Different models may work in different situations, in different countries, and at different times depending of the needs and availability of students and faculty. However, what is now needed is a larger commitment by U.S. medical schools to become more involved, not from the standpoint of increasing their research funding but from the standpoint of increasing their service to the world. As Rassiwala and colleagues’ article so clearly points out, there is a great interest among students and faculty to do this. It is important that we have the same sort of commitment by the leadership of our schools to fully realize this potential.
1. Rassiwala J, Vaduganathan M, Kupershtok M, Castillo FM, Evert J. Global health educational engagement—a tale of two models. Acad Med. 2013;88:1651–1657
2. Crump JA, Sugarman JWorking Group on Ethics Guidelines for Global Health Training (WEIGHT). . Ethics and best practice guidelines for training experiences in global health. Am J Trop Med Hyg. 2010;83:1178–1182
3. Lahey T. Perspective: a proposed medical school curriculum to help students recognize and resolve ethical issues of global health outreach work. Acad Med. 2012;87:210–215