Medical students are increasingly showing interest in short-term electives in low-resource international settings. In 2009, 43.2% of graduating U.S. medical students had participated in a global health elective during their undergraduate medical training.1 For the purpose of our research, we defined global health elective as an elective in a low-resource setting, and we defined low-resource setting as a location where the majority of the population is marginalized or otherwise has a lower standard of living than the average American or Canadian citizen. Such electives often provide students with an unsupervised introduction to global health, as mandatory curriculum is frequently absent.2 – 6 The educational benefits for medical students engaged in global health electives are numerous and well documented,2,7 – 9 and the risks are highly debated, well elaborated in the literature, and beyond the scope of this report. However, unprepared and inexperienced trainees can present unique ethical challenges and be safety risks to themselves and to the communities in which they study.3 – 6,8 – 12
Medical schools often support student-organized global health electives, and many do so by providing logistical support and funding or by awarding academic credit to students who participate.13 – 17 Yet, important questions regarding global health electives remain unanswered, including whether institutions are responsible for ensuring that these electives meet educational, ethical, health, and safety standards for trainees and the patients in the communities in which they study, and whether medical schools should play a role in training students to meet cultural and language competencies.
Predeparture training (PDT), only one of several key components to any global health elective,6,10 can be an important tool to begin addressing these issues. For the purpose of our research, we defined PDT as any preparation that students complete before taking part in a global health elective that has as its goal building trainee competence in the skills necessary to maximize learning while also minimizing harm to themselves and the communities in which they study. Whereas recent global health literature has called for effective and universal PDT,4,14,18 – 21 we currently lack comprehensive data on whether Canadian medical schools provide or require PDT for their students participating in global health electives. To understand the current landscape and the evolution of PDT in Canadian medical education, we surveyed faculty and student global health leaders at all Canadian medical schools in 2008 and 2010 to assess the delivery of and requirements for PDT.
Global health faculty leaders of the Global Health Resource Group at the Association of Faculties of Medicine of Canada (AFMC), and student leaders of the Global Health Program at the Canadian Federation of Medical Students (CFMS) developed the two surveys, administered in 2008 and 2010. They used an iterative process to do so, whereby a set of proposed survey questions was e-mailed to all members of the AFMC Global Health Resource Group and CFMS Global Health Program for input and feedback on two occasions.
The 2008 survey asked eight general questions about PDT offered at each medical school, including whether such training was mandatory (defined as necessary to receive institutional credit or funding), what topic areas were covered during training, the frequency and length of training sessions, and whether provisions were made for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) (Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A70). The survey also included questions about postreturn training, as medical schools often offer both PDT and postreturn sessions as a coupled mechanism to enforce what students learned during their time abroad. We added six questions to the 2010 survey to assess whether training curricula followed the national recommendations for PDT22 as outlined by the AFMC Global Health Resource Group and the CFMS Global Health Program (Table 1), the format of the training sessions, who funded the program, which faculty and staff ensured the continuance of PDT every year, who funded HIV PEP, and whether the medical school provided an emergency contact for students while they are abroad (Supplemental Digital Appendix 2, http://links.lww.com/ACADMED/A70). The health sciences research ethics board at the University of Western Ontario reviewed both surveys and informed researchers in writing that ethical approval was not required.
In 2008, the CFMS Global Health Program asked each student global health liaison, a CFMS preexisting role at each medical school in Canada, to complete the survey. The AFMC Global Health Resource Group asked a faculty global health representative at each medical school to complete the survey. If the original faculty recipient was not able to complete the survey, we asked the student global health liaison from his or her institution to identify another faculty member who best would be able to answer questions about PDT at that institution. The process was repeated in 2010. There was no process or control to ensure that the same faculty global health representative or student global health liaison responded to both surveys.
In February 2008 and May 2010, we distributed surveys by e-mail to the one student and one faculty member identified at each of the 17 Canadian medical schools, for a total of 34 initial recipients. To maximize the response rate, we e-mailed both surveys a second and third time to nonresponders using individualized e-mail messages; both follow-up e-mails were sent within three months of the initial survey request. We offered no incentive to complete the surveys. Neither survey was anonymous, allowing us to reconcile any conflicting responses between the faculty member and student from the same institution through correspondence with researchers, faculty, and students from that institution.
We aggregated survey data from the student and faculty representatives at each institution for comparison across medical schools. We used descriptive analysis to capture the sample characteristics. We compared responses to the 2008 and 2010 surveys only when questions were identical. All analyses were performed using SAS 9.1 statistical software (SAS Institute, Inc., Cary, North Carolina).
In 2008, one faculty member and one student (100% response rate) from each of the 17 medical schools completed our survey. Eleven of 17 (65%) schools offered PDT. Six of those 11 schools (55%) categorized PDT as mandatory before participating in a global health elective. PDT sessions ranged from a total of 30 minutes to 30 hours depending on the institution. Responsibility for planning and implementing PDT also varied from school to school. At 6 of the 11 (55%) schools offering PDT, medical students worked together with faculty to administer training sessions; at one school, students administered PDT independently of faculty. At the remaining 4 schools (36%), faculty delivered PDT. Table 2 reports the complete 2008 survey results.
In 2010, 16 of 17 (94%) student representatives and all 17 (100%) faculty representatives completed our survey. Sixteen of 17 (94%) schools offered PDT. Eleven of those 16 (69%) schools categorized PDT as mandatory before participating in a global health elective. Of the 16 schools offering PDT, 8 (50%) held sessions once an academic year, 4 (25%) held sessions twice a year, and 4 (25%) held sessions more than twice a year. Fourteen of the 16 (88%) schools offered less than 13 hours of PDT total, with most schools providing between 3 and 8 hours of instruction; 2 (13%) schools offered more than 24 hours of training. As in 2008, responsibility for planning and implementing PDT varied from school to school (see Table 2).
The method of instruction also varied from school to school in 2010. All 16 schools offering PDT held small-group sessions, 12 (75%) held didactic lectures, 9 (56%) distributed a student handbook, and 1 (6%) offered online tutorials. Ten of the 16 schools (63%) ran their PDT with a budget of less than $500 per year, whereas 4 (25%) schools had an operating budget greater than $1,500. Table 2 reports the complete 2010 survey results.
The number of Canadian medical schools offering PDT has grown substantially from 2008 to 2010. In 2008, 11 schools offered PDT; in 2010, 16 schools did so. Along with an increase in the number of schools offering PDT, we also found a near doubling in the number of schools that categorized such training as mandatory—from 6 schools in 2008 to 11 schools in 2010.
Students have been instrumental in initiating PDT at many institutions.14 In 2010, students planned, implemented, and ensured that PDT was offered annually at five Canadian medical schools, up from one school in 2008. We attribute this increase mainly to those schools that began offering PDT after our first survey in 2008; three of the five new PDT programs in 2010 were completely student run. This student initiative was in part secondary to the CFMS effort to provide PDT to all Canadian medical students by 2009.19 Although we are encouraged that students pursuing global health electives are willing to take responsibility for their training by creating PDT programs where such programs do not exist, it is critical that faculty provide the foundation and oversight to ensure that these courses are both compatible with their medical schools' educational objectives and are sustainable from year to year.
Our 2010 survey results revealed that, although there is no uniform approach to designing and implementing PDT across Canadian medical schools, 75% of those schools that offered PDT relied on the CFMS-AFMC Global Health Resource Group's national recommendations for PDT.22 Still, schools tended not to cover all five suggested subject areas: ethics, personal health, and cultural competence were the only recommended topics to be universally implemented. The length of time and the method of instruction also differed dramatically among schools. We are unaware of any research or consensus on what content to teach, how long the training sessions should be, or what format is best suited to provide that content. Moreover, many global health electives and PDT lack well-defined competencies.20 Better-articulated competencies for both PDT and global health electives could help to determine the appropriate amount of time and method of instruction needed to meet educational goals and to provide students with the knowledge, skills, and behaviors that they need to complete their global health electives.
Beyond standardizing PDT, medical schools need to invest time in defining the educational objectives and understanding the utility of global health electives. Although useful and interesting for medical students, difficult questions remain unanswered. For instance, how do the students who participate in these electives contribute to the communities that they visit? Is there a local cost, and, if so, who pays for it?5,6,13 PDT can encourage medical students to ask these questions, promoting individual reflection regarding the appropriateness of each global health elective. However, we are unsure whether a short PDT course can engender the thoughtful critique that we believe medical students should conduct before studying in a vulnerable, low-resource community. Ultimately, along with offering comprehensive PDT and developing appropriate competencies to guide such training, the medical school itself, when global health electives are credited or funded, must understand the impact of its students on the communities in which they study.
Our study has a number of limitations. First, PDT is evolving rapidly in Canada, and it is difficult to accurately capture programs that are in a state of evolution. Second, by surveying only one designated faculty and student representative from each medical school, we may have misrepresented some programs. Obtaining an accurate sense of who ultimately was in charge of each PDT program was also challenging. In 2010, we asked, “Who ensures PDT happens each year at your medical school?” At five schools, that responsibility fell to students. At 10 schools, faculty were involved in the maintenance of PDT, yet they took sole responsibility at only four schools. Further research, then, is needed to determine the extent to which faculty and students take responsibility for PDT. Finally, although student-run PDT is common in Canada, our findings may not necessarily hold true for other medical schools in the United States or Europe.
As opportunities to participate in global health electives become more available, medical schools should ensure that their students are appropriately prepared to maximize their experience and to minimize the risk to themselves and to the communities in which they study. Universal PDT is one step toward increased accountability for global health programs. The availability of PDT training at Canadian medical schools has increased between 2008 and 2010, predominantly through efforts led by students. Though clearly an improvement, additional faculty support is needed to ensure that PDT has well-defined educational objectives, is integrated into the overall medical training program, and is sustainable from year to year. Further investigation into the quality, consistency, and efficacy of PDT will be important as programs evolve. To improve students' experiences with global health electives, more work is needed to define appropriate educational competencies and to ensure that such electives continue to benefit participating communities.
The authors wish to thank Dr. Danyaal Raza and Dr. Natalie Bocking for their involvement and kind review of this article. They would also like to thank the members of the CFMS Global Health Program and the AFMC Global Health Resource Group for their support and continued dedication to predeparture training.
Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A70.
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The health sciences research ethics board at the University of Western Ontario reviewed the surveys and informed researchers in writing that ethical approval was not required.