International health experiences have become an important component of medical school curricula for many students across the world. However, most international electives involve students from the “North” (including the resource-rich nations within Europe and North America) traveling to resource-poor areas (the global “South”) in Africa, Asia, and Latin America.1,2
Opportunities for international students to participate in U.S.-based electives are limited,3 and although the proportion and type of opportunities that are allocated to international students from the South are unknown, a disparity clearly exists.1 This disparity has raised ethical concerns prompting a call for academic health centers in more affluent countries to initiate collaborative partnerships with medical schools in less affluent international settings.2 There is a paucity of literature regarding the design and structure of international rotations for students from the South. Furthermore, little is known about the impact of such experiences on these students, as most studies have focused on the perspectives of students from economically advantaged nations traveling to underresourced international settings.
In response to these problems, the University of Michigan Medical School (UMMS) has, since 2007, sponsored a bilateral exchange program between UMMS students and medical students from universities in Ghana. This program was established for several reasons. First was a desire to respond collaboratively to a request from colleagues in Ghana who desired placements in U.S. institutions but were having difficulty finding schools that would host their students. Second, there was a desire to increase the access of UMMS students and residents to learning opportunities in Ghana and to do so in a balanced approach that would bring value to the learners in Ghana. The structure by which students from Ghanaian medical schools are hosted at UMMS is described here, as are results from an attitudinal survey assessing the value and impact that Ghanaian students attribute to participation in a U.S.-based elective.
The Ghana–Michigan medical student exchange
In 1989, UMMS’s Department of Obstetrics and Gynecology partnered with the University of Ghana Medical School (UGMS) in Accra, Ghana, and the Kwame Nkrumah University of Science and Technology School of Medical Sciences (KNUSTSMS) in Kumasi, Ghana. Bilateral exchanges between residents from UMMS and these two institutions were developed to strengthen the obstetrics–gynecology training program in Ghana.4
In 2007, the program began accepting senior medical students. Ghanaian students typically spend three to four weeks in Ann Arbor, Michigan, participating in direct patient care and observing clinical activities through rotations that are similar to those experienced by UMMS third- and fourth-year students. Students also receive an orientation to the clinical environment with topics such as use of the electronic medical record and medical databases, proper sterile technique, searching the medical literature, and learning in the UMMS Simulation Center. A list of core competencies and learning objectives are provided to students at the beginning of their rotation.5
Students are assigned to specific clinical rotations depending on availability and the interests of the student. Students predominantly rotate in obstetrics–gynecology or emergency medicine. Typically, six Ghanaian students rotate at UMMS during the three- to four-week period. In accordance with a bilateral memoranda of understanding between UMMS and the Ghanaian partner schools, neither Ghanaian students nor Michigan students are charged tuition when rotating at one of the partner institutions. Through the generosity of one of UMMS’s department chairs, Ghanaian students receive a $300 stipend to help offset per diem costs. Lodging and airport transit are arranged by UMMS. Students are responsible for financing airfare, visas, health insurance, transportation in Ann Arbor, and all incidentals (average cost: $3,000 per student). Most students require financial assistance, typically provided by their family and occasionally provided by small grants from companies or organizations in Ghana.
Ghanaian students who have completed at least some clinical rotations at their home institutions are eligible to participate in a UMMS rotation. These students are typically in their first or second clinical year (fourth and fifth years, respectively, of a six-year medical school curriculum). Before 2010, students were accepted by UMMS for participation on a first-come, first-served basis. In 2010, a more rigorous selection process was instituted. Clinical students are now recommended for participation by deans or department chairs at their home institutions on the basis of class rank and personal merit.
Assessing the value and impact of a UMMS rotation on Ghanaian medical students
We e-mailed all 73 Ghanaian medical students from UGMS and KNUSTSMS who had participated in rotations at UMMS between January 2008 and December 2010, asking them to complete a survey. All participants gave their electronic consent prior to participation. This study was reviewed and performed under an exemption granted by both the ethical and protocol review committee of UGMS, which provided blanket exemption for all universities in Ghana, as well as the University of Michigan institutional review board.
Participants completed a 45-item online survey supported by SurveyMonkey (SurveyMonkey, Palo Alto, California). We developed the survey (see Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A206) specifically for this study, based on a combination of literature review, exploratory interviews, and expert review, followed by an iterative review and revision process. The survey included a demographic section that collected background information, including region of residence, level of training, other international experiences, and intended career path. An attitudinal section used a five-point Likert scale to assess students’ perceptions of the value and impact of participation in a UMMS-based rotation. Students were also given the opportunity to provide open-ended, narrative feedback at the end of the survey.
Participants were offered $5 in phone credits as a token of appreciation for their participation. After completing the survey, participants were directed to an independent Web page to claim their phone credits, thus retaining anonymity.
We retrieved data from SurveyMonkey and exported them into SPSS version 19.0 (IBM Corp., Armonk, New York) for analysis. Frequencies and basic descriptive statistics were calculated for each key variable. Demographic characteristics were selected to stratify the analysis and examine differences based on factors such as gender, age, or rotation (e.g., obstetrics–gynecology versus emergency medicine). Analyses were conducted using cross tabs and Pearson chi-square.
Between January 2008 and December 2010, 73 Ghanaian medical students participated in a clinical elective at UMMS. During this same time, 33 UMMS students traveled to medical schools in Ghana for similar rotations.
Of these 73 Ghanaian medical students, 51 (70%) agreed to take part in our study. Demographic data for the study participants are summarized in Table 1. Figure 1 illustrates the types of clinical experiences and interactions students had during their UMMS rotations.
Survey results suggest that Ghanaian medical students derive significant benefits from participation in a U.S.-based clinical elective. Notably, 37 of 38 respondents (97%) felt that the UMMS rotation was a valuable part of their medical training, with 30 of 36 (83%) reporting that the learning objectives were clear. Students reported (1) improved medical knowledge (37/40; 93%); (2) greater appreciation for evidence-based medicine (34/36; 94%); (3) increased comfort searching medical literature (39/40; 98%); and (4) improved knowledge of U.S. medical care (38/39; 97%). Twenty-five of 32 students (78%) reported improvement in interpreting clinical information.
Many Ghanaian students experienced shifts in attitudes and perspectives as a result of their rotation. Thirty-seven of 38 respondents (97%) said that participation in the UMMS rotation led to personal growth and development. When asked about their perceptions of their future medical practice, the majority of participants (32/35; 91%) said that the UMMS experience changed the way that they were thinking about their career, and 35 of 39 (90%) cited a change in their approach to patient care. Twenty-four of 31 respondents (77%) felt better equipped to serve the people in their home community. Thirteen of 25 respondents (56%) felt more inclined to stay and work in their own community.
The benefits of participation in a U.S. elective were tempered by the fact that many students also reported having an increased desire to pursue training and career opportunities abroad as a result of their experience. Twenty-eight of 33 respondents (85%) felt more inclined to pursue training opportunities outside of their home country than they had been before the rotation, and 13 of 26 (50%) felt more interested in pursuing a career abroad than they did before their rotation. Statistically, there were no significant demographic differences between students reporting an increased interest in pursuing a career abroad and those who did not (data not shown). Although it cannot be assumed that a statement of interest is an indicator of future migration, the possibility must be considered in light of the crisis in Africa’s health care human capacity.
Another weakness in the program appeared when students reported having less hands-on experience during their rotation than would be expected of a typical U.S. clinical student. Only 18 of 33 (55%) of the students were asked to render opinions on management, and only 14 of 35 (40%) were able to examine patients.
Limitations of this study include both its sample size and its overall response rate of 70%; missing data further decreased the sample size for each question and necessitated the reporting of item-specific N values. Another limitation relates to the cross-sectional, self-reported nature of the study design; as such, direct conclusions cannot be drawn as to whether this experience in isolation led to specific learning outcomes for students. Finally, despite efforts to encourage candid responses, study participants may have felt compelled to inflate the value of their experiences because of fears of offending their hosts. However, given the anonymous, Web-based nature of the data collection, this is unlikely to be a significant challenge to the validity of the findings presented here.
This is one of the first documented examples of a bilateral medical student exchange in which visiting students from Ghana outnumber outgoing UMMS students by more than two to one. This also constitutes one of the first attempts to assess the impact of international exchanges on students from the global South. There is a great need to document other existing bilateral exchange models in order to provide better insight into the feasibility of bilateral exchanges for academic institutions in the North seeking to build more reciprocity in their partnerships with Southern institutions.
Ghanaian medical students reported that participation in a U.S.-based elective can both be valuable and affect the development of skills and knowledge that shape future decisions regarding training and career choices. However, two areas of potential concern exist: first, the low rate of hands-on experience during their rotations, and second, their increased desire to partake in training and career opportunities abroad. Further research is warranted to explore in greater detail these and other issues identified in our study. As such, we have conducted semistructured qualitative interviews with a subset of study participants from the Ghana–UMMS exchange, the results of which are forthcoming.
One limitation of this exchange program is that participants must have the financial resources to travel to the United States, meaning that they likely represent a unique sampling of students from Africa. This group may be more attracted to pursuing careers abroad and more susceptible to the risks of “brain drain.” Regardless, creative approaches are warranted to ensure that bilateral exchanges are accessible to all medical students, not just the financially privileged.
Finally, little is known about the impact of the visiting students and trainees from the South on their Northern hosts, including the time required from faculty and other learners to accommodate these students into their programs. Further studies are needed to understand potential implications of reverse education and cultural exchange.
In summary, medical students from the global South benefit both personally and professionally by participating in rotations in the global North. The bilateral exchange program between UMMS and universities in Ghana can serve as a model for other medical schools interested in pursuing similar collaborations. However, these experiences must be thoughtfully designed to be equitable and to prevent future “brain drain.” Further studies are warranted to inform the design and implementation of balanced and equitable bilateral exchanges to support the educational needs of visiting trainees.
Acknowledgments: The authors would like to acknowledge the significant contributions of the late Dr. Christine Ntim-Amponsah, professor of ophthalmology and former dean at the University of Ghana Medical School, to the conceptualization and design of this study. The authors would also like to thank Jennifer Jones and Carrie Ashton for providing valuable insight into the background of the exchange program.
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© 2014 by the Association of American Medical Colleges
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