INTRODUCTION
During the last decade, the presidents of our major universities have embraced globalization of the curriculum of their institutions. Having had the opportunity themselves of visiting seen firsthand the importance of developing programs to help our university students become global scholars. That means we are going to enroll medical students who have already had international experiences, as well as students who want to work internationally during medical school and residency. The difference from the past generation is dramatic: when I was a medical student, only 2 of us in a class of 100 at the State University of New York at Buffalo went overseas—now, according to data from the Association of American Medical Colleges (AAMC) Medical Student Graduation Questionaire, about 25% to 30% of medical students go overseas.
What are we doing to prepare these students? The curriculum in global health is similar to that of family medicine in the 1970s. We knew that what we were doing was right, although we did not know how to do it well, but we gained experience rapidly. In global medicine, we have written our vision, mission, objectives, and outcomes, but we are still learning. We are moving from a travel experience to one for which students are prepared, goals are set, objectives are written, and evaluations are designed. Students are excited to go overseas, and they have a great experience, but it behooves us as faculty to make certain that we are preparing them well, that they are supervised, that they get the experiences we want them to get, and that they have time for reflection and reporting back.
COMPETENCIES FOR GLOBAL MEDICINE
In global medicine, we have to match the competencies we have laid out for general medical student education. What are we expecting when somebody goes on an international elective? I will summarize the specific competencies applied to global medicine.
Medical Knowledge
Students taking international electives report that they learn about new diseases uncommon in the United States. Yet with 28 million Americans traveling abroad for business each year and millions of others for pleasure, as well as the large number of immigrants in our communities, future physicians will see some of these diseases throughout their career.
A Return to Basics
As a medical student overseas, I learned much more about history taking, even though there was a language barrier and I had an interpreter. My interpreter challenged me, “What are you asking that for? What you really need to ask in this culture is ——.” “Well, why are you ordering this? They are not going to do that.” The physical examination is also important. How often do physicians rely on computed tomography scans or sonography to find a spleen or liver, to confirm a suspicion? In Liberia, I remember taking care of a child with severe diarrhea and vomiting, and a medical student said, “I don’t know what to do because I don’t know what the electrolytes are.” My response was, “Well, you have this child in front of you and you have to make a decision. So what can you learn, without a backup laboratory, from the history and physical examination to help you manage the patient?” Such an experience in a resource-poor nation can return us to our foundation; that which our forefathers learned before they had the laboratory students can learn and apply to really help people.
Cultural Sensitivity
International rotations teach students sensitivity to diverse populations. When cultures are different from our own, we are struck by the divergence. My family lived in Zimbabwe for 1 year, and for the first time in their lives, our white children were a racial minority in a population that was 99% black. It was never, however, an experience identical to that of so many minority children either at home or abroad, because our children did not experience the suffering endured by those in poverty.
Rotations abroad also teach students the larger context of resource priorities in a poor nation in contrast to those in the United States. Students are flexible and usually adapt readily to their experiences in resource-poor nations. When they return to the United States, however, they are overwhelmed by the excess and waste in our health delivery system.
Educational Arrangements
The specific educational arrangements of the international rotation are also important. In the United States, we would not send a student to a rural clinic without preparation; so too, for international rotations. Medical schools and faculty must consider certain questions: What do we want students to learn? What preparation do they need in advance? What kind of supervision? How will we help them put their experience in perspective? If we send them without preparation, objectives, responsibilities, and supervision, they will miss so much of the possible richness of the experience.
MEASURES OF SUCCESS
What are the measures of success when students participate in global medicine electives? One level of success is whether students have progressed in their development of their competencies. Another is whether the experience made an impact. Are they now involved in the community? Do they have a broader vision of health care? Do they have activism for the underserved? Most of them do, but we must learn how to measure these outcomes.
A different perspective on care is also important; an altered perception applies to more than just appreciation of the contrast between rich and poor nations. At the University of Massachusetts, we sent a groups of students to Japan. One exercise was a panel presentation in which they described what happened to an elderly woman with a fractured hip in Japan and in the United States. Management of the patient with the same condition in various settings—in the hospital, in the rehabilitation center, and at home—differed markedly across countries, although the outcomes were the same. What a wonderful perspective the students gained!
There is a tendency to measure the success of an international elective with a career choice in primary care. I believe that focus is too narrow. Rather, success is about engendering a commitment to action. That students choose radiology, trauma surgery, or dermatology is not a failure; it is their choice. Instead, the victories are in what they do in these specialties. The radiologist who develops a screening program for early breast cancer for underserved immigrants, or the trauma surgeon who undertakes a campaign for seat belt use in inner-city populations, or the dermatologist who undertakes a citywide educational program in melanoma—these are all successes.
In the long run, we hope to encourage students to think more broadly and see the patient in the context of his or her community or even the world.
Conflicts of interest: none reported