International Health Electives Research Articles

International Health Electives: defining learning outcomes for a unique experience

BackgroundAn International Health Elective (IHE) can be a unique learning experience for students. However, it has proven difficult to clearly define learning outcomes that capture the complexity of an IHE and are aligned with future professional performance. This study aimed to further define learning outcomes for IHEs in low- to middle-income countries (LMIC) from a student perspective.MethodsWe conducted a deductive analysis of pre-departure and post-elective reflective reports of fifth-year medical students who participated in an IHE as part of their program. This provided possible learning objectives that were further explored in semi-structured individual interviews with medical students who had recently returned from an IHE.ResultsWe analyzed 33 reports of students participating in an IHE from 2017–2019 and held 19 interviews. Thematic analysis revealed 9 themes: developing intercultural competence, developing appreciation for differences in health care delivery systems, understanding international health, understanding the global burden of disease, developing a career perspective, developing clinical skills in resource low settings, becoming cost conscious, developing social responsibility and self-actualization.ConclusionsWe identified 9 learning outcomes that are directly and indirectly related to clinical practice. They add to the on-going discourse on the benefits of IHEs. These outcomes can be further developed by investigating the perspectives of home and host supervisors and educationalists, while taking the local context into account. Follow-up studies can evaluate to what extend these outcomes are achieve during an IHE.

Opportunities, barriers and expectations toward international voluntary medical missions among health trainees in Saudi Arabia.

The objective is to assess the feasibility, barriers, expectations and motivation of health trainees in Saudi Arabia regarding medical missions. This study seeks to fill the gap in global health curricula and regulations, as well as provide guidance for trainees participating in international health electives in Saudi Arabia. This cross-sectional survey of health trainees (in medical, surgical and other allied health professions) was conducted across Saudi Arabia from March 2017 to February 2018 using a standardised survey adapted to assess expectations, barriers, awareness of available opportunities and the effect of mentorship in improving motivation toward medical missions. A total of 589 respondents completed the survey, with a response rate of 83.7%. Most respondents were under 35 years old, with an equal sex distribution. Furthermore, the respondents primarily had medical and surgical specialties training and graduated from the western region of Saudi Arabia. Health trainees who considered volunteering during training but did not have previous experience in missions acknowledged that the presence of a staff member experienced in missions in their training environment positively affected their interest in missions (p = 0.038). The most common reasons for interest in volunteerism were to enhance one's own technical and clinical skills and help others in need. Interest in tourism and learning about new cultures are additional reasons. Only 7/589 participants had experience and expressed the barriers they faced during volunteerism. Interestingly, their colleagues who did not have a similar experience perceived almost the same barriers. A major barrier faced by experienced participants was the 'lack of elective time', compared to the 'lack of available organised opportunities' by the inexperienced group. In conclusion, coordinating health trainees' missions through a unified authoritative body would provide better opportunities, override challenges and improve their perceptions and participation in these missions.

Residents' Reflections on Cost-Conscious Care after International Health Electives: A Single-Center Qualitative Study.

Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC). The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC. The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees' IHE experiences to characterize their perceptions of HVCCC. The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020. The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC. GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills. IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees' ideology of and commitment to HVCCC practices.

Limited availability of global health opportunities in US orthopaedic trauma fellowship programs.

Purpose:Orthopaedic residents are increasingly seeking international health electives (IHEs) during training, and many such experiences involve providing orthopaedic trauma care. However, little is known about the availability of IHEs during orthopaedic trauma fellowship training. The purpose of our study is to assess the global health opportunities available to US orthopaedic trauma fellows.Method:We conducted an online, Research Electronic Data Capture (REDCap)-based survey of orthopaedic trauma fellowship program directors (PDs) in the United States. The survey link was sent by the Orthopaedic Trauma Association (OTA) Fellowship Committee to all US OTA-approved orthopaedic trauma fellowship PDs. Follow-up reminder e-mails were delivered at set time intervals from baseline over a period of 4 weeks.Results:The overall response rate was 80% (43/54). Only 3 of 43 responding programs (7%) offer a structured global health program, but over the last 10 years, 12.5% of the remaining programs (5/40) have had a fellow participate in an IHE during fellowship training. Around 100% of PDs reported fellow satisfaction with their IHEs, and all PDs agreed that the educational experience provided by their fellows’ IHE participation was valuable. Among programs with no recent fellow IHE participation and without a structured global health program, 9% of PDs (3/35) expect to institute such a program. Lack of funding, lack of established international partner sites, and fellow time away were the most common perceived barriers to IHE participation. A total of 54% of PDs agree that participation in an IHE during training plays a major role in shaping fellows’ future professional and volunteer activities.Conclusion:There are limited global health opportunities among US orthopaedic trauma fellowship programs, with only 7% (3/43) offering a structured global health program. Perceived barriers include lack of funding, lack of established partner sites, and concerns related to clinical/call coverage. Greater efforts to establish sustainable funding and international partnerships may increase opportunities for IHEs during orthopaedic trauma fellowship training.

Dealing With Patient Death on International Health Electives: A Qualitative Study of Residents' Experiences.

International health electives (IHEs) provide numerous educational benefits; potential harms are less well understood. One potential harm is trainee distress associated with increased patient death during IHEs. The purpose of this study was to explore residents' and fellows' IHE experiences with patient death. The authors used applied thematic analysis to explore residents' and fellows' IHE experiences with patient death. The Mayo International Health Program supports IHEs from all specialties across three Mayo Clinic sites. Data were collected and analyzed in two steps. First the authors collected, coded, and analyzed narrative reflections from 43 postrotation reports gathered in 2001-2017 and identified themes relating to experiences with patient death. Second, in 2016-2017 the authors conducted semistructured interviews with six previous participants to refine thematic analysis. Participants described impacts of experiencing increased patient death and identified themes in two domains: difficult experiences with patient death and potential interventions to help residents process their experiences. They identified four themes illustrating why these experiences were difficult: lack of preparation for increased exposure to death, lack of closure, consequences of limited resources, and differences in cultural beliefs regarding death. While pretrip preparation for dealing with death was viewed as important, trainees identified support during and debriefing after IHEs as additional important interventions. Given the popularity of IHEs, residency programs should consider the effect on trainees of increased exposure to patient death. Study findings can inform IHE preparation, support, and debriefing to minimize distress associated with witnessing patient deaths on IHEs.

A new vision for bioethics training in global health

A new vision for bioethics training in global health

Availability of global health opportunities in North American Paediatric Orthopaedic Fellowship Programmes.

PurposeOrthopaedic residents are increasingly seeking international health electives (IHEs) during training, many of which involve providing paediatric orthopaedic care. However, little is known about the availability of IHEs during orthopaedic fellowship training. Our study sought to assess the global health opportunities available to North American paediatric orthopaedic fellows.MethodsWe conducted an online, REDCap-based survey of paediatric orthopaedic fellowship programme directors (PDs) in the United States and Canada. The survey link was sent by the Pediatric Orthopaedic Society of North America (POSNA) Evidence-Based Medicine Committee to all POSNA-approved paediatric orthopaedic fellowship PDs. Follow-up reminder emails were delivered at set time intervals.ResultsThe overall response rate was 55% (26/47). Only three of 26 responding programmes (11.5%) offered a structured global health programme but 42.3% of programmes (11/26) reported fellow IHE participation within the last ten years. In all, 91% of PDs reported that fellows were extremely satisfied with their IHE, and 91% agreed that IHEs are valuable for trainees. Perceived barriers to fellow participation in IHEs included lack of funding, lack of established partner sites, lack of interest among fellows and concerns related to time away compromising clinical/call coverage. In all, 65.4% of PDs agree that IHE participation during training plays a major role in shaping fellows’ future volunteer activities.ConclusionThere are limited global health opportunities among North American paediatric orthopaedic fellowship programmes, with only 11.5% offering a structured global health programme. Greater efforts to establish sustainable funding and international partnerships may increase opportunities for IHEs during paediatric orthopaedic fellowship training.Level of EvidenceLevel II

What do international health electives and state examination scores have in common? - A cohort study to compare the results of written medical licensing examinations with the participation in international health electives during the final year of undergraduate medical education in Germany.

Objective: The final year of undergraduate medical education in Germany is called the practical year (PY), where emphasis is placed on developing practical skills requisite of soon-to-be physicians. Many students choose to spend part of this year abroad, yet little is known about their results on the medical licensing examinations. Is there a predisposition of high-performing students to go abroad as compared to lower performers? Are international health electives during the PY followed by higher scores in the final section of the German medical licensing examination (GMLE2)?Methods: We conducted a retrospective cohort study among undergraduate medical students at the LMU Munich, who participated in the final section of the German medical licensing examination between autumn 2009 and spring 2011. Of the 1,731 eligible students, 554 (32%) participated in our study. We analyzed for statistical associations of international health electives with written test scores of both sections of the medical licensing examination as well as grades earned during medical school training. We then used multiple regression analysis to identify relevant predictors of GMLE2 scores.Results: Approximately half of study participants pursued international health electives during the PY (51.1%). The number of students going abroad increased with the scores achieved on the first section of the medical licensing examination (GMLE1, p<0.001). Stratified by their GMLE1 scores students who pursued electives abroad during their PY achieved higher GMLE2 scores (p<0.001). The strongest predictor for GMLE2 scores were grades obtained during medical school training; age and study duration indicated lower scores; and those engaging in international health electives correlated with higher scores.Conclusions: Students with higher GMLE1 scores go abroad during PY more often. Beyond that, students who pursue international health electives achieve higher GMLE2 scores than those who stay in Germany during PY. There is an unmet need for additional research to identify which factors make these students perform better and what motivates them to go abroad.

Medical students' perception of international health electives in the undergraduate medical curriculum at the College of Medicine, King Saud University.

BackgroundInternational health electives prepare medical students during their student years of medical education in choosing, matching, and succeeding in the residency of their choice. They serve as a unique educational experience prior to residency training.ObjectiveThis study was conducted to explore 4th- and 5th-year medical students’ perspective about international health electives and to evaluate their educational effects.MethodsAn anonymous online survey with 22 items concerning perceptions about the electives with a 5-point Likert scale was administered to medical students at the College of Medicine, King Saud University.ResultsFor the majority of the students (81.6%) the elective course was arranged by the university and only 18.4% of students individually arranged their own. Most of the students (65.7%) agreed that the objective of the elective course was clear to them in advance. A total of 71.1% of students agreed that the program (elective) was responsive to their needs (both academically and socially).ConclusionThis is the first study looking at international electives in the context of the undergraduate medical curriculum in Saudi Arabia. The study showed that the international electives are a useful and unique experience for medical students (both academically and socially).

Transformative Learning and Professional Identity Formation During International Health Electives: A Qualitative Study Using Grounded Theory.

International health electives (IHEs) are widely available during residency and provide unique experiences for trainees. Theoretical models of professional identity formation and transformative learning may provide insight into residents' experiences during IHEs. The purpose of this study was to explore transformative learning and professional identity formation during resident IHEs and characterize the relationship between transformative learning and professional identity formation. The authors used a constructivist grounded theory approach, with the sensitizing concepts of transformative learning and professional identity formation to analyze narrative reflective reports of residents' IHEs. The Mayo International Health Program supports residents from all specialties across three Mayo Clinic sites. In 2015, the authors collected narrative reflective reports from 377 IHE participants dating from 2001 to 2014. Reflections were coded and themes were organized into a model for transformative learning during IHEs, focusing on professional identity. Five components of transformative learning were identified during IHEs: a disorienting experience; an emotional response; critical reflection; perspective change; and a commitment to future action. Within the component of critical reflection, three domains relating to professional identity were identified: making a difference; the doctor-patient relationship; and medicine in its "purest form." Transformation was demonstrated through perspective change and a commitment to future action, including continued service, education, and development. IHEs provide rich experiences for transformative learning and professional identity formation. Understanding the components of transformative learning may provide insight into the interaction between learner, experiences, and the influence of mentors in the process of professional identity formation.

6 - Qualitative Analysis of Post-Travel Reflection Essays From An International Health Elective in Tanzania

6 - Qualitative Analysis of Post-Travel Reflection Essays From An International Health Elective in Tanzania

Using multiple mini interviews as a pre-screening tool for medical student candidates completing international health electives

ABSTRACTThere continues to be an increase in the number of learners who participate in international health electives (IHEs). However, not all learners enter IHEs with the same level of knowledge, attitude, and previous experience, which puts undue burden on host supervisors and poses risks to student and patient safety. The Multiple Mini-Interview (MMI) is a technique that has become a popular method for undergraduate and postgraduate-level health science admissions programs. This paper describes the MMI process used by our program to screen first-year medical students applying for pre-clinical IHEs. Two country-specific cases were developed to assess non-cognitive skills. One hundred percent (100%) of the students (n = 48) and interviewers (n = 10) who participated in MMIs completed anonymous surveys on their experience. The majority of students rated the scenarios as realistic (>90%); 96% found the MMI format fair and balanced; 96% of students felt that they were able to clearly articulate their thoughts; 75% of students stated that they had a general understanding of how the MMIs worked; only 33% of students would have preferred a traditional one-to-one interview. Feedback from both interviewers and students was positive toward the MMI experience, and no students were identified as unfit for participation. Ultimately, 43 students participated in pre-clinical IHEs in 2016. In this paper, we will outline our MMI process, detail shortcomings, and discuss our next steps to screen medical students for IHEs.

Applicants' Interest in International Ophthalmology during Residency Training: Influence in Selecting U.S. Residency Programs

Background In recent years, the Accreditation Council for Graduate Medical Education (ACGME) Residency Committee for Ophthalmology formally recognized international health electives for credit. By engaging in international health experiences, ophthalmology residents achieve the anchors essential to the core competencies set forth by the ACGME. Objective To explore how the availability of international ophthalmology opportunities may influence applicants' selection of U.S. ophthalmology residency programs and to identify applicants' perceived goals and barriers of participation in international ophthalmology experiences. Methods For this cross-sectional study, an electronic invitation to a 22-item questionnaire was sent to all 413 applicants to the ophthalmology residency program at the Penn State Eye Center during the 2017 Match. Results Responses were received from 261 applicants, yielding a response rate of 63.2%. Nearly all respondents (95.4%) reported interest in participating in an international ophthalmology experience during residency training, with 52.1% of respondents reporting being “extremely interested.” More than half of respondents (53.6%) had previously participated in a healthcare-related experience in an international setting. The availability of international opportunities increased the interest of 67.4% of respondents when choosing which residency programs to apply to, and influenced 65.2% of respondents to rank a residency program higher, with the respondents with previous international experience more likely to be favorably influenced (p &lt; 0.001, p = 0.04, respectively). The goal identified by the largest number of respondents as “most important” was to “offer service to the underserved” (59.0%). The most commonly identified anticipated barriers to participating in an international experience during residency training included concern about scheduling conflicts and call coverage (81.7%), followed by lack of funding (71.4%). Conclusion There is significant interest in international ophthalmology among ophthalmology residency applicants, and the availability of international opportunities during training may influence the applicants' selection of programs. Statistically significant differences were found among respondents with and without previous international healthcare-related experience. These findings warrant further investigation into how residency programs can best address this interest and integrate international ophthalmology experiences into the residency curriculum.

Graduate medical education competencies for international health electives: A qualitative study

Background: Residency programs offer international health electives (IHEs), providing multiple educational benefits. This study aimed to identify how IHEs fulfill the Accreditation Council for Graduate Medical Education (ACGME) core competencies.Methods: We conducted a thematic analysis of post-rotation reflective reports from residents who participated in IHEs through the Mayo International Health Program. We coded reports using a codebook created from the ACGME competencies. Using a constant comparative method, we identified significant themes within each competency.Results: Residents from 40 specialties participated in 377 IHEs in 56 countries from 2001 to 2014. Multiple themes were identified within each of the six ACGME core competencies: Patient Care and Procedural Skills (4), Medical Knowledge (5), Practice-Based Learning and Improvement (3), Interpersonal and Communication Skills (5), Professionalism (4), and Systems-Based Practice and Improvement (3). Themes included improving physical exam and procedural skills, providing care in resource-limited setting, gaining knowledge of tropical and non-tropical diseases, identifying socioeconomic determinants of health, engaging in the education of others, and increasing communication across cultures and multidisciplinary teams.Conclusions: Through IHEs, residents advanced their knowledge, skills, and attitudes in each of the six ACGME competencies. These data can be used for development of IHE competencies and milestones for resident assessment.

Avoiding pitfalls in overseas medical educational experiences

In the United States, there are a growing number of medical students participating in international health electives. These experiences have the potential to be mutually beneficial to both the host country and the student. However, there is a significant risk of unethical and damaging practices during these trips, including concerns for sending trainees without appropriate pre-travel preparation with inadequate accountability to local health care providers at a stage in their education that imposes an undue burden on the local health facilities. This article describes one first year medical student’s experience in navigating common challenges faced in international health electives and offers practical advice enlightened by the literature on how to overcome them. We emphasize the need for students to ensure adequate pre-trip preparation, communicate their level of training clearly, practice cultural humility, ensure personal safety, and engage in projects needed by the host community.

Exploration of Learning during an International Health Elective Using Photovoice Methodology.

Based on surveys and structured interviews, International Health Experiences (IHEs) improve cultural sensitivity, communication, and self-confidence among health professions students. However, open-ended methods to explore student learning during an IHE are not widely utilized. We sought to explore pharmacy student-identified learning during an IHE in an open-ended fashion using Photovoice methodology. Pharmacy students on an IHE in Guatemala were given disposable cameras and asked to photograph images that reflected their learning. Through the application of Photovoice methodology students captured, reflected upon, and presented photos to describe the learning they experienced. Themes were drawn from the reflective and focus group data collected. During three IHEs, six students captured seventy-seven photos. Four main learning themes emerged: culture/cultural competence, professional growth, shifting of attitudes, and meaningful/emotional experiences. Pharmacy students documented learning in expected (cultural competence, professional growth) and unexpected (emotional experiences) domains during an IHE. Photovoice may be an effective methodology for the exploration of learning, allowing students to capture their own learning including and beyond what is expected by their instructors.

How do international health electives impact medical students in their long term career paths?

How do international health electives impact medical students in their long term career paths?

High Disparity Between Orthopedic Resident Interest and Participation in International Health Electives.

Few orthopedic surgical residency programs offer international health electives (IHEs). Efforts to expand these programs have been increasing across medical disciplines. Whether orthopedic residents will participate remains unknown. This study quantified and characterized orthopedic resident interest and barriers to IHEs in US residency programs. A web-based survey was administered to residents from 154 US orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education 2014 to 2015. Questions assessed demographics and program background, previous medical experience abroad, barriers to participation, and level of interest in participating in an international health elective during their training and beyond. Twenty-seven (17.5%) residency programs responded. Chi-square analysis showed that residents who expressed interest in participating were significantly more likely to have experience abroad compared with those who expressed no interest (P<.004). Analysis using Mann-Whitney U test suggested that those who expressed interest were more likely to believe IHEs are important to resident training (P<.0011; mean Likert scale score of 3.7 vs 2.6), provide valuable experience (P<.001; mean Likert scale score of 4.2 vs 3.2), and should be required for orthopedic residencies (P<.001; mean Likert scale score of 2.8 vs 1.9). Residents are strongly interested in participating in IHEs during their training, and many may integrate global health into future practices. Residents perceive lack of funding and scheduling flexibility as barriers preventing them from participating. Prior experience abroad influences level of interest, and international clinical experience may enhance future perception of its value. [Orthopedics. 2016; 39(4):e680-e686.].

McMaster University Internal Medicine International Health Elective: A Survey-Based Study to Understand Achievements and Lessons Learned

The McMaster Internal Medicine International Health Elective (IHE) has been placing senior medical residents (PGY-3) in an elective setting in a teaching hospital in Kampala, Uganda, for the past 7 years. This article discusses a study in which the authors electronically mailed a survey to alumni of this elective to evaluate important aspects of program participation from the residents’ point of view. The factors most commonly cited as being important in the decision to apply to the McMaster IHE were to gain experience practising medicine in a resource-limited setting and to gain exposure to diseases and conditions not commonly encountered in Canada. Most residents (61.5%) planned to have some involvement in global health prior to their elective, and 100% felt the elective experience made them more likely to take part in global health activities in the future. IHEs offer a unique opportunity for residents to explore global health. Residents participating in this survey found the McMaster Internal Medicine IHE to be a successful endeavour.

Preparing students for the ethical challenges on international health electives: A systematic review of the literature on educational interventions

International health electives pose specific ethical challenges for students travelling from to low and middle income countries. We undertook a systematic review of the literature on interventions to prepare students to identify ethical issues addressed, educational approaches and to collate evidence on the effectiveness of different strategies. We searched nine electronic databases of peer-reviewed literature and identified grey literature through key word searches; supplemented through citation mapping and expert consultation. Articles that described ethical training conducted by universities or professional bodies were included for review. We reviewed forty-four full text articles. Ten sources of published literature and seven sources of grey literature met our inclusion criteria. We identified thirteen ethical situations that students should be prepared to manage and eight generic skills to support this process. Most interventions were delivered before the elective, used case studies or guidelines. Some suggested ethical principles or a framework for analysis of ethical issues. Only two papers evaluated the intervention described. Our paper collates a small but growing body of work on education to prepare students to manage ethical issues. Ethical training should have elements that are delivered before, during and after the elective. Interventions should include case studies covering thirteen ethical issues identified here, linked to ethical principles and a process for responding to ethical issues. We suggest that evaluations of interventions are an important area for future research.