Reframing undergraduate medical education in global health: Rationale and key principles from the Bellagio Global Health Education Initiative

Medical students' experience and learning outcomes of overseas community involvement project: a qualitative study

BACKGROUND

Medical students in Singapore engage in short term medical missions, locally known as Overseas Community Involvement Projects (OCIPs). Little is known about the learning outcomes of an OCIP and how this complements their medical education back home. Understanding this can help the medical educators structure the OCIP to optimise its learning value.

OBJECTIVES

This study aims to gain an in-depth understanding of the experiences and learning outcomes of the medical students who participated in the OCIP.

METHODS

This was a qualitative study involving Singaporean students from one medical school travelling to Nepal. Data was collected from reflective journals, overall group reflections and two focus group discussions. The data was thematically analysed using the Accreditation Council for Graduate Medical (ACGME) core competencies for medical professionals.

RESULTS

The data could be classified under various themes within the six domains of the ACGME framework. The study revealed themes of: humanism, socioeconomic and cultural determinants of health under the domain of patient care, application of medical knowledge, investigating and evaluating the needs of a population and feedback to drive improvement under the domain of practice-based learning and improvement, use of non-verbal cues and communicating across language barriers under the domain of interpersonal and communication skills, healthcare systems and delivery, resourcefulness and adaptability, health equity and accessibility under the domain of systems-based practice, ethics, role-modelling, teamwork and leadership skills, interprofessional skills and resilience under the domain of professionalism. Understanding the students' motivations, utilising reflections, and following the patients' journey facilitated attainment of these outcomes.

CONCLUSIONS

This OCIP experience translated to learning outcomes aligned with the ACGME framework. There is great potential for the experiential learning from a well-structured OCIP to help with personal and professional development and global health education.

International short-term placements in health professions education-A meta-narrative review

INTRODUCTION

In order to be prepared for professional practice in a globalised world, health professions students need to be equipped with a new set of knowledge, skills and attitudes. Experiential learning gained during an international placement has been considered as a powerful strategy for facilitating the acquisition of global health competencies. The aim of this review was to synthesise the diverse body of empirical research examining the process and outcomes of international short-term placements in health professions education.

METHODS

A systematic review was conducted using a meta-narrative methodology. Six electronic databases were searched between September 2016 and June 2022: Medline, Embase, CINAHL, PsycINFO, Education Research Complete and Web of Knowledge. Studies were included if they reported on international placements undertaken by undergraduate health professions students in socio-economically contrasting settings. Included studies were first considered within their research tradition before comparing and contrasting findings between different research traditions.

RESULTS

This review included 243 papers from 12 research traditions, which were distinguished by health profession and paradigmatic approach. Empirical findings were considered in four broad themes: learner, educational intervention, institutional context and wider context. Most studies provided evidence on the learner, with findings indicating a positive impact of international placements on personal and professional development. The development of cultural competency has been more focus in research in nursing and allied health than in medicine. Whereas earlier research has focussed on the experience and outcomes for the learner, more recent studies have become more concerned with relationships between various stakeholder groups. Only few studies have looked at strategies to enhance the educational process.

CONCLUSION

The consideration of empirical work from different perspectives provides novel understandings of what research has achieved and what needs further investigation. Future studies should pay more attention to the complex nature of the educational process in international placements.

Applicability of working abroad for physicians with a specialization in Global Health and Tropical Medicine

BACKGROUND

In The Netherlands, physicians specialized in global health and tropical medicine (Ps-GHTM) are trained to work in low-resource settings (LRS) after their training program of 27 months. After working for a period of time in LRS, many Ps-GHTM continue their careers in the Dutch healthcare system. While there is limited evidence regarding the value of international health experience for medical students and residents, it is unknown to what extent this applies to Ps-GHTM and to their clinical practice in the Netherlands.

METHODS

In this qualitative study we conducted semi-structured interviews and focus group discussions (FGDs) with Ps-GHTM to explore the perceived applicability of their experience abroad for their subsequent return to the Netherlands. Topic guides were developed using literature about the applicability of working abroad. Findings from the interviews served as a starting point for FGDs. The interviews and FGDs were analysed using directed content analysis.

RESULTS

15 themes are described relating experience abroad to healthcare delivery in The Netherlands: broad medical perspective, holistic perspective, adaptive communication skills, creativity, flexibility, cultural awareness, self-reliance, clinical competence, cost awareness, public health, leadership, open-mindedness, organization of care, self-development, and teamwork. Highlighting the variety in competencies and the complexity of the topic, not all themes were recognized by all respondents in the FGDs nor deemed equally relevant. Flexibility, cultural awareness and holistic perspective are examples of important benefits to work experience in LRS.

CONCLUSION

Ps-GHTM bring their competencies to LRS and return to the Netherlands with additionally developed skills and knowledge. These may contribute to healthcare delivery in the Netherlands. This reciprocal value is an important factor for the sustainable development of global health. Identifying the competencies derived from work experience in LRS could give stakeholders insight into the added value of Ps-GHTM and partly help in refining the specialization program.

International Health Electives: defining learning outcomes for a unique experience

BACKGROUND

An 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.

METHODS

We 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.

RESULTS

We 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.

CONCLUSIONS

We 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.

Challenges and opportunities for educating health professionals after the COVID-19 pandemic

The education of health professionals substantially changed before, during, and after the COVID-19 pandemic. A 2010 Lancet Commission examined the 100-year history of health-professional education, beginning with the 1910 Flexner report. Since the publication of the Lancet Commission, several transformative developments have happened, including in competency-based education, interprofessional education, and the large-scale application of information technology to education. Although the COVID-19 pandemic did not initiate these developments, it increased their implementation, and they are likely to have a long-term effect on health-professional education. They converge with other societal changes, such as globalisation of health care and increasing concerns of health disparities across the world, that were exacerbated by the pandemic. In this Health Policy, we list institutional and instructional reforms to assess what has happened to health-professional education since the publication of the Lancet Commission and how the COVID-19 pandemic altered the education process.

Preparation, relationship and reflection: Lessons for international medical electives

Background:

International medical electives (IMEs) provide opportunities for global health education within undergraduate medical curricula; however, ethical and practical preparations vary.

Methods:

Single-centre, prospective, mixed-methods study, utilising online questionnaires with students and host supervisors, contemporaneous reflective diaries and focus groups, to explore the preparedness and experiences of final-year UK medical students undertaking IMEs.

Results:

Students experienced communication challenges and felt underprepared prior to IME. Students undervalued cultural preparation, whereas host supervisors primarily desired humility and cultural sensitivity. Visitors to high-income countries underpredicted cultural differences with reflective practice supporting understanding of global health inequalities. Burden on hosts and ethical dilemmas related to acting beyond competence remained significant concerns.

Discussion:

International medical electives provide experiential learning, and with authentic reflection facilitate professional development. Enhanced culturally competent preparation and debriefing is however essential for collaborative and responsible student learning. Acting beyond competency persists, requiring concerted reform during the pandemic-mandated hiatus of IMEs.

Global health education in China's medical schools: A national cross-sectional study

INTRODUCTION

Despite China's large and growing global presence, data about global health (GH) education (GHE) in China's medical schools are limited. We aimed to describe GHE in these schools and determine whether some may teach GH concepts without labeling them as such.

METHODS

In 2019, 161 Chinese medical schools eligible for accreditation by the Ministry of Education were invited to complete a questionnaire as part of a national survey. Data were analyzed using descriptive analyses, Chi-square tests, Fisher exact tests, and logit models.

RESULTS

Approximately 57% of schools completed the survey (n = 93). 33 (35.5%) indicated that GHE was included in the curriculum. Although the majority of responding schools reported the absence of GH in the curriculum, GH topics were identified at many institutions. Schools affiliated with the central government or an aspiring world-class university were more likely to report the inclusion of GHE and offered more opportunities at international away sites.

CONCLUSIONS

Chinese medical schools are frequently teaching GH topics, but may not label the instruction as such. Policy-makers and educators should be equipped with a global perspective to facilitate GHE at China's medical schools and take measures to address differences between schools.

Whose voices should shape global health education? Curriculum codesign and codelivery by people with direct expertise and lived experience

There are contrasting opinions of what global health (GH) curricula should contain and limited discussion on whose voices should shape it. In GH education, those with first-hand expertise of living and working in the contexts discussed in GH classrooms are often absent when designing curricula. To address this, we developed a new model of curriculum codesign called Virtual Roundtable for Collaborative Education Design (ViRCoED). This paper describes the rationale and outputs of the ViRCoED approach in designing a new section of the Global Health Bachelor of Science (BSc) curriculum at Imperial College London, with a focus on healthcare in the Syrian conflict. The team, importantly, involved partners with lived and/or professional experience of the conflict as well as alumni of the course and educators in all stages of design and delivery through to marking and project evaluation. The project experimented with disrupting power dynamics and extending ownership of the curriculum beyond traditional faculty by codesigning and codelivering module contents together with colleagues with direct expertise and experience of the Syrian context. An authentic approach was applied to assessment design using real-time syndromic healthcare data from the Aleppo and Idlib Governorates. We discuss the challenges involved in our collaborative partnership and describe how it may have enhanced the validity of our curriculum with students engaging in a richer representation of key health issues in the conflict. We observed an enhanced self-reflexivity in the students’ approach to quantitative data and its complex interpretation. The dialogic nature of this collaborative design was also a formative process for partners and an opportunity for GH educators to reflect on their own positionality. The project aims to challenge current standards and structures in GH curriculum development and gesture towards a GH education sector eventually led by those with lived experience and expertise to significantly enhance the validity of GH education.

Global health classroom: mixed methods evaluation of an interinstitutional model for reciprocal global health learning among Samoan and New Zealand medical students

Background

Global health education partnerships should be collaborative and reciprocal to ensure mutual benefit. Utilisation of digital technologies can overcome geographic boundaries and facilitate collaborative global health learning.

Global Health Classroom (GHCR) is a collaborative global health learning model involving medical students from different countries learning about each other’s health systems, cultures, and determinants of health via videoconference. Principles of reciprocity and interinstitutional partnership informed the development of the GHCR. This study explores learning outcomes and experiences in the GHCR between students from New Zealand and Samoa.

Methods

This study used a mixed methods approach employing post-GHCR questionnaires and semi-structured face-to-face interviews to explore self-reported learning and experiences among medical students in the GHCR. The GHCR collaboration studied was between the medical schools at the University of Otago, New Zealand and the National University of Samoa, Samoa.

Results

Questionnaire response rate was 85% (74/87). Nineteen interviews were conducted among New Zealand and Samoan students. Students reported acquiring the intended learning outcomes relating to patient care, health systems, culture, and determinants of health with regards to their partner country. Interview data was indicative of attitudinal changes in relation to cultural humility and curiosity. Some reported a vision for progress regarding their own health system. Students in the GHCR reported that learning with their international peers in the virtual classroom made learning about global health more real and tangible. The benefits to students from both countries indicated reciprocity.

Conclusions

This study demonstrates GHCR to be a promising model for collaborative and reciprocal global health learning using a student-led format and employing digital technology to create a virtual classroom. The self-reported learning outcomes align favourably with those recommended in the literature. In view of our positive findings, we present GHCR as an adaptable model for equitable, collaborative global health learning between students in internationally partnered institutions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00755-8.

Support for global health and pandemic preparedness in medical education in Germany: Students as change agents

The COVID‐19 pandemic has reinforced Germany's role as global health player, but the education system is lagging behind and does not adequately prepare health professionals for the new challenges. This study aims to strengthen global health in undergraduate medical education in Germany. Major objectives include: to review the current situation, explore changing demand for global health and introduce innovative teaching models and the drivers for change. Mixed methods and an explorative approach were applied, comprising a scoping review, online surveys carried out at Hanover Medical School, March/April 2020. Target groups were undergraduate medical students (n = 384) and additionally lecturers (n = 172), and finally new multiprofessional teaching courses initiated by students and developed collaboratively. The results reveal only slow pace of change on the level of the education system, while demand for global health education has increased markedly in all actor groups, but strongest in the group of students in the preclinical phase. Implementation of global health programmes illustrates how students can become change agents and enhance institutional innovation bottom‐up. However, in order to achieve wider transformative potential, these efforts must be flanked by macro‐level policy changes and integrated in future pandemic preparedness strategies.

Internationalization of Medical Education-a Scoping Review of the Current Status in the United States

This article explores the current status of internationalization of medical education in the United States. Dominant themes of articles published from 2000 to 2018 indicate that common formats are institutional partnerships, international learning at home, and student mobility programs. Critical analysis on the basis of internationalization of higher education, recommendations, and future perspective is given.

Is time running out? The urgent need for appropriate global health curricula in Germany

Recently, representatives of politics, health officials and academia in Germany have advocated a greater role for Germany in matters concerning global health. However, health professionals in Germany are rarely taught about global health topics and accordingly real expertise in this field is lacking. To advance knowledge and competencies at German universities and adequately equip health professionals to achieve Germany’s political goals, global health curricula must be developed at medical schools and other institutions. Such ambitions raise questions about the required content and dimensions of global health curricula as the field is currently highly heterogeneous and ill defined. To systematically identify strengths and shortcomings of current curricula, we scrutinised the global health curriculum at our institution, Charité—Universitätsmedizin Berlin, using an analytical framework that integrates the various approaches of global health. Our analysis identified that four (technical, social justice, security and humanitarian) of five approaches are present in our core global health curriculum. Local and global aspects of the field are equally represented. We propose that the use of such a structured analytical framework can support the development of GH curricula for all health professionals—in Germany and elsewhere. But it can also help to evaluate existing curricula like ours at Charité. This framework has the potential to support the design of comprehensive GH trainings, serving German aspirations in politics and academia to promote health worldwide.

Long-term impact of Global Health educational experiences in Rome: an attempt of measurement

Background

Global health education (GHE) is spreading in Europe and in other parts of the world. Since 2008, Sapienza University of Rome has offered activities to medical and other health profession students related to global health (GH), which is grounded in the theory of social determinants of health and inspired by social justice. The educational activities included elective courses as well as community and service-learning experiences, referred to as GH gyms. This study attempts to measure the long-term impact of these educational experiences, especially to demonstrate their influence on the perceived social responsibility of future health professionals.

Methods

A questionnaire was elaborated and tested on a small sample of participants. It was sent to participants by e-mail. Quantitative results were analysed through descriptive statistics and qualitative answers were carefully read and classified.

Results

A total of 758 students from different faculties took part to the educational experiences. Only 488 e-mail addresses were available. One hundred and five (21.5%) questionnaires were returned. Participation in GH gyms was perceived to have had a higher influence on future professional and personal choices, when compared to participation in elective GH courses.

Conclusions

The study shows that consideration of health and social issues related with inequities in health and the use of interactive teaching methodologies had important effects on social responsibility of a large number of students. As there could be a selection bias among respondents, more research is needed to understand the impact of GH educational experiences. The inclusion of global health education in health and social curricula and the use of interactive methodologies with a correct evaluation of results are the indications that emerge from this research, together with the necessity of a strong involvement of students, professors and the whole academic reality.

Medical education: an Italian contribution to the discussion on global health education

BACKGROUND

In Italy an important contribution to the spread of global health education (GHE) grew from the establishment and work of the Italian Network for Global Health Education (INGHE). INGHE gave a national shared definition of global health (GH), grounded in the theory of determinants of health, inspired by a vision of social justice, and committed to reduce health inequities. The aim of this article is to share with the international community INGHE's point of view on Medical Education.

METHODS

To express its view of medical education at the national level, INGHE established a dedicated commission, which elaborated a first draft of the document and then shared and discussed it with all other members.

RESULTS

INGHE elaborated a paper where it explained the need to change medical education in order to prepare future health professionals for the challenges of the globalized and unequal world. In this article the authors summarize the experience of INGHE and share with the international community its document.

CONCLUSIONS

The authors believe it is necessary now, more than ever, to insert this new approach to health at social and academic levels. Students should play a fundamental role in the spread of GHE, and activities related with GHE could be considered an important part of the third mission of universities to promote social justice.

Educating universal professionals or global physicians? A multi-centre study of international medical programmes design

Introduction: Medical schools increasingly offer curricula that specifically aim to prepare students for an international medical career. This is challenging as well as controversial: curriculum designers must balance specific local healthcare requirements with global health competencies doctors need in our globalised world. By investigating how international medical programme designers experience this balancing act, this study aims to contribute insights to the debate on local versus global medical education.Methods: We conducted a multi-centre instrumental case study across three universities with international medical programmes in three countries. The study involved 26 semi-structured interviews with key curriculum designers recruited through purposive sampling. Additionally, we performed a curriculum document analysis. Data were thematically analysed within a multidisciplinary team.Results: Participants described two profiles of international medical programme graduates: 'a global physician', equipped with specific competencies for international practice, and 'a universal professional', an overall high-level graduate fit for future practice anywhere. These perspectives presented different curriculum design challenges.Conclusions: International medical programmes teach us how we can rethink graduate profiles in a globalising world. Yet, educational standardisation poses risks and securing equity in global health education is challenging, as is preparing students to be adaptable to the requirements of a rapidly changing future local healthcare context.

Transformative learning as pedagogy for the health professions: a scoping review

CONTEXT

Transformative learning (TL) has been described as learning that challenges established perspectives, leading to new ways of being in the world. As a learning theory it has resonated with educators globally, including those in the health professions. Described as a complex metatheory, TL has evolved over time, eliciting divergent interpretations of the construct. This scoping review provides a comprehensive synthesis of how TL is currently represented in the health professions education literature, including how it influences curricular activities, to inform its future application in the field.

METHODS

Arksey and O'Malley's six-step framework was adopted to review the period from 2006 to May 2018. A total of 10 bibliographic databases were searched, generating 1532 potential studies. After several rounds of review, first of abstracts and then of full texts, 99 studies were mapped by two independent reviewers onto the internally developed data extraction sheet. Descriptive information about included studies was aggregated. Discursive data were subjected to content analysis.

RESULTS

A mix of conceptual and empirical research papers, which used a range of qualitative methodologies, were included. Studies from the USA, the UK and Australia were most prevalent. Insights relating to how opportunities for TL were created, how it manifests and influences behaviour, as well as how it is experienced, demonstrated much congruency. Conceptions of TL were seen to be clustered around the work of key theorists.

CONCLUSIONS

The training of health professionals often takes place in unfamiliar settings where students are encouraged to be active participants in providing care. This increases the opportunity for exposure to learning experiences that are potentially transformative, allowing for a pedagogy of uncertainty that acknowledges the complexity of the world we live in and questions what we believe we know about it. TL provides educators in the health professions with a theoretical lens through which they can view such student learning.

Working in global health: A planning and implementation framework for international electives

Purpose: Propose a framework for planning and undertaking an international elective. Methods: On returning from conducting maternal health and well-being research in several remote communities in India, two undergraduate medical students have reflected on and documented their experiences with the view to assisting other students (and their supervisors) considering undertaking an international elective. Results: A framework for undertaking clinical or research electives in remote or rural communities is presented. The framework comprises three distinct phases: Pre-departure planning and briefing, in-country experiences and returning from the elective and considers a range of factors to ensure that, as a minimum, visiting students "do no harm" and are themselves not harmed. Conclusions: Students' home institutions have a duty of care for preparing them for their international electives by providing pre-departure training, support during the elective and comprehensive de-briefing on their return. These electives should be evaluated (including by host communities) to ensure that exchanges are socially accountable, with no harm to the often-vulnerable communities in which students gain considerable experience. Also important is that future students build on the positive experiences of their predecessors to ensure sustainability of any interventions in host communities.

Ethical dilemmas during international clinical rotations in global health settings: Findings from a training and debriefing program

PURPOSE

This study describes the impact of an open-access, case-based global health ethics workshop and describes the breadth of dilemmas faced by students to inform future interventions.

METHODS

Eighty-two medical students who undertook electives at 16 international sites between 2012 and 2015 received web-based surveys at three time points, incorporating quantitative and free-text probes of knowledge, skills, and attitudes related to global health clinical ethics dilemmas. Sixty students (73%) completed the pre-workshop survey, 38 (46%) completed the post-workshop survey, and 43 (52%) completed the post-trip survey.

RESULTS

Analysis demonstrated improvement following the workshop in self-rated preparedness to manage ethical dilemmas abroad, identify ways to prepare for dilemmas, engage support persons, and manage related emotions (all comparisons, p < 0.001). Participants described 245 anticipated or actual dilemmas, comprising nine domains. Nearly one-third of the dilemmas that were experienced involved the student as an active participant. Only 21% of respondents experiencing a dilemma discussed the dilemma with a local support person.

CONCLUSIONS

This analysis describes an ethics curriculum that prepares students to face ethical dilemmas during international clinical rotations. It broadens the representation of the dilemmas that students face, and highlights areas for curricular focus and optimization of on-site and post-trip student support resources.

A Comparison of the Expectations and Experiences of Medical Students From High-, Middle-, and Low-Income Countries Participating in Global Health Clinical Electives

Phenomenon: Global health education (GHE) is expanding to include socioculturally and resource-different settings, with the goal of developing a workforce with members who can promote health equity locally and globally. GHE is also no longer limited to students from high-income countries (HICs). However, it is unknown whether the motivations and experiences of medical students from HICs and from low- and middle-income countries (LMICs) participating in GHE clinical electives through institutional partnerships are similar or different. Such an understanding is needed to design programs that meet the needs of participants and effectively train them in the principles and practice of global health.

APPROACH

This was a cross-sectional, mixed-methods survey of LMIC students from partner sites rotating at one U.S. medical school, and U.S. students from one medical school rotating at partner sites, between 2010 and 2015. Variables included demographic characteristics of participants, components of the curriculum at the home institution, and components of the away rotation, including perceptions of its content and impact. Content analysis was used to identify themes in the responses provided to open-ended questions.

FINDINGS

In all, 63 of 84 (75%) LMIC and 61 of 152 (40%) U.S. students participated. Recall of predeparture training was low for both LMIC and U.S. students (44% and 55%, respectively). Opportunities to experience different healthcare systems, resource-different settings, and cultural exposure emerged as motivators for both groups. Both groups noted differences in doctor-patient relationships, interactions between colleagues, and use of diagnostic testing. U.S. respondents were more likely to perceive differences in the impact of social determinants of health and ethical issues. Both groups felt that their experience affected their interactions with patients and perspectives on education, but U.S. students were more likely to mention perspectives on healthcare delivery and social determinants of health, whereas LMIC respondents noted impacts on career goals. Insights: These results argue that GHE is not restricted to resource-constrained settings and that students from LMICs have similar reasons for participation as those from HICs. LMIC students also identified a lack of emphasis on GHE topics like social determinants of health during GH electives, which could diminish the effectiveness of these experiences. Both U.S. and LMIC students emphasized the cultural component of their GHE experience but had different perceptions regarding core tenets of GHE, such as the social determinants of health and health equity, during these experiences.