Internationalization of Medical Education—Building a Program to Prepare Future Leaders in Healthcare

Abstract

In a globally interconnected world, internationalization of medical education has become increasingly important. While many programs focus on international programs for clinical students, the number of programs for preclinical medical and dental students is small. Based in the Anatomy course, the program presented here involves early international collaborations between preclinical students from six countries. Our work involves small-group video sessions and a large international student videoconference (including cultural and didactic components). The online connections progress with in-person basic sciences summer internships undertaken at the international partner institutions. This collaborative program features unique elements that facilitate cultural exchange and help develop leadership skills in healthcare early in a student’s career. We present recommendations for international program implementation.

Introduction

Global Health Education

Global health (GH) is an area of study, research, and practice that prioritizes improving health and achieving equity in health for all people worldwide [1]. GH education is frequently seen as part of an international, altruistic, “Global North to Global South” educational experience or program, or as part of a health equity program at home—with elements of humanitarianism, altruism, social justice, and health equity. Despite efforts, standardized and formal programs have not been established—leaving educators questioning whether current efforts are reaching all students, preparing them adequately, and properly addressing changes in global health [2–11].

Having knowledge about health in a global context has become important for healthcare leaders in recent years [12]. At a time of global interconnectedness and globalization, GH education becomes increasingly important in medical education and can prepare medical students and faculty to address global health issues [13, 14]. With increasing frequency, medical students gain experience in international healthcare through electives abroad—most often in developing countries as part of GH initiatives [13, 15–21].

Internationalization of Medical Education

Internationalization in higher education is defined as “The intentional process of integrating an international, intercultural, or global dimension into the purpose, functions, and delivery of post-secondary education, in order to enhance the quality of education and research for all students and staff and to make a meaningful contribution to society” [22]. Internationalization within tertiary education has been researched and reported on widely around the world, but not much emphasis has been placed on considering specifically the internationalization of medical education (IoME) [23–25]. A deeper understanding in this area is needed [26]. For the purpose of this publication, IoME encompasses the procedures and programs set in place specifically to internationalize medical education, i.e., to intentionally integrate an international, intercultural, or global dimension into medical education in order to enhance its quality.

IoME is not confined to changes in the medical curriculum but can involve various stakeholders and dimensions of medical education including students, faculty, institutions, and governments [26–28]. Three models for IoME have been described [29]: the “market model” which aims at competitiveness of students and institutions; the “liberty model” that relates to the notion of giving students insight into intercultural exchange; and, most often identified with IoME, the “social transformation model” which associates IoME with global health and global health education inside and outside their own countries [24, 29].

Internationalization elements can be seen at different levels and different formats [27, 28]. On the student level, IoME can involve didactic lectures in the classroom, peer-to-peer connections, outbound mobility activities for international student travel, and inbound mobility by increasing the proportion of international students [7].

While IoME can include elements of GH education, it is not limited to concerns with underserved populations or health equity. Importantly, it includes exposure to both developing and developed countries’ issues.

IoME programs have the potential to enrich learning by acquisition of general competencies acquired through international exposure—positively affecting intercultural competence, empathy, and tolerance, to name a few [30].

Importantly for healthcare leaders, IoME can enhance learning about key issues that are specific to health education worldwide—in regard to medical education systems, healthcare systems (e.g., the shortage of specialists and healthcare personnel worldwide, differences in health economics, and remuneration), health policies (e.g., federal requirements and insurances), international public health challenges (e.g., emerging epidemics, infectious diseases, the Ebola crisis, and mental health), and health ethics (e.g., aid-in-dying—formerly euthanasia, abortion, birth control, infertility treatment, stem cell research, and organ transplantation).

Because IoME can enhance students’ understanding of social, cultural, and ethical differences, it can prepare future physician leaders to practice with a broader frame of reference and better understanding and awareness of cultural differences.

Despite efforts to internationalize medical education—sometimes involving interdisciplinary approaches [13, 31]—there has been little attention paid to addressing early social interaction among future physicians living in different parts of the world. Although international programs are increasingly popular, little effort has been made to establish international student-group collaborations—in order to practice professionalism on an international level.

Very often international contact normally occurs at a later stage in medical education, during clinical rotations and occasionally during basic science fellowships [32, 33]. There is an advantage to obtaining international experience after successful clinical training at home, as students have acquired confidence and basic medical knowledge. However, the downside to experiencing international exposure in the final years of medical school is that students at this late stage are often focused on job searches and how to make themselves competitive for residency. If they do go abroad, an international experience becomes an important but one-time event—potentially, without any continuity or long-term effect. Although it has been shown that any international exposure can benefit students, medical schools often do not include international contact or collaboration during the preclinical years except for few limited special GH track programs or electives [13, 34–38].

Objective

The purpose of our study was to offer an international structured program for preclinical medical and dental students. Through early international peer exposure and international travels, we aimed to facilitate bonding among international peers—thereby enabling future international collaboration on healthcare issues.

The purpose of this monograph is to share our experience with the development of an IoME program and what we recommend to others who plan similar programs. We convey how our program became successful, sustainable, and contributes to our students’ education.

Development and Format of the Program

The program presented here is anchored in the Anatomy course and targets early international exposure via small-group peer-to-peer collaboration of future healthcare leaders and student mobility utilizing an international basic science experience as a vehicle—thus enhancing student careers and improving cultural competency.

Program Format

Students

The participating students were volunteers and in their preclinical years of medical or dental school: most of them were either enrolled in their Anatomy courses or had just completed their Anatomy courses. In the early pilot program, we randomly included students who expressed interest in participating. As our program grew and the demand for consistency and quality rose, we asked our partners to only select committed students that have academic career aspirations, have good academic records, and have interest in an exchange experience.

Partners

Initially, the program was introduced in the Anatomy course with the collaboration of two universities and was subsequently expanded to a larger international program with six participating universities over three continents. Current participating schools include Canada (McGill University, Faculty of Medicine, Montreal), Finland (University of Helsinki, School of Medicine, Helsinki), Germany (Martin Luther University, Medical Faculty, Halle-Wittenberg), Japan (Kyoto University, Graduate School of Medicine, Kyoto), Taiwan (National Taiwan University, College of Medicine, Taipei), and the USA (Columbia University, Vagelos College of Physicians and Surgeons, P&S, New York). Partners were found via mutual professional societies (i.e., Anatomical Society, American Association of Anatomists) and via professional connections in the basic sciences.

Selection Criteria for Partners

The exchange experience within our program was intended to cover students’ needs in regard to experience in the basic sciences, learning about academic life in a different setting, acquiring cultural competencies for future collegial collaborations, increasing competitiveness via research experiences, and early networking. Humanitarian or altruistic experiences, often achieved by traveling to low-middle income countries, were not part of the goals in our program. Selection criteria to find equal partners in our program, therefore, targeted schools that could offer students an exchange experience that is comparable to the quality offered at their home institutions. The mission of our program necessitated that we defined inclusion criteria for our partnerships: (1) the country must be politically stable and considered safe for young students to travel (i.e., no ongoing war), (2) the school must be a reputable school in its respective country, (3) the research laboratories have to be vetted by faculty, (4) the majority of students have to be fluent in English and vetted by faculty for excellence and good academic standing, and (5) international exchange students must have the intention of returning to their home country so that early international networking can be maintained (i.e., via social media and other means), and build a support community for future global healthcare leaders/collaborators.

In addition to the inclusion criteria, all partner schools are vetted for additional unique characteristics (i.e., Halle has a long history of Anatomy teaching). Purposefully, partners are located in industrialized countries—yet culturally different enough from each other to expose our junior students to very different environments.

The current program presents data from six schools selected by these standard inclusion criteria. Additional partners are being added for the upcoming year 5 (e.g., the University of Sydney, Sydney, Australia; King’s College, London, UK; the Medical University of Vienna, Vienna, Austria; the Tokyo Women’s Medical University, Tokyo, Japan; and the Ludwig Maximilians University, Munich, Germany).

Program Elements

Format changes were made from 1 year to the next based on student feedback and on what we observed/learned.

Small-Group Discussion Format

In the first portion of our program, students were randomly paired in small groups. Initially, group sizes ranged from six to ten students (two countries) but were reduced to 4–6 in order to provide a better ratio for students to connect. We began the program as a pilot study with a suggested one-time meeting and a free flow discussion format with a hope that students would reconnect outside the program. Over time, per students’ request, we developed a more structured “curriculum” with sample discussion topics for the small-group sessions (Table 1). In the beginning of the fall semester, students met in four sessions: (a) session 1 covered the topic of Anatomy and body donation, (b) session 2 was a comparative discussion on one or more of the provided healthcare discussion topics, (c) session 3 was dedicated to a collaborative group work on a summary paper, and (d) in session 4, the students worked together on a presentation for the final international student conference (see below). The length of each session was at the student groups’ discretion with a minimum of 1 h each. Sample questions were provided as suggestions to ease the flow of the discussions.

Table 1.

Discussion topics

Discussion blocks	Selection of topic
Healthcare education	Differences in medical school curriculum Differences in residency and other postgraduate training Tuition
Healthcare delivery systems	Differences in healthcare systems Differences in health insurance systems Differences in remuneration and fees Differences in hospital systems and general medical practice Shortage of healthcare workers
Public health challenges in your countries	Aging Obesity Epidemics (infections) Addiction Mental health
Health ethics and law	Abortion Euthanasia Stem cell and embryonic research, Infertility Organ donation

Group Project

An international collaborative small-group project was included to prepare students for international collaborative team work, which involved writing a short paper in partnership with international peers—covering one of the healthcare topics that are listed in Table 1. The groups worked on this project collaboratively in sessions 3 and 4.

International Virtual Student Conference

The small-group sessions culminated in a live online international videoconference. The purpose of the international conference was to introduce students from different parts of the world to each other. For many students, the conference was their first international public speaking, in front of a group of their international peers. All students and faculty from three continents met for 3 h. Each group presented its collaborative paper in a 5–10-min presentation. More recently, an intercultural exchange to the conference agenda was added where a student from each country (“national student leader”) presented their country culturally to their peers—covering topics such as history, food, architecture, and currency.

Copies of the papers were sent out ahead of time to the faculty for initial review and to all the student participants subsequent to the conference.

Social Media

Initially, the students started a Facebook page to remain connected long-term after the large conference, but it was later created at the start of the program to give them more time to interact during the program. Faculty members were only minimally involved to give the students ownership of this portion and the group was managed solely by the students. Via this page, students interacted outside of the program with each other and planned their travels (see below). Other social media for small-group communication (e.g., Whatsapp) were also used.

Student Mobility

The videoconference portions were completed in early February. In the summer break following the student videoconferences, students completed basic science research internships at their peers’ institutions for a 4–8-week research internship in an area of their choice. Faculty assisted with identifying research laboratories, projects, funding, and clarification of visa issues. Students contacted their peers for help with housing, travel logistics, and plans for leisure activities.

Feedback

Each year, after the completion of the program, a questionnaire was sent to the students via email using Qualtrics© as the survey and Excel© as analysis software. In the initial phase, the surveys were aimed solely at objective quantitative data—to investigate the feasibility of the format. However, in years 3 and 4, we added questions that addressed and investigated the subjective qualitative component (i.e., what students felt they had learned). No statistical analysis of the questionnaires was performed. No control groups were included. All changes and adaptations of the program were based on student feedback. Students initiated the exchanges, initially at the end and later at the beginning of the program.

Progression of the Program

Figure 1 provides a summary of the elements that we included as the program progressed over the years.

Fig. 1.

Development of the program

Results

Results presented here focus on the student responses obtained in year 4. Results captured qualitative responses only as there are no control groups that provided means for quantitative research. Questionnaire response returns ranged from 50 to 60% each year.

Year 1 (2014) to Year 3 (2016)

The overwhelming majority of students appreciated the sessions. They felt they learned something new about the medical education and healthcare systems of their peers and they were culturally inspired (Table 2). The majority of students felt the program should be part of the medical curriculum and continued into the clinical years.

Table 2.

Student questionnaire responses years 1–3. Summary of selected results from year 1 to year 3

	Yes (%)	I have no opinion (%)	No (%)
What was your overall opinion – did you like the sessions? (year 1)	97	3	0
Did you learn something about medical education & other healthcare systems? (year 1)	94	6	0
I wish there were more/regular interactions like this. (year1)	82	12	6
If this study was part of an official program would you like to have more structured meetings? (year 2)	45	33	22
Did you learn something about Anatomy and the course? (year 3)	97	N/A	3
Did you learn something about the other medical school(s) or healthcare systems? (year 3)	100	0	0
This interaction inspired me to learn about the other country (i.e., medical & cultural) (year 3)	82	11	7
This interaction inspired me to visit the other country (year 3)	70	11	19
Should this interaction be part of the medical curriculum? (year 3)	71	22	7
Should this interaction continue into the clinical years? (year 3)	74	22	4
Should this interaction start in the Anatomy course? (year 3)	74	19	7

Although we chose partners that are relatively culturally similar, our results indicated that students often lacked very basic knowledge of the medical education and healthcare systems of their peers’ countries. Not surprisingly, the students felt they learned about the differences (Table 3).

Table 3.

Student testimonies—small group video sessions

“One obvious difference we discussed is cost, and how medical school for them in Germany was free. They mentioned that there was still a shortage of primary care doctors in their country, which has led to incentives to get medical students to stay post-graduation, but we discussed how the high cost of education in the US often leads people to choose specialty care in order to pay back their loans with a higher salary, rather than primary care.” (USA)	“I learned a lot of new things, such as private insurance not being the main insurer in many parts of the world. I also thought it was very interesting that in Taiwan, primary care is mainly administered at hospitals, and private medical practices struggle to keep up.” (USA)
“General structure of medical school in the US, financing studies in the US. their anatomy course and the differences between ours.” (GERMANY)	“The German healthcare system is more complicated than I would have imagined. Germany suffers a similar rural-urban doctor supply difference. The US has astoundingly easy access to pharmaceuticals compared to Germany and other countries.” (USA)
“It was very interesting to get to know how difficult and expensive it can be, if you want to study medicine in the US.” (GERMANY)	“About how expensive can studying be in the US, about how complicated it is to find a solution for public health care that everyone agrees on.” (FINLAND)
“I got to know that studying medicine is very expensive in the USA and that the System is completely different, because first they have to do general academic studies, for example in Spanish, and after that they start with medical school” (GERMANY)	“They had to pay a lot for their education. Possibly this also made them more focused and determined to get through university”. (FINLAND)
	“That there is a group of people who cannot afford private insurance but are not covered in the public insurance, community hospitals”.(GERMANY)
	“The influence of religion on how they think about euthanasia and reproductive technology”. (JAPAN)
	“I learned how the systems are similar, yet slightly different in laws, which accounts for the differences seen.” (CANADA)
	“Taiwan does not have a premed in contrast with most other countries. Also, our tuition is much more affordable.” (TAIWAN)

Year 4 (2017)

A total of 110 students from six countries participated (n = 20 groups). Presentation topics that were selected from the health ethics section included abortion (n = 1), euthanasia/aid-in-dying (n = 2), opioid epidemic (n = 1), general public health challenges (n = 2), fertility (n = 2), population health (n = 1), and stem cell and embryonic research (n = 1). The remainder of the groups presented on differences in medical education and healthcare delivery. Two groups decided not to present due to scheduling conflicts.

Self-reported learning objectives that were achieved in the small groups included cultural learning, appreciation, tolerance of non-English speaking peers, ownership, and leadership. After the large-group conference, the majority of students appreciated the cultural exchange and felt they learned something about the different healthcare education systems, public health, ethics, and GH. The majority of students felt they are more aware of cultural differences, had a better understanding of other systems and languages, and learned how to work with international peers (Fig. 2a, b).

Fig. 2.

a Students’ perceived learning small-group video sessions, year 4. b Students’ perceived learning large group, year 4

A total of 26 students from the cohort visited their peers’ countries in the summer of 2018.

Questionnaire results from the travels were limited but preliminary results indicate a positive experience for all exchange students (see Table 4).

Table 4.

Student testimonies—exchange travels

“I liked doing my research experiences abroad in Germany and Japan because I obtained a wider perspective on how science research is conducted in other countries and how international cooperation can lead to research breakthroughs. I also, of course, learned valuable research skills and techniques. Lastly, I obtained a wider world-view on medical school and healthcare systems in other countries, as well as knowledge on different cultures and viewpoints. I feel more prepared to work with an increasingly diverse field of researchers and healthcare providers, as well as patients.”

“It was great in terms of cultural exchange and in terms of developing my professional skills.”

“In both Germany and Japan, I met up with students involved in the Skype project, including the ones I directly Skyped in Germany. Meeting up with them was extremely valuable. I was shown the best places to eat, how to navigate public transportation, and so much more. I was also able to hang out and learn about their medical school experiences and their experiences in healthcare within their respective countries. It was wonderful!”

“I met with other participants to the program and we built strong friendships.”

“I learned to thrive in a completely new setting and to adapt to some difficult and critical situations on my own”

“I learned what it meant to feel extremely vulnerable (new country, language, and customs), which will tremendously help me when I need to care for patients from other cultures. I learned a tremendous amount about the German healthcare system”.

“This was an absolutely incredible experience that completely changed my view of my own life as well as the world around me. I would love to continue to be exposed to different cultures throughout my time in medical school, so it would be great if we could somehow incorporate more of these visits during our clinical years. My time in Halle was absolutely amazing and I miss it a lot!”

“For me, one of the greatest parts of my trip was my interactions with my lab mates and the friendships I have made with them”.

“This was indeed an incredible experience, where I met medical students from all around the world. I am hoping to keep in touch with them during the rest of our training and perhaps even beyond!”

Educational Elements

Our preclinical students experienced several elements of IoME: peer-to-peer collaboration, cultural exchange, international student travel, and learning about other healthcare delivery systems—in line with what is necessary for GH programs to achieve success [7].

This program offers a number of educational elements that can be divided into program format and program content (Table 5).

Table 5.

Elements of the program

Format	Content
Stepwise format (starting virtually and proceeding to student exchanges)	Public and global health education: Introduction to international healthcare education Introduction to international healthcare systems—differences and similarities Introduction to differences/similarities in health law and ethics Awareness building, regarding Public and global health challenges
Peer-to-peer education (learning from and teaching their peers)	Intercultural exchange/cultural competency
Preclinical students	General learning objectives via international travels
Anatomy as a commonality	Basic sciences experience for medical and dental professionals
Early international collaborations, teamwork	Leadership skills
International student conference for early international public speaking and listening and cultural learning
Quality, excellence of partner countries, and pre-selection of students
Fostering bonding of future healthcare leaders through international exchanges/travel and social media

Program Format

Stepwise Format

Our format—starting virtually and proceeding on to physical student exchanges—ensures that junior students are better prepared for visiting their partners abroad. They have already learned about the culture of the country and have formed friendships with their international peers prior to embarking on a physical visit. The format also ensures that only dedicated students participate in the exchanges.

Peer-to-peer Contact

Learning from and teaching each other in the form of peer-to-peer education has been shown to be effective in learning [39]. Friendship and learning have been shown to be beneficial in health professions education [40–42]. These early friendships can promote future professional collaborations and are a valuable source for international networking. Therefore, these early connections can facilitate bonding among future leaders in healthcare. To our knowledge, this is the only published program that focuses on early international peer-to-peer networking through the Anatomy course.

Involvement of Preclinical Junior Students

Only a limited number of programs focus on preclinical students’ international enrichment [31, 35, 37, 38, 43]. Preclinical students typically have more flexibility in their schedules and the majority of them are still in the formative stages of their lives (typically late teens to twenties). International exposure can have lifelong effects on cultural competency in this group of students.

The Anatomy Course

Historically, Anatomy courses have established the basic foundation for medical thinking, professionalism, teamwork, communication skills, and end-of-life topics [44, 45]. Because of the ubiquitous presence of Anatomy courses in medical schools around the world, integrating common activities into this course at different schools via their curricula is easy. Traditionally, the majority of the Anatomy faculty is closely engaged in the basic sciences, and Anatomy provides a good platform to touch upon greater concepts related to basic sciences (including death and ethics). The connection of Anatomy faculty to research laboratories provides easy access for student research opportunities. Anatomy faculty typically establishes close relationships with their students due to the nature of the Anatomy course—frequently having biweekly to daily interaction in the cadaver laboratories.

For most medical students, the Gross Anatomy laboratory is their first physical encounter with a deceased person. Addressing death and related issues can serve as a way to facilitate conversation between international students/peers.

Although other studies have reported on preclinical international interactions [31, 35–38], this is the first program that introduces GH concepts and IoME to preclinical students via their Anatomy course. The majority of our students felt that this international interaction was well placed in the Anatomy course, giving them a platform to discuss their Anatomy education, their medical curricula, and their experience of working on cadavers and bonding with each other.

Early International Collaboration and Teamwork

As medicine becomes a profession requiring teamwork and interdisciplinary collaboration, it is beneficial for students to communicate and collaborate early internationally [46]. We cannot teach cultural differences related to specific areas of the world, but we can heighten sensitivity to cultural differences, thereby instilling cultural competency.

International Conference

While in the USA public speaking is often practiced before medical school, some countries do not foster public speaking. For non-native English speakers, this conference provides an opportunity to publicly present in English. For native English speakers, listening to non-native English speakers can be challenging, and early exposure can aid in developing more empathy and tolerance. The addition of a cultural introduction as part of the international conference aids in cultural competency for the students.

Quality

Our selection process (see above) ensured a compatible student cohort. We attained a level of similar quality that is needed for the educational purposes of this program.

Program Content

Public and Global Health

Although in most cases, public health is not a standard part of the medical school curriculum, many schools offer electives in public health or global health (PGH) education [4, 7, 28]. To the best of our knowledge, this is the first report of preclinical medical and dental students being asked to learn about PGH issues introduced via the Anatomy course. Our program gives students an introductory way to cover potential educational deficiencies. This experience will not substitute for a full course in PGH, but it can still be regarded as an introduction to PGH for awareness building and may lead to initiatives in PGH issues or enrollment in other PGH electives.

General Competencies

Similar to other international programs, our program provides students with the means to refine skills such as problem solving, collaboration, appreciation, empathy, tolerance, professionalism, and personal development, all of which are important at this formative phase of the students’ lives [14, 47–50]. Appreciation and tolerance are topics that are difficult to convey in training or school. We noticed in our questionnaires that after interaction with their peers, students were generally appreciative of what they have at home—regardless of their home country. This is an area that is out of the scope of this monograph but warrants more investigation in the future.

Basic Sciences Experience

Our program differs from many GH and international programs in that we encourage students to undertake summer internships in basic sciences laboratories. There are reasons to choose basic sciences over clinical electives. First, students are in their preclinical years of education. Second, a basic science research experience is desired for certain training specialties [51, 52]. Third, we included future physician scientists in international exposure and enhance their understanding of international collaborations. We are targeting a group of academically interested students who otherwise may not seek international experiences in their training. Participation in an international laboratory will provide the students with the experience of academic life outside their own country—an experience difficult to achieve in a clinical rotation.

Cultural Competency and Exchange

Cultural competency is very important in medical education—particularly in this time of global mobilization. In this program students learn about other countries in the cultural exchange portion of the large videoconference and through interactions with their international peers (including participating in research abroad). This exercise is meant to heighten awareness of cultural differences, not only when dealing with patients but also when working with colleagues in other countries.

Leadership

Certain elements of our program are tailored towards students that are willing to take on extracurricular activities to practice ownership of projects, independence, and managerial skills. These can be helpful tools for leadership training. The international exchanges/travel and social media connections promote the bonding of these like-minded students.

Key Elements for Success

Our program success is based on key elements that we consider important. The suggestions listed below are in no particular order and will need to be adapted for individual programs and institutions.

The Right Partners

Selection of partners should align with the mission and vision of individual programs. The authors caution against selecting a program partner outside the home institution based on convenience (i.e., an existing personal connection) or seemingly popular for student travels (i.e., a country in Africa). It is important that the program benefits both partners and that partners are treated equally. If the goal of a program is to provide humanitarian work, partners have to be selected based on what type of help is requested. By selecting equal partners, we created a homogenous group of academically interested peers in different countries. This homogeneity seemed important for long-term networking goals. In our program, we aimed for our students to feel equal to one another. The dynamic of peer friendships can become unbalanced if one group feels inferior or superior to the other.

Commitment and Local Student Liaisons

We learned that committed contacts/partners are essential for the success of this program. Management of international exchange programs can be challenging especially with time zone differences and busy student schedules. In addition to local faculty, we introduced a local “national student leader” system. Each school selected a national student leader who acted as the point person for one school’s student cohort. By involving a peer, it also reduced the hesitation of students reaching out to their faculty. This student leader also represented the country at the international conference. This link proved to be essential in order to maintain communication with a large cohort of students outside one’s own institutions.

“Bottom Up” Approach

One important question to ask is for who this program is intended. Often, international programs are dictated by institutional needs of having “an” international program. The disadvantage of a “top down” approach is that faculty might select a partner and create a program independent of students’ needs. The strength of this program was the direct involvement of students in the program development. Student feedback in the form of a “bottom up” approach is essential for a successful program. The selection of countries, number of sessions, discussion topics, size of student groups, and the student exchanges stem from feedback of participating students in all countries. It is important to take these suggestions seriously.

A Formalized and Structured Program

When establishing an exchange program with junior students, we recommend a structured program. In our pilot project, we had left it at the students’ discretion to format the time they spent with each other. However, given the stage of the students’ academic life (some of the students had just graduated from high school), we noticed that students became unfocused and confused if too much independence was given. The gradual progression from guided online international connections to independent physical exchange visits proved to be a successful format and prepared our students well for their international internships.

The Need for a Commonality

Although medical school itself can be a common theme for the students, a precise commonality can aid in bonding and serve as an “ice breaker.” We chose Anatomy since it is taught ubiquitously and touches upon the concepts of life and death and ethical challenges as well as the sciences [50]. Since international programs do not have a common “home,” an anchoring department was helpful for faculty to connect as well.

Early Exposure

Many programs choose to involve clinical rotations to expose students to international experiences. We do agree that preclinical students will not be able to appreciate the difference of healthcare delivery in another country prior to exposure in their own country. However, as outlined before, international exposure can start during the junior years even if exchanges are not possible. Electives or courses on GH or interactions with international students can be integrated into their curriculum, may spike their interest, and can be maintained for the clinical years when clinical rotations become an option.

Role of Professional Societies

Historically, PH and GH education originated in the schools of public health. Only recently have medical and dental schools begun incorporating elements into their curriculum—often without an official home department. Finding partners, therefore, may be challenging. The majority of our partnerships were established through connections from professional societies (i.e., the Anatomical Society, American Association Anatomists, and medical research societies). In our search, we were surprised by the number of anatomists who were interested in or have been working on international collaborative PH and GH projects. Thus, these societies can serve as resources for IoME programs.

Sustainability and Resources

When starting new programs, a lack of funding can be a challenge. One key element in our success is the very limited need for resources from the budget-constrained participating schools and departments. Using resources that are readily available is helpful. The video sessions were held via commercial platforms such as “Skype,” “Zoom” and the conferences were held in the AV room of the libraries, lecture halls, or conference rooms. Student travels were supported by student stipends from various funding agencies or self-funded by students.

Dedicated Partners and Faculty

Lastly, dedicated partners and faculty are the most important element for sustainability and success. It is important to share individual goals with one another and for partners to feel equal in the collaboration. All of our partners are self-motivated and very involved. In addition, securing institutional support is helpful.

Challenges and Limitations

We are aware that our program has its limitations and challenges.

One major challenge was limited participation, due partly to restrictions in recruitment options (per IRB), and partly due to a demanding curriculum that might limit the students’ willingness to participate. In year 4, we had two groups withdraw from the large videoconference because of time constraints. We hope that over time, as more students benefit from this program, the senior students’ experiences will attract more junior students to participate.

We are aware that junior medical students do not have enough knowledge of all of the topics that were suggested in session 2—particularly, healthcare education systems, healthcare delivery systems, healthcare law, and healthcare ethics. However, as part of the exercise, we aimed to get the students interested in these areas and to research these subjects in conjunction with their international peers.

Securing funding for student travel was difficult, due to the nature of our exchange program. We do not partner with low-middle-income countries in this phase and most GH foundations will not provide research fellowships to students for basic sciences research.

Most importantly, a qualitative study is needed to investigate the value of this early international experience—beyond just the participating students’ perceptions and appreciation. Our questionnaires aimed to ascertain whether students liked the program and to learn what suggestions they had for future improvement. We limited the above to their subjective impressions regarding what they thought they had learned—without objective measurements. In our opinion, early exposure via IoME during the preclinical years can increase the chance of long-term sustainable international collaboration, and should be introduced early in a student’s medical education. Longitudinal studies will be needed to prove our hypothesis.

We are aware of a selection bias because these students volunteered, and thus are interested in international experience. Therefore, results from our questionnaires are not representative of all students.

Investigating the correlation between learning objectives and outcomes is beyond the scope of this descriptive article. While we intend to study this issue in the future, it is too early to measure what impact these interactions and experiences might have on future physicians and dentists.

Nevertheless, this Anatomy-based program with its simple structure and minimal requirement for resources has the potential to grow into a large-scale and sustainable internationalization program—leading to global connectedness among healthcare professionals (especially, future healthcare leaders), thereby facilitating international medical/healthcare collaboration and improving GH in the long-term.

Conclusion and Future Direction

In this preliminary study, we describe the development of an IoME program based on the Anatomy course. Specifically, we focused on the feasibility of the program format and what we learned during this process. True learning objectives and outcomes cannot be assessed here and were not the aim of the project—this will be studied at a later time. However, we can conclude that the students’ perception of their learning experience was positive, albeit very limited results on student travel are available at this point.

We connected future international colleagues and leaders in healthcare at a very early stage in their careers and hope to be able to contribute to leadership preparation.

Our vision is that this early bonding of future healthcare leaders will facilitate international collaboration on GH issues going forward. Future studies will provide data for our hypothesis. Tentatively, we plan a third in-person conference abroad, so that students can continue their friendships—subsequent to their summer research internships. Details are being worked out.

The format of our study can serve as a seed for future international activities in the clinical years and beyond. The majority of our students desired to see a continuation of the study into the clinical years. Therefore, our long-term goal is to initiate an official framework that offers students international exposure throughout all the years of medical school.

This novel approach via the Anatomy course has the potential to provide additional roles and usefulness in GH for traditional Anatomy courses worldwide—i.e., as a hub for international student collaborations, international forums to exchange thoughts on the topic of death, or for larger scale international student exchange programs [53].

Disclosure for Funding

This study was partially funded by the Virginia Apgar Society of Medical Educators, Columbia University, New York, NY.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Ethical Approval

This study was approved by IRB protocol # AAAO3715 (Columbia University) and protocol # A06-B42-17A (McGill University).