Embracing structured international health experiences in mainstream medical education is critical to the development of future doctors

Globalisation has dramatically changed and continues to change the way the world works. Societies, businesses and individuals are increasingly adapting to a world with fewer borders and geographical constraints than in the past.1 Global health has been defined as:

an area for study, research and practice that places a priority on improving health and achieving health equity for all people worldwide, [which] emphasises transnational health issues, determinants and solutions; involves many disciplines between and beyond the health sciences; and synthesises population-based prevention with individual-level care.2

Despite the emergence and establishment of global health as an academic discipline, it largely resides within public health education and practice, and is typically taught and learnt within Master of Public Health programs, rather than through experiences within mainstream medical education. In Australian and New Zealand medical programs, clinical learning with a global health focus is generally achieved through the inclusion of clinical placement electives that permit student-initiated and organised international health experiences (IHEs).2 In cases where the IHEs are arranged by the university, they are generally short and optional.

Market forces and increasing demand for international health experiences

Clinical learning beyond a medical student’s home university is a relatively new phenomenon, but IHEs have expanded dramatically over the past 30 years. In the United States, the proportion of graduating medical students who completed a clinical learning experience abroad was only 6% in 1978, but has risen progressively to 22% in 2004, and 31% in 2010.3,4 Estimates for the United Kingdom indicate that 90% of medical students undertake IHEs, with 44% doing these in developing countries.5 In Australia, the Medical Schools Outcomes Database shows that half of Australian medical students undertook an IHE elective between 2006 and 2010. Of those, the majority (59%) did so in lower or middle income countries.6

When combined with the growth of medical enrolments over the past decade,7 the actual number of Australian and New Zealand medical students undertaking clinical learning in international settings is significant. Interestingly, this rapid increase in global clinical learning has been driven almost entirely by student demand and has been predominantly organised by students.2,3

The value proposition of global experiences

A recent report commissioned by Universities Australia8 highlighted the benefits of global experiences to students in a range of disciplines, and to the nation. These include promoting deep learning and cognitive development in relation to cultural differences; and encouraging civic engagement, including increased understanding of moral and ethical issues, openness to diversity, more positive perceptions of multiculturalism, and greater levels of tolerance and the reduction of ethnocentrism. These are qualities that, if held by future medical graduates, will promote the health of the multicultural Australian community and the broader global community.

In medicine specifically, there is consistent evidence for the educational and personal benefits of IHEs in both pre-certification and early post-practice settings, as well as their broader value for the health care system. A number of qualitative and quantitative evaluations, including those comparing medical students who have undertaken IHEs with those who have not, have shown the positive impact of IHEs on personal consultation, clinical and diagnostic skills;3,9,10 significantly higher average scores in the preventive medicine and public health portions of the National Board of Medical Examiners assessments;11 and a greater appreciation of the importance of public health, health service delivery and cross-cultural communication.3,9–12 Further, an increased appreciation of the role of primary care and the importance of addressing the unmet needs of under-served communities is demonstrated by the career destinations of these graduates.3,10

Many global student experiences take place between two developed countries. While these IHEs have advantages in terms of risk minimisation for students, they can limit the potential benefits that might present with experiences in developing countries. A frequent theme that emerges from evaluations is the way in which IHEs can facilitate a personal transformation in medical students’ attitudes and cultural sensitivities.3 Jacobs and colleagues emphasised the value of students experiencing cultures, health systems and learning environments different from their own when they undertake an IHE, and being able to compare different health systems and cultures in such transformative learning. They noted that the “perception of differences between the cultures resulted in a rethinking of the participants’ own views, attitudes, and actions”.12 Experiences where students undertake electives in developing countries provide this opportunity for greater comparative learning, because of the stark differences in case mix, culture and health systems between developed and developing countries. However, associated risk factors and perceived “voluntourism” raise concerns for medical schools.2 Although understandable, a focus on risk instead of opportunity has the potential to limit what could be achieved through a more open approach to medical education that embraces global health experiences. Such an approach can lead to stronger graduate outcomes, especially in the domains of citizenship and professionalism, and to positive impacts on patient outcomes and the health care systems in the host and home countries.3,8,11

Medical schools’ responsibilities in international health electives

The involvement of Australian and New Zealand medical schools in quality assuring IHEs is critical, especially in an environment where the student demand to undertake global clinical experiences is rising. Medical schools are required by the Australian Medical Council to provide “opportunities for students to pursue studies of choice that promote breadth and diversity of experience”.13 Medical schools largely address this requirement by including an elective term within the clinical placement component of their programs. In the US, the equivalent accrediting body has recently mandated pre-departure training for IHEs for accredited medical schools.14

Australia’s Tertiary Education Quality and Standards Agency (TEQSA) has a strong quality framework concerning domestic student study abroad, designed to “assure that a provider’s responsibilities under the TEQSA Act and the Higher Education Framework are upheld and maintained where the provider is involved in offshore higher education provision”.15 This responsibility includes the quality assurance of student support and course delivery, and the equivalence of student learning outcomes. By virtue of the tendency to frame IHEs within electives, the quality assurance of learning and assessment, and the assessment of the adequacy of such experiences by accrediting bodies, may not be as robust as other more formalised clinical placement experiences. Is it time for medical schools to consider the purposeful creation and inclusion of more structured, quality assured and, where possible, longitudinal global health experiences within their medical programs? This would best be achieved through the establishment of strong and mutually beneficial partnerships with international organisations, universities and health care providers.9 Further, a set of rigorous academic standards and clearly stated outcomes that respond to clinical needs and students’ desired developmental goals should be developed to ensure the implementation of evaluation, review and improvement cycles.

Conclusion

Medical education is not immune to globalisation. The strong demand from Australian students for global clinical learning, and their mobilisation to deliver opportunities that meet this demand, including the creation of student international health organisations,16 indicate the value that students place on IHEs. There is demonstrable educational value in clinical learning abroad, and it is timely for medical schools and accrediting bodies to advance the study of global health beyond Master of Public Health programs by integrating IHEs into existing medical curricula.