Table 2. Barriers and Proposed Solutions for Expansion of International Clinical Rotations (ICRs).

Stakeholder	Barriers	Proposed solutions
Accreditation organizations and review committees	Have not developed core competencies or training guidelines for residents doing ICRs.* Do not officially recognize time spend doing clinical training in another country. Generally have not helped to foster an exchange between domestic residency programs and foreign institutions.	Discuss the utility of ICRs as part of physician training and establish core competencies and training guidelines. Allow ≥ 1 month of an ICR, and the associated procedures, to apply towards accreditation requirements. Become active in exploring “twinning” arrangements and bilateral exchange programs.
Residency administration and program directors	Do not provide scheduled time for residents to participate in ICRs. Do not provide administrative support to assist residents in finding appropriate ICRs. Often do not provide adequate financial support for ICRs.	Allow interested residents to spend ≥ 1 call-free elective month on an ICR. Facilitate in identifying and establishing structured ICRs. Provide support, ideally with salary and travel assistance, for residents on ICRs. Seek to establish relationships with hospitals/institutions in developing countries to foster bilateral exchange.
Residents	Face financial constraints. Face scheduling conflicts. Would be required to spend time away from family. Must spend significant time locating an ICR.	Must have completed first year of residency and be medically licensed. Spend ≥ six weeks at the host hospital. Present work/experience to home institution upon return. Consider overlapping with prior and/or future resident for continuity.

^*The American Academy of Pediatrics has developed core competencies and guidelines for international clinical rotations.