Service–learning is defined as a “structured learning experience that combines community service with explicit learning objectives, preparation, and reflection.”1 In medical education, service–learning can empower students to think critically about disparities and social justice in a medical context.1 International service–learning is becoming an integral part of many students’ educational experiences. In 2010, nearly 31% of graduating U.S. and Canadian medical students participated in a global health experience,2 compared with only 6% of 1984 graduates.3 In a 2008 study, McKinley and colleagues4 found that 61.2% of responding medical schools offered preclinical international service–learning trips (ISLTs) and/or summer international experiences to their students.
Several studies assessing the impact of international service–learning have demonstrated a number of benefits for medical students and trainees, including positive changes in perspectives and attitudes.5–8 A majority of studies have focused on experiences lasting four to eight weeks. However, many preclinical students engage in considerably shorter, highly variable, one-week ISLTs. With few exceptions,9 studies assessing the impact of these one-week experiences on preclinical students are largely anecdotal.10
Very little is known regarding the specific activities or thought processes that lead to changes in perspectives and attitudes in international service–learning participants, particularly in the context of one-week ISLTs. The purpose of this qualitative study was to understand what meaning preclinical students attribute to their participation in one-week ISLTs and what specific experiences during the trips accounted for such perspectives.
ISLTs at the University of Michigan Medical School
Students at our institution took part in one-week ISLTs from the late 1990s until 2010, when the one-week ISLTs were discontinued. Historically, these experiences were the product of student-driven initiatives; therefore, faculty involvement in the trips was variable. During years in which the ISLTs were conducted, students took the lead in all major planning and preparation for ISLTs, including partnering with local organizations and physicians in the countries of interest, developing trip itineraries and proposed activities, procuring medical supplies and medicines, and making travel arrangements. Some faculty mentors were actively engaged during trip planning and execution, whereas others were only involved peripherally as advisors and supervisors during the trips.
By 2010, some ISLTs had been in existence for nine years or more. In these cases, previous student groups had maintained ongoing contact with partner organizations and community leaders and had repeatedly served in these communities. ISLTs were generally targeted toward first-year students selected and directed by a group of more senior students who had previously participated in the respective ISLTs. Thus, the more senior students provided the institutional memory for ISLTs. Trips traditionally occurred during students’ one-week spring break in February.
Financial support and oversight regarding travel restrictions and safety were provided by Global REACH (Research, Education, and Collaboration in Health), an office of the medical school whose mission is to facilitate health research, education, and collaboration among University of Michigan Medical School faculty, students, and its global partners for the benefit of communities worldwide. In addition to facilitating ISLTs, Global REACH coordinates other international experiences at the University of Michigan Medical School, including more formal mentored international research opportunities and fourth-year international electives.
Method
Setting
Our study focused on first-year students who participated in ISLTs in February 2010. Students underwent a competitive application process in October 2009 and were evaluated on the basis of application essays and, in some cases, interviews and language competency by second-year students who had previously participated in ISLTs.
Fifty-two University of Michigan Medical School students participated in one-week ISLTs to Cuba, the Dominican Republic, Guatemala, Jamaica, or Peru. Of the 52 students, 44 were first-year students, 7 were second-year students, and 1 was a fourth-year student. As previously mentioned, faculty involvement varied substantially from trip to trip, as did the trip models. The different trips are outlined in Table 1.
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Table 1: University of Michigan (UM) Medical School International Service–Learning Trips (ISLTs) Attended by 52 UM Medical Students, February 2010
Select second-year medical students who had previously participated in ISLTs formed a student group known as the Student Alliance for Global REACH, which collaborated with Global REACH to host several mandatory preparatory lectures and discussions for students who had been selected to participate in February 2010 ISLTs. Students were required to attend five preparatory sessions between October and February. Students also met with their individual ISLT team every one to three weeks during this time frame for trip-specific planning. The goal of these activities was to introduce students to general challenges and ethical issues in global health and international work, particularly with regard to participation in ISLTs.
Participants
To study students’ perceptions of their ISLT experiences, we focused on a subset of first-year students who participated in the University of Michigan Medical School’s one-week ISLTs during February 2010. We used a random number generator (GraphPad Software, Inc., LaJolla, California) to select an interview sample from the 44 first-year students who participated in ISLTs during the study period. Only first-year students were chosen to avoid potential biases introduced by upperclassmen who had repeat ISLT experiences. As a sample, we identified 24 students sequentially and invited them to participate via e-mail between March and July 2010. Students had one week to respond; nonresponders received a maximum of two follow-up e-mails. Seventeen students agreed to participate at this stage. All participants received an overview of the study with the assurance that any contributions would be kept confidential. This study was reviewed and performed under an exemption granted by the University of Michigan Health Sciences institutional review board.
Data collection
We used a qualitative approach because of its ability to identify and explore in depth the meaning that individuals confer on their subjective experience.11 In March through August 2010, one investigator (N.C.A.) conducted individual, face-to-face, semistructured interviews lasting 40 to 80 minutes with participating students. Each interview included two key questions: “How did participation in this trip affect you personally?” and “What experiences resulted in that outcome for you?” A summary of additional interview questions is provided in List 1. The interview structure was deliberately open and flexible to allow the investigator to probe into the students’ experiences and backgrounds. Before the interview, participants completed a 15-item online questionnaire identifying their demographic and educational background and prior experiences abroad (Appendix 1).
List 1 Summary of Questions Posed to 13 University of Michigan Medical School Students During Interviews About Their First-Year International Service–Learning Trip Experiences, 2010
Appendix 1: Background Questionnaire for University of Michigan Medical School Students Participating in Interviews About Their First-Year International Service–Learning Trip Experiences, 2010
Interviews were recorded and transcribed verbatim. The interviewer reviewed all transcripts and removed all identifying information before distributing transcripts to other investigators. Each participant was provided a copy of his or her transcript and was invited to provide additional comments or clarifications. In one case, a student also submitted a blog about her experiences, which was included in the analysis in addition to her interview. Because this entry could clearly identify her to the investigators, the participant granted permission specifically to include the blog without changes as part of the analysis.
Data analysis
We used grounded theory to analyze the data in two phases.11 The first phase included seven participant interviews conducted between March and June 2010. In this initial phase, the interviews were analyzed for quality control of interviewing techniques. Two investigators (N.C.A. and A.K.K.) independently coded the transcripts to identify emerging open codes (i.e., major themes). The two investigators then compared open codes and reached a consensus about major themes. Analysis of data from the first phase of the study did not result in major changes in the core interview questions; however, it led to the interviewer’s emphasis on lines of questioning that added to a growing understanding of some of the themes identified during the first phase (e.g., ethical conflicts, power differentials).
The second phase involved additional interviews conducted from July to August 2010. Interviews were conducted until new interviews did not add significantly new information beyond what had been collected, indicating that we had reached thematic saturation.11 The same two investigators (N.C.A. and A.K.K.) identified open codes and axial codes (subthemes clarifying and linking major themes) through multiple and iterative individual readings of all of the transcripts. Consensus was reached through discussion. These codes were shared with the other investigators to identify any areas requiring clarification. Finally, we performed selective coding of all of the interview data to develop and articulate an overarching theory of the effect of ISLTs on the student participants.
Results
Of the 44 first-year students attending ISLTs in February 2010, we identified 24 students with the random number generator, and 17 agreed to participate (71%). We reached thematic saturation after 13 interviews. The final study participants represented all five trips: Cuba (n = 4), the Dominican Republic (n = 3), Guatemala (n = 3), Jamaica (n = 2), and Peru (n = 1). No students chose to give additional feedback or commentary after being provided their respective interview transcripts.
The 13 students we interviewed provided information about previous international experiences on the background survey. Eight (62%) were either immigrants (n = 3; 23%) or were born to immigrant parents (n = 5; 38%). Twelve students (92%) had prior international experience, including 6 (46%) who had lived abroad for more than one year consecutively, 3 of whom were immigrants. Five students had spent six months or less abroad for reasons other than leisure (38%). One student had previously only traveled for leisure, and one had no prior international experience. Of the 12 students with prior international experience, 7 (58%) had previously been to developing countries for service-related projects.
Comparable information about previous international experiences was available for 3 of the 4 students who completed the online survey but were not interviewed. Such data were not available for the remaining 27 of the 44 first-year students who participated in the ISLTs. Of the 3 students who completed the survey but were not interviewed, 2 came from families of immigrants, and 2 had prior work experience in developing countries. In comparison, for the entire Class of 2013 (i.e., the graduating class of the students in the study), 21% (35/170) of students were born outside of the United States; 51% (87/170) had prior experience studying or working abroad, and, of those, 64% (56/87) had experience working in developing countries. No data were available for the class as a whole regarding the immigrant status of students’ parents or the length of time that they spent abroad.
When students were asked about the reasons for which they decided to participate in ISLTs, they articulated very concrete motives with practical applications. For example, “I had a couple different goals … to learn Spanish … [and to] understand a little bit more about how their health care system worked outside of whatever aid that Americans were giving them.” Another student “wanted to get the clinical experience and practice taking histories because that’s something that they expect you to do by the end of your first year.”
Only one student mentioned a motive for attending an ISLT that was grounded in a hope that the experience would help refine his interest in global health: “I wanted to do something that would benefit me in terms of my long-term, global health goals, which are pretty vague.”
Our analysis of the responses revealed seven major codes, which we grouped into three broad categories: (1) explicit benefits, (2) implicit insights and lessons, and (3) future directions. The themes and categories are summarized in Table 2.
Table 2: Open and Axial Codes and Selected Statements From Interviews With 13 University of Michigan Medical School Students About Their First-Year International Service–Learning Trip Experiences, 2010
Explicit benefits
When asked explicitly if they had met their stated goals and what they had learned, 11 students (85%) perceived some improvement in clinical or language skills and/or knowledge of the health care system of the countries visited (Table 2). Additionally, 10 students cited exposure to different perspectives as a positive personal benefit. For example:
A lot of your job is communication and a lot of your job is empathy. It’s hard to see sometimes that a patient may have … just a completely different perspective than you do, and you have to be able to address that, and I think a really good way of realizing that … is [to] show [students] something that’s even more different.… [I]f you’re suddenly thrown into a place where the language is different, where the education system is different, where there are different beliefs about illnesses …, you can’t help but realize that people see things so differently.
Finally, seven students also perceived that they had a positive effect on the communities they served, by providing clinical care for patients, for example, or showing respect and attention to the underserved.
Implicit insights and lessons
In addition to the benefits students cited when explicitly prompted to share what they had learned (Table 2), several insights and lessons emerged through further discussion and questioning during the interview. We would describe these insights and lessons as implicit because students did not readily express them but, rather, arrived at them after reflection and discussion. Often, they emerged when the interviewer prompted students to reflect on specific experiences that that they had not expected.
Five students were surprised to find during the planning process or during the ISLTs themselves that their classmates did not always share the same idealistic priorities or standards. For example, one student stated that his concern for the health of people in the Third World or developing countries did not appear to be an educational priority for most of his classmates on the trips. He stated,
I don’t know what their motivations were for coming on the service–learning trip, but it was pretty clear that my motivations or the educational goals that I had weren’t necessarily theirs.
All students were also struck by the privilege, power differential, and dynamics between the American groups and local health care providers. Three of these students also tied the relative lack of supervision with the power differential between American and local health care providers. One student commented on this sense of privilege:
[T]here’s a power differential…. [Local] health promoters, I think, pick their battles … [and] are not going to question the doctors too much. If the doctors say, “These medical students are good to take histories,” they’re not going to try to question that because of the status difference and because the health promoters are native … people who maybe don’t feel the prestige of having a Western education and an MD.
Students cited a number of ethical concerns connected with short-term trips. In particular, five students stated that they were surprised by the “laxity of supervision” during the ISLTs and felt it was at odds with what they viewed as best practices in medicine. Seven students mentioned their concerns about whether it was appropriate for medical students to be performing clinical tasks that exceeded their level of training.
I think that it’s a slippery slope for you [a medical student] to subqualify yourself to go down … as an American “doctor,” sort of this omniscient being. That, I think, is dangerous, and from a public health standpoint if you go anywhere for a week or two and you do something, what are you really accomplishing?
Six students also noted that short-term trips could have possible detrimental effects on patients and communities.
[If you know] “I’m going home in a week” … you’re not going to be a part of that community, and that’s a barrier to actually connecting to that community and being invested in that community…. [Y]ou might not really have their interests … in mind…. [W]hen you’re really looking out for your own interests and there’s a huge power and economic differential … there’s a potential for exploitation, and … if you’re not really able to know the local interests, there’s a potential for doing harm.
Future directions
All students reported that participating in an ISLT influenced their perspectives about the future, including further international experiences and their perceived roles as health care providers, and all expressed that they had an increased awareness of the complexities of working in global health. As such, students felt they had a more realistic view of the influence they could hope to have on patient populations in the future, but they also felt better equipped to take a more critical approach to subsequent global health efforts. Reflecting on their experiences, three students reported that the trips had fostered their awareness of the necessity for community partnerships as well as longer-term involvement in the communities. One felt that the experience had affected her perspective on her future in medicine as well:
[It] add[s] another aspect to how I think about things and maybe how to approach some of those … questions that are really fundamental to health care, [such as], “What does everyone deserve?” and “How should we allocate things?”… [It] maybe has affected my approach to how I would like to be a physician and how I approach health care.
Finally, although no formal questions were asked regarding reflection, 7 of the 13 interview participants stated that they did not have a formal opportunity to reflect on the experience individually or as a group. Of these, 5 students commented that the interview was the first instance in which they had engaged in active reflection after the completion of the ISLT, and 1 student added that the interview helped elucidate certain ideas that she previously did not know she had about the trip.
Discussion
Although global efforts in medical education are attracting increasing interest from students and medical schools,4 few studies have attempted to assess the subjective experiences and insights of students participating in short-term ISLTs.8,12 Students from our institution participated in a variety of ISLTs that ranged from completely clinical to completely nonclinical experiences, yet several common themes emerged from interviews with participants (Table 2). After participating in one-week ISLTs, students reported significant educational benefits and insights, including enhanced language or clinical skills as well as heightened understanding of the complexities within global health and the implications of power and privilege in resource-poor settings. Although these types of results have been documented in literature concerning four- to eight-week international experiences,5–8 few reports9 have documented these outcomes regarding one-week experiences.
Although one-week ISLTs can have benefits for students,9,10 the potential consequences of such trips for resource-poor communities should be critically considered. These experiences may prioritize the education of visiting students over the needs of the community and may become nothing more than “medical tourism,” which has been regarded as ethically dubious and exploitative to vulnerable populations.8,13–16 Our study revealed that students also questioned the value and effects of the service they provided and realized the necessity of engaging in a partnership with the community to ensure that all parties’ interests are represented and met. This sentiment was consistent regardless of the ISLT (clinical or nonclinical) in which students were involved.
Interestingly, when asked to reflect on the motivations they originally had for participating in an ISLT, almost no student articulated motives related to issues of social justice or disparities. Expectations seemed centered instead on the acquisition of clinical skills and language competency, benefits that arguably would have had tangible implications on students’ training and careers. Mezirow17 asserts that adult learners often focus on immediate, practical, short-term objectives that are tied to subject-matter mastery. These practical goals often yield skill-based learning outcomes that may occur without reflection because they are expected. In this sense, the goals related to clinical and language skills were at the foreground of students’ consciousness, and fulfilling them constituted explicit educational benefits of the ISLTs. In contrast, the implicit insights and lessons revealed by this study began as experiences that were at the periphery of students’ consciousness. They emerged through facilitated discourse that triggered acts of self-reflection, and thus, unlike the explicit benefits they acquired, these insights were often unexpected.
The fact that implicit lessons emerged through in-depth discussions with students highlights three important aspects of this study and its methodological approach. First, the implicit lessons that the students learned but did not readily articulate emphasize the contribution that deep-seated knowledge may make to this type of experiential learning. In contrast to explicit knowledge that the students may readily articulate, the type of implicit lessons that they gain, although not necessarily available for immediate recall, may profoundly influence students’ understanding about themselves and the world around them. Gaining self-awareness and developing one’s worldview may be the most powerful aspects of service–learning activities.
Second, the implicit lessons documented in the current study underscore the importance of creating an educational “space” for reflection as part of the ISLTs. In the present study, students recognized the important role that reflection and discourse played in advancing their learning. Five students noted that the study’s interview was their first formal opportunity to reflect on their experience. Some were even surprised by the learning that emerged during interviews. Indeed, the process of the semistructured interview was an act of reflection that may have independently brought about some of the learning outcomes that were documented. Reflection is central to service–learning.1 Its role in international service–learning experiences has been suggested anecdotally12,18 and is further demonstrated here. A prospective study by Rowan-Kenyon and Niehaus9 on the influence of one-week study-abroad trips on students suggests that a key element in the learning process resulting from such trips is postexperience discussion. We concur with this conclusion and suggest that for such experiences to be truly meaningful, they must be brought to the foreground through reflection. At the University of Michigan Medical School, students develop reflective practices in doctoring and medicine during the first two years of medical school principally through the small-group activities of the Family Centered Experience and Longitudinal Case Studies courses. These courses incorporate patient narratives, readings, multimedia presentations, and creative art to enhance explorations of, and critical reflection on, the experience of illness, doctoring, personal perspectives, biases, and values, and issues of equity and social justice in the context of medical care.19,20 Such interactive small groups, facilitated by clinician–educators trained in enhancing reflection and discussion,21 may inform the design of similar groups associated with ISLTs.
Third, given that many of the lessons learned were implicit, we believe that the qualitative, in-depth approach taken by this study is the most effective means to explore student learning, experiences, and insights in this type of educational activity. As opposed to the a priori hypotheses and structured questions and responses used in quantitative survey techniques, qualitative approaches allow students to fully express the meanings they construct of significant learning experiences.11
There are some limitations to the study. First, the specific characteristics of the ISLTs at the authors’ institution may differ greatly from those of other medical schools, and, therefore, the effect of these programs on student perceptions may vary according to local contexts and requirements. Second, the number of study participants was small, so it is possible that despite the attention paid to saturation of the themes, additional insights were missed. Third, the data suggest that the students who participated in the study may not be representative of their class or of medical students as a whole (particularly regarding country of origin). Although the results of this—as well as any—qualitative study are, by definition, not generalizable,11 this type of qualitative approach may allow educators to understand the depth and possibilities of the type of learning that occurs during ISLTs.22,23
We would argue that, at its best, this type of learning has the potential to be transformative for student participants. Mezirow24 describes the ability of new experience to disrupt those “habits of expectation that constitute our frame of reference,” or the assumptions that govern the way we interpret our experiences. Transformative learning therefore involves a major shift in one’s frame of reference toward one that is more open, flexible, and capable of change.25 In the setting of work in communities—domestic or international—with unmet health care and societal needs, transformative learning may involve the students’ developing an empathetic connection with those who may be very different from themselves. This “constructive engagement with otherness,”26 when combined with a sense of surprise or moral outrage, may foster an orientation and commitment to working for social justice.27 By differentiating those aspects that are explicit, nonreflective learning processes from those that are implicit, reflection-based learning processes, we can better develop methods for supporting students in achieving specific learning objectives, and we can more effectively address and overcome some of the ethical dilemmas concerning medical missions and exploitation of vulnerable populations.16 Because clinical skills and knowledge of health care systems are nonreflective outcomes that can be developed in nearly any environment, it can be argued that medical educators should reframe ISLT learning objectives with the understanding that students must pursue additional relevant objectives, such as an enhanced understanding of issues of power and privilege, health care disparities and inequities, and ethical dilemmas involved with working with impoverished or disadvantaged communities. In contrast, because implicit insights and lessons are tied to the experience of engaging with a population that is wholly different from what students are accustomed to, programs must ensure that students are adequately prepared to constructively engage with “the Other” by providing adequate preparation and space for reflection before, during, and after ISLTs.
The critical perspective regarding the ethics of international medical education fostered by ISLT participation can thus be put to constructive use. Students now conscious of these ethical dilemmas may be more critical of how they direct their energies in international work in the future. This could be a step toward students’ developing a “critical consciousness,” in which they are able to shift their gaze from themselves to the conditions and people around them, hopefully then to take action in favor of social justice.20,28 This realization may be just as important in students’ professional development, if not more so, than the attainment of clinical and language skills and may help to orient these types of international efforts toward responsibly addressing disparities in global health.
Acknowledgments: The authors would like to thank the student participants in the study as well as Christina Mireles for skillful preparation of the transcripts and Robert Ruiz for helpful feedback.
Funding/Support: None.
Other disclosures: None.
Ethical approval: This study was reviewed and ruled exempt by the University of Michigan Health Sciences institutional review board.
Previous presentations: The results of this study were presented at the 2011 International Conference on Communication in Healthcare, Chicago, Illinois, October 2011, as well as at the 2011 Global Health Conference, Montreal, Canada, November 2011.
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