Preparing Medical Students for the World: Service Learning and Global Health Justice

Abstract

In this article, we discuss the growth of international service learning in undergraduate medical education and tie it to a burgeoning interest among students and educators in global health justice. The process of experience, reflection, and action is the cornerstone of cultivating a sense of social justice among students. Finally, we examine both risks and benefits to international service learning for medical students. We define “service learning,” distinguish it from service and volunteerism, and offer praxis as a manifestation of professionalism.

Introduction

Service learning in medical education has arrived. Although service learning has made significant inroads in other areas of health care education,[1] a wider discussion on how service learning functions in medical education, social analysis, and addressing social injustices is needed. In this article, we define “service learning,” distinguish it from volunteerism and service in general, and then explore its potential benefits and pitfalls. We pay particular attention to how service learning can affect medical students' understanding of global health justice and why justice should be a core component of service learning curricula.

Defining Service Learning

Service learning has its intellectual roots in the works of John Dewey. Dewey emphasized collaborative learning, social development, and working for the benefit of others.[2] Interest in service learning as an educational tool has a history that spans the 20th century and reflects broader societal concerns and priorities (ie, educators embraced service learning during the social upheaval of the 1960s and 1970s, popularity declined in the 1980s, but interest has risen again in the past couple of decades).[3] Service learning is often defined as a kind of experiential learning whereby students are placed in the community to provide some kind of service.[4] One useful definition of service learning appeared in Academic Medicine in the late 1990s:

Service-learning is a structured learning experience that combines community service with preparation and reflection. Students engaged in service-learning provide community service in response to community-identified concerns and learn about the context in which service is provided, the connection between their service and their academic coursework, and their roles as citizens.[5]

This kind of learning falls within the context of a larger formal curriculum that includes clearly defined goals, expectations, and outcomes. A recently adopted Liaison Committee on Medical Education (LCME) addition to medical school accreditation standards supports this development in its new statement that medical schools should make sufficient opportunities for service learning available to their students. (See http://www.lcme.org/standard.htm#servicelearning) The growth in participation in global health experiences to over 25% of US medical school graduates suggests a larger role for service learning.[6] Gaaserud and colleagues' definition of international health and medicine is appropriate to our discussion of global health service learning:

[International health and medicine is] the practice of medicine outside the practitioner's culture that addresses the cultural, economical, political and environmental factors that affect the health, health perceptions and health-behavior of individuals and populations in diverse communities across the globe.[7]

Currently, most international health and medicine service learning experiences take place in an extracurricular setting. For instance, here at the Loyola University Chicago Stritch School of Medicine the campus ministry office has played a long-standing role in facilitating an extensive summer immersion experience for students after their first year. These students are placed in various locales in the Caribbean, Central America, or sub-Saharan Africa. They receive a formal orientation and then spend 2 weeks with fellow students, attending physicians, and one of our chaplains practicing in community-based clinics. They are exposed to healthcare disparities between countries and sharp contrasts in healthcare delivery systems and expectations as they work with patients and healthcare professionals in these locations. When they return, they write a reflective essay on their experiences and discuss them with one of the program's staff members.

Such immersion feeds into a variety of student needs – the need to volunteer, the need to serve, the need to learn about different cultures, and the need to learn and reflect upon one's own place in the world. Some schools even require an international health rotation during a student's medical education. For instance, the Ben Gurion University in Israel requires its students to rotate to a medical school in Kenya, Ethiopia, India, or Nepal. Such opportunities have been viewed very positively by the students at this school.[8] At the same time, some students ultimately find themselves asking whether they have helped others or just themselves.[9]

How Service Learning Differs from Volunteerism or Service

Given this reaction, it is important to distinguish service learning from service and perhaps also from volunteerism. In a volunteerism model, students either informally or formally volunteer for various activities. For instance, a number of students at the Stritch School of Medicine regularly volunteer to provide meals to homeless persons in downtown Chicago. Volunteers are not typically connected to a formal educational curriculum or structure, and volunteerism itself does not necessarily have the potential to affect social change that service learning does. Rather, student volunteers may respond to a perceived need in the community and attempt to fulfill some kind of obligation for the community.

Many schools promote service activities among their students, and service learning programs are starting to flourish. If we limit our discussion to service, however, we are really only looking at part of the definition provided by Seifer.[5] In addition to the important work of community service, service learning requires structure, preparation, reflection, and evaluation. Our medical school offers an honors program in bioethics and professionalism, which is an example of service learning because it imposes a framework for students to reflect on what they are doing while requiring evaluation by faculty.[10] These reflections provide a valuable opportunity for students to better integrate these powerful experiences into their professional development.

Concomitant with the growth of service learning has been a burgeoning interest in global health among many medical students.[11] Several schools report growing interest in global health initiatives and service (indeed, the entire February 2008 issue of Academic Medicine was devoted to this topic[12]); for instance, “[t]eaching and research at Boston University (BU) have long been enhanced by a strong social mission and commitment to service.”[13] Other schools reported a variety of innovative approaches, ranging from partnerships with foreign governments (Duke and Singapore) to new educational initiatives (such as the new MS degree in global health being offered by UCSF). While some have labeled these students “medical missionaries,”[14]] we think it is important to further specify the notions of service learning and global health so that they include a focus on respect for the cultures of others and the development of an analytic understanding of social justice with the goal of achieving greater health equity and reducing health disparities. In addition to the 3 competencies of global health education proposed by Houpt and coworkers (ie, burden of global diseases, traveler's medicine, and immigrant health),[11] we believe that the social determinants of health competency is an essential component in global health service learning as discussed below.

Physicians, such as Paul Farmer and Edward O'Neil, Jr, have emerged as household names among many students and faculty These physicians articulate the need for the core ethical value of justice to remain forefront in global health, medical ethics, and professionalism.[15] Farmer's work has had a particular impact on many premedical and medical students. His contention that “in arguing that health care is a human right, one signs onto a lifetime of work dedicated to erasing double standards for rich and poor” challenges the health profession as a whole while inspiring many students.[16] We welcome the growing interest in global health issues among students and faculty. We generally agree with O'Neil when he cites the work of “Gustavo Gutierrez, the father of liberation theology, [who] once advised people to forget the ‘head trip’ of studying the problems of the poor and take a ‘foot trip’ to work among them.”[17] Seeing the injustice of the world most certainly requires a “foot trip,” but our medical educational initiatives should not neglect the important intellectual work that solving such injustices requires.

We believe, then, that a student's experience and knowledge of global health and justice has to be rigorous and organized. For example, our school requires an examination of global health issues during the first year by requiring students to organize into small groups and prepare brief presentations on a given nation's health status. These presentations provide some much-needed depth and understanding of what is happening in these countries on a variety of levels – politically, economically, culturally, and so forth. Without this kind of learning activity, a foray into a developing country for an immersion experience may allow for some great personal growth through experiential learning and reflection, but crucial intellectual growth may be neglected. Thus, it is imperative that students be exposed to good scholarship related to global health as well as sound information about various countries.[18]

Students going abroad are exposed to social contexts demonstrating intense global health and economic disparities. For some students, these experiences may be overwhelming as they try to make sense of these. Therefore, service learning education programs must empower medical students with the vocabulary of social determinants of health to enable them to analyze their experiences, reflect, and act in response to them. Education regarding social determinants of health – that is, the social conditions that impact access to care, behaviors, and health outcomes[19] – should be a central feature of service learning curricula. Students equipped with the language to analyze their experiences through such lenses as class power, gender, and race may then better understand the communities they visit and the underlying factors that shape these communities.

Praxis as a Manifestation of Professionalism

The process of praxis, especially as described through the work of Gutierrez and education theorist Paulo Freire, embodies this cycle of experience, reflection, and action in the context of pursuing social justice. In the broadest sense, praxis is “the action and reflection of men and women upon their world in order to transform it.”[20] As a didactic tool, it is easy to teach; however, it takes a lifetime to master. Praxis is central to lifelong learning in the broadest sense and paramount in service learning programs. Praxis, through global health service learning in particular, can play an important role in developing young physicians' conceptions of professional duties. The notion of medical professionals as not only healers but also as reporters and advocates reflects the professional roots of the medical vocation.[21] Narrative and testimony of persons living in poverty profoundly affects medical students in ways that simply viewing poverty cannot. For example, when one of the authors (List) conducted needs assessments with his colleagues in various resource-poor settlements in greater Nairobi, Kenya, the emotional impact on him and other students amplified how they experienced conditions as they recorded data and wrote down the stories of the women and men there.[22] In one settlement, women lined up for hours and told students that they wanted to be part of the needs assessment, because it was the first time that they had felt “heard and listened to” in their lives. It is one thing to see global disparity and quite another to listen to the bitter details of its manifestation. In addition, it was through these needs assessments that community-identified concerns were clearly articulated to further refine the nature of student involvement in the community. An understanding of the crucial function of listening skills for the medical student can be experienced in a most dramatic way vis-à-vis service learning in resource-poor settings, and the incorporation of education in the art of praxis can serve as a way to improve medical professionalism through service learning.

A natural corollary in some ways, we promote the notion that higher-learning institutions must not only create service learning opportunities but also play some role in further sustaining and supporting student's ongoing work in the communities in which they experience service learning. Medical institutions at the University of California-San Francisco and Stanford University, for example, encourage independent and institutionally affiliated international health experiences for medical students and residents. They allocate grants and other funds for student international service learning that accommodate both student and institutional initiatives and partnerships abroad. The development of global health institutes at a number of university medical schools and the growth of the Global Health Education Consortium serve as important networking venues for medical educators and students to find material resources while considering varied service learning methodologies in the pursuit of global health justice.[23]

Literature examining how students are impacted via global health service learning curricula, as well as their working knowledge of international health and medicine, remains sparse. At least 3 areas in this field need more research: (1) assessing student understanding and interest in service learning; (2) assessing medical institutional curricula; and (3) engaging the community members abroad impacted by the presence of students in these curricula. A recent study of students in the UCLA/Drew Medical Education Program, a unique program that focuses medical education on medicine in underserved populations, found that training in the UCLA/Drew compared to UCLA School of Medicine was independently associated with intention to practice medicine in underserved communities, suggesting that a medical education program can have a positive effect on students' goals to practice in underserved areas.[24] While one might not be surprised by this outcome, similar analyses of other underserved and global health service learning curricula are essential for the future of this educational movement and to determine the strengths and weaknesses of these programs.

Risks and Benefits of Service Learning

Risks, as well as opportunities, arise when students serve and learn abroad. The risks and concerns include negative features of medical tourism and leaving students paralyzed by intense experiences abroad.[1] Most important, the risk for dependence on or resentment toward medical students exists. Service learning that promotes cultural sensitivity, individual and community empowerment, and education in the historical and global forces that shape communities abroad may reduce these risks significantly. Yet, students engaged in service learning in some of the most impoverished places experience a burden of knowledge that for many demands a response and unparalleled opportunity to address disparities.[25] Medical educators who can further empower these students through training in critical reflection and response stand to inspire a broader movement for more justice in global health.

There are numerous other benefits to service learning opportunities for students engaged in international health. Students improve their communication and listening skills, rely less on technology and more on their clinical physical diagnosis skills, improve their knowledge of diseases prevalent in the developing world, and become more sophisticated with regard to public health issues in resource-poor settings. The students develop important clinical skills for themselves as physicians in training and play an important role in partnering with clinicians in these settings.[26]

A final benefit to service learning in medical education is that it cultivates essential citizenship skills. Although the perception is that physicians become apolitical during their professional lives (due to the demands of training and practice), recent research strongly suggests that many if not most physicians highly value the public role of a physician.[27] As Wynia and colleagues have argued, civic professionalism requires a vigorous profession that is committed to certain ideals.[28] Global health equity is certainly one ideal to which many medical students already subscribe; the ardor for such work may be maintained by a few graduates who seriously embrace international health and incorporate it into their careers. For others, it may simply mean an opportunity for medical tourism.[29]

“Medical tourism” as discussed here differs from the medical tourism commonly reported in the media (ie, patients from developed countries traveling to developing countries to have certain kinds of medical procedures, often at a fraction of the cost). Rather, our discussion of medical tourism refers to medical students viewing their immersion experiences as glorified trips abroad rather than considering them an integral part of their professional development. Our feeling is that global health service learning has a profound effect on many medical students. We hear repeatedly about the transformative effect it has on our students. One of the challenges we face is how to make such transformative experiences more lasting and more sustainable for the places that students visit. Our goal then is to create greater sustainability in these places, while also contributing to the professional development of our students. The potential for service learning as a means for refining the necessary skill set for this type of social justice vocational work has yet to be unleashed in its full capacity.