Capturing medical students' idealism

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.

Medical Electives in Sub-Saharan Africa: A 15-Year Student/NGO-Driven Initiative

Medical schools are developing global health programmes, and medical students are requesting global health training and creating opportunities when these are not provided by medical schools. This article described the Wolisso Project (WP), a medical experience on clinical electives in Sub-Saharan Africa, driven by a collaboration between a student organisation and a Nongovernmental Organization (NGO). Preclinical medical students spent 4 weeks as part of a multidisciplinary medical team in Africa. Post-elective questionnaires were administered to all subjects who participated in the project. Of all, 141 students responded to the questionnaire. The participants came from 30 Italian universities. The main difficulties reported are due to the lack of resources for the exercise of the medical activity, and difficulties related to language and communication. The African experience had a positive impact on the progress of the studies upon return, with an increase in determination and motivation. The experience had also positive influences on the future professional choices and carriers. The experience seems to contribute not only to the professional growth, but also to the personal development. A key factor in the positive outcomes of this experience is it being implemented by an NGO with long-term working relationships with the African populations. Another is that the project is carried out in health facilities where NGO staff have been working for a long time. These factors reduce the potential risks connected with this type of experience. They ensure a satisfactory level of supervision, the lack of which has been a serious problem in many similar experiences. A well-structured, mentored experience in international health can have a positive impact on preclinical students' attitudes, including their compassion, volunteerism, and interest in serving underserved populations. Only a small number of Italian universities facilitate pre-graduate medical elective experiences in LMICs. The WP seems to be attempting to compensate for the lack of international experience in LMICs offered by universities. Italian medical schools should incorporate changes in their curricula to train socially responsible physicians.

Stigma, Empathy, and Attitude (SEA) educational module for medical students to improve the knowledge and attitude towards persons with mental illness

OBJECTIVE

The objective was to develop an educational module on stigma, empathy, and attitude towards mental illness and evaluate its effectiveness among undergraduate medical students.

METHODS

In phase I, the authors developed the Stigma, Empathy, and Attitude (SEA) module consisting of interactive teaching-learning components through an experts-based consensus (two rounds of Delphi). In phase II, the effectiveness of the module was evaluated. SEA module (one-hour interactive lecture and three hours' small group teaching) was delivered to the fifth-semester undergraduate medical students (N = 240) once during their psychiatry rotation. Students were assessed with the Mental Health Knowledge Schedule (MHKS), Mental Illness: Clinician's Attitudes (MICA) scale, Jefferson Scale for Empathy (JSE), and Social Distance scale (SDS), to measure mental health knowledge, attitude, empathy, and stigma, at baseline and after delivery of the module. Feedback on the module was obtained from the participating students and faculty.

RESULTS

Baseline data was obtained for 157 students, and post-intervention assessment was completed for 66 students. There was a significant increase in MHKS score (p < 0.001, Cohen's d = 0.59) and a significant reduction in the MICA score (p = 0.016, Cohen's d = 0.31) after the intervention. However, there was no change in empathy and social distance, as measured by JSE (p = 0.23) and SDS (p = 0.31). A majority of the faculty and students were satisfied with the module and felt it should be part of the psychiatry curriculum.

CONCLUSIONS

The SEA module was found to improve medical students' knowledge and attitude towards mental illness and could be integrated as part of the psychiatry curriculum. However, it was ineffective in changing empathy and stigma in the students.

Global surgery for medical students - is it meaningful? A mixed-method study

Introduction

There has been an increase in global health courses at medical universities in high-income countries. Their effect on students, however, is poorly understood. In 2016 an elective global surgery course was introduced for medical students at Karolinska Institutet in Sweden. The course includes a theoretical module in Sweden and a two-week clinical rotation in Uganda. The present study aimed to assess the format and determine its effect on students’ knowledge of global surgery and approach towards patients of non-Swedish origin.

Method

A mixed-methods design was used. Semi-structured case-based interviews were conducted individually with 18 students and analysed using qualitative content analysis. Examination scores and the course evaluation were analysed with Kruskal Wallis one-way analysis of variance, Pearson’s Chi-square and a Wilcoxon signed-rank test as appropriate.

Results

The course was appreciated and students reported gained insights and interest in global surgery. Students’ ability to reason about global surgery issues was improved after the course. Students considered complicating aspects in the meeting with patients of non-Swedish origin. Students with abroad clinical experience felt less compelled to act on preconceptions.

Discussion

The global surgery course at Karolinska Institutet is appreciated and students gained valuable knowledge. The case-based interviews acted as a catalyst for reflection and showed that students felt insecure as they lacked knowledge about globally common surgical conditions and struggled with generalized preconceptions of patients of non-Swedish origin. To further support students to integrate theoretical knowledge and professional development, we suggest the introduction of problem-based learning.

Conclusion

The ability of the course to inspire students’ commitment to global surgery is promising as this engagement is the key to reaching the goal of equitable health globally. Offering such courses is a step towards inspiring and recruiting the future clinicians and researchers needed for expanding the field of global surgery.

What Is the State of Compassion Education? A Systematic Review of Compassion Training in Health Care

PURPOSE

To investigate the current state and quality of compassion education interventions offered to health care providers during training or practice, determine how the components of each education intervention map onto the domains of an empirically based clinical model of compassion, and identify the most common approaches to compassion education.

METHOD

The MEDLINE, Embase, CINAHL Plus with Full Text, Sociological Abstracts, Web of Science, ERIC, and Education Research Complete databases were searched from inception to March 2020 in this systematic review. Studies that evaluated a compassion education intervention for health care providers or those in training to enhance compassion toward patients and/or families were included. A narrative synthesis of the included studies was performed. The components of each intervention were mapped onto the domains of compassion described in the Patient Compassion Model.

RESULTS

One hundred eight peer-reviewed publications describing 103 interventions were included. Modalities ranged from establishing curricula and interventions in clinical settings to programs that used humanities-based reflective practices, clinical simulation, role modeling, and contemplative practices, with many education interventions adopting a multimodal approach. Most interventions mapped to the virtuous response domain of the Patient Compassion Model; very few mapped to the other domains of this model.

CONCLUSIONS

Most interventions were limited as they focused on a single domain of compassion; did not adequately define compassion; were assessed exclusively by self-report; were devoid of a comparator/control group; and did not evaluate retention, sustainability, and translation to clinical practice over time. The authors suggest that compassion education interventions be grounded in an empirically based definition of compassion; use a competency-based approach; employ multimodal teaching methods that address the requisite attitudes, skills, behaviors, and knowledge within the multiple domains of compassion; evaluate learning over time; and incorporate patient, preceptor, and peer evaluations.

Student-run free clinic volunteers: who they are and what we can learn from them

BACKGROUND

Initiatives employing medical students' volunteerism and idealism, such as the Student-Run Free Clinics (SRFC) program, are prevalent in US medical schools. Many studies evaluated various aspects of volunteering, sometimes resulting in conflicting evidence. This study simultaneously sought to identify the characteristics of volunteers vs. non-volunteers, and to characterize the volunteers' perception of the SRFC.

METHODS

We administered a survey to the Long School of Medicine (LSOM) Class of 2018 before their third year of medical school. The authors compared and contrasted the findings of the SRFC volunteers with their non-volunteering counterparts by analyzing their demographics, volunteering history, academic performance, and clinical skills. The volunteers were also asked about their SRFC experiences.

RESULTS

While most volunteers were female (62 %) and non-traditional students (67 %), the difference was not statistically significant (p = 0.15 and p = 0.38, respectively). Additionally, there were no statistically significant differences between the two groups in measures of academic performance (p = 0.25). Most of the volunteers learned about the SRFC program prior to starting medical school. Further, while SRFC volunteers were more likely to engage in additional local volunteering initiatives, the difference was not statistically significant (p = 0.03, prespecified  α= 0.006). Importantly, volunteers agreed/strongly agreed that SRFC volunteering emphasized aspects that were missing or underemphasized in the formal medical school curriculum.

CONCLUSIONS

Medical students' age, gender, undergraduate major, and non-traditional status were not statistically different between volunteers vs. non-volunteers. However, there may be tendencies for volunteers to be female, non-traditional, and locally engaged. Further, the timing of knowledge of the SRFC program may not affect student involvement in the SRFC, either. Most importantly, however, while volunteering does not affect the students' academic performance, it may provide improvements in clinical competencies.

A multicentric study on stigma towards people with mental illness in health sciences students

BACKGROUND

There is evidence of negative attitudes among health professionals towards people with mental illness but there is also a knowledge gap on what training must be given to these health professionals during their education. The purpose of this study is to compare the attitudes of students of health sciences: nursing, medical, occupational therapy, and psychology.

METHODS

A comparative and cross-sectional study in which 927 final-year students from health sciences university programmes were evaluated using the Mental Illness: Clinicians' Attitudes (both MICA-2 and MICA-4) scale. The sample was taken in six universities from Chile and Spain.

RESULTS

We found consistent results indicating that stigma varies across university programmes. Medical and nursing students showed more negative attitudes than psychology and occupational therapy students in several stigma-related themes: recovery, dangerousness, uncomfortability, disclosure, and discriminatory behaviour.

CONCLUSIONS

Our study presents a relevant description of the attitudes of each university programme for education against stigma in the formative years. Results show that the biomedical understanding of mental disorders can have negative effects on attitudes, and that education based on the psychosocial model allows a more holistic view of the person over the diagnosis.

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.

Transformative medical education: must community-based traineeship experiences be part of the curriculum? A qualitative study

BACKGROUND

There are shortcomings in medical practitioners' capacity to adapt to the particular needs of people experiencing circumstances of social vulnerability. Clinical traineeships create opportunities for the acquisition of knowledge, competencies, attitudes, and behaviors. However, some authors question the learnings to be made through classical clinical training pathways. This article explores the learnings gained from a traineeship experience within a community-based clinical setting intended for patients experiencing social vulnerability and operating under an alternative paradigm of care. To our knowledge, there is little research intended to identify and understand what medical trainees gain from their experience in such contexts.

METHODS

This exploratory qualitative study is based on twelve interviews with practicing physicians who completed a traineeship at La Maison Bleue (Montreal, Canada) and three interviews conducted with key informants involved in traineeship management. Based on Mezirow's theory of transformational learning, data were analyzed according to L'Écuyer's principles of qualitative content analysis. NVivo software was used.

RESULTS

The main learnings gained through the traineeship are related to (1) greater awareness of beliefs, assumptions and biases through prejudice deconstruction, cultural humility and critical reflection on own limitations, power and privileges; (2) the development of critical perspectives regarding the health care system; (3) a renewed vision of medical practice involving a less stigmatizing approach, advocacy, empowerment, interdisciplinarity and intersectorality; and (4) strengthened professional identity and future practice orientation including confirmation of interest for community-based practice, the identification of criteria for choosing a future practice setting, and commitment to becoming an actor of social change. Certain characteristics of the setting, the patients and the learner's individual profile are shown to be factors that promote these learnings.

CONCLUSIONS

This article highlights how a traineeship experience within a clinical setting intended for a clientele experiencing circumstances of social vulnerability and operating under an alternative paradigm presents an opportunity for transformative learning and health practice transformation toward renewed values of health equity and social justice. Our findings suggest medical traineeships in community-based clinical settings are a promising lead to foster the development of fundamental learnings that are conducive to acceptable and equitable care for people experiencing social vulnerability.

Development of Cynicism in Medical Students: Exploring the Role of Signature Character Strengths and Well-Being

Reports of medical students experiencing burnout-related symptoms (e.g., cynicism) have increased in recent years. Little is known about the developmental process of this phenomenon and its relations with signature character strengths and well-being. The aim of this longitudinal analysis was to explore changes in the level of cynicism of medical students while in preclinical education. We further examined how the applicability of signature character strengths and well-being are related to this developmental process. Medical students (N = 99) participated in three online surveys over 3 years during medical school. Latent growth modeling, latent class growth modeling, general mixed modeling was conducted, and post hoc mixed ANOVA, Friedman test and Welch test analyses were examined. The results showed an increase in cynicism among medical students from first to last measurement. Two groups with distinct developmental trajectory patterns of cynicism were identified. Students with high levels of cynicism (high-level group) and students with changing levels of cynicism (increasing group) perceived higher applicability of signature character strengths in private life compared to the study context. Moreover, the high-level group experienced significantly lower psychological well-being (in particular mastery, optimism, and relationship) in their first year of medical education. This explorative study offers a comprehensive understanding of cynicism development in medical students during medical school and its relations to the applicability of signature character strengths and well-being. Prospective replication studies are needed to replicate the results obtained in this study.

The impact of a psychiatry clinical rotation on the attitude of South African final year medical students towards mental illness

BACKGROUND

Stigmatising attitudes of health care professionals towards mental illness can impede treatment provided for psychiatric patients. Many studies have reported undergraduate training to be a critical period for changing the attitudes of medical students, and one particularly valuable intervention strategy involves time spent in a clinical psychiatric rotation. In South Africa, medical students are exposed to a clinical rotation in psychiatry but there is no evidence to show whether this has an effect on attitudes toward mental illness.

METHODS

This prospective cohort study involved a convenience sample of 112 South African medical students in their 5th or 6th year of undergraduate training. This sample attended a 7-week psychiatry rotation. The Attitudes to Mental Illness Questionnaire (AMIQ) was used to assess students' attitudes toward mental illness before and after the clinical rotation which includes exposure to a number of psychiatric sub-divisions and limited didactic inputs.

RESULTS

There was a significant improvement (p < 0.01, t-test) in the students' attitude toward mental illness following the psychiatric rotation. Females displayed a more positive attitude towards mental illness at the end of the rotation compared to males. The participants' attitude significantly deteriorated for the non-psychiatric vignette describing diabetes (< 0.01, t-test).

CONCLUSIONS

Our findings suggest that clinical training and exposure to a psychiatric setting impacts positively on medical students' attitude towards mental illness, even when this training does not include any focused, didactic anti-stigma input.

Understanding perceptions of global healthcare experiences on provider values and practices in the USA: a qualitative study among global health physicians and program directors

OBJECTIVES

The study aimed to qualitatively examine the perspectives of US-based physicians and academic global health programme leaders on how global health work shapes their viewpoints, values and healthcare practices back in the USA.

DESIGN

A prospective, qualitative exploratory study that employed online questionnaires and open-ended, semi-structured interviews with two participant groups: (1) global health physicians and (2) global health programme leaders affiliated with USA-based academic medical centres. Open coding procedures and thematic content analysis were used to analyse data and derive themes for discussion.

PARTICIPANTS

159 global health physicians and global health programme leaders at 25 academic medical institutions were invited via email to take a survey and participate in a follow-up interview. Twelve participants completed online questionnaires (7.5% response rate) and eight participants (four survey participants and four additionally recruited participants) participated in in-depth, in-person or phone semi-structured interviews.

RESULTS

Five themes emerged that highlight how global health physicians and academic global health programme leaders perceive global health work abroad in shaping USA-based medical practices: (1) a sense of improved patient rapport, particularly with low-income, refugee and immigrant patients, and improved and more engaged patient care; (2) reduced spending on healthcare services; (3) greater awareness of the social determinants of health; (4) deeper understanding of the USA's healthcare system compared with systems in other countries; and (5) a reinforcement of values that initially motivated physicians to pursue work in global health.

CONCLUSIONS

A majority of participating global health physicians and programme leaders believed that international engagements improved patient care back in the USA. Participant responses relating to the five themes were contextualised by highlighting factors that simultaneously impinge on their ability to provide improved patient care, such as the social determinants of health, and the challenges of changing USA healthcare policy.

Impact of Global Health Electives on US Medical Residents: A Systematic Review

BACKGROUND

The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes.

OBJECTIVES

The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature.

METHODS

An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents.

FINDINGS

Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks.

CONCLUSIONS

Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.

Impact of Global Health Electives on US Medical Residents: A Systematic Review

Background:

The prevalence of global health in graduate medical education in the United States (US) has soared over the past two decades. The majority of US internal medicine and pediatric residency programs now offer global health electives abroad. Despite the prevalence of global health electives among US graduate medical programs today, challenges exist that may impact the experience for visiting trainees and/or host institutions. Previous reviews have predominately focused on experiences of undergraduate medical students and have primarily described positive outcomes.

Objectives:

The aim of this study was to summarize the overall impact of global health electives on US internal medicine, medicine-pediatric, and pediatric residents, paying specific attention to any negative themes reported in the literature.

Methods:

An Ovid MEDLINE and Ovid EMBASE literature search was conducted to identify studies that evaluated the effects of global health electives on US internal medicine, medicine-pediatric, and pediatric residents.

Findings:

Ten studies were included. Four positive themes emerged: (1) improvement of medical knowledge, physical examination, and procedural skills, (2) improvement in resourcefulness and cost-effectiveness, (3) improvement in cultural and interpersonal competence, and (4) professional and career development. Two negative themes were identified: (1) health risks and (2) safety risks.

Conclusions:

Global health electives provide a number of perceived benefits for US medical trainees; however, we importantly highlight health and safety concerns described while abroad. Global health educators should recognize the host of unique challenges experienced during a global health elective and investigate how to best mitigate these concerns. Incorporation of mandatory pre-, intra-, and post-elective training programs and establishment of universally adopted global health best practice guidelines may serve to address some the challenges visiting trainees encounter while abroad.

Attitudes of undergraduate medical students toward mental illnesses and psychiatry

BACKGROUND

Worldwide, studies show negative attitude among medical students toward psychiatry and mental illness. The knowledge of the attitude and awareness of the undergraduate medical students toward psychiatry, mental health, and psychiatric disorders are most important as they are going to be involved in the care of these patients either directly or indirectly during the later years of their careers.

AIM

This study aims to assess attitude toward psychiatry and mental illness among undergraduate medical students.

METHODOLOGY

The responses of 67 medical students from the 6^th semester (third professional year) batch who completed their 2-week clinical posting of psychiatry in 4^th semester (i.e., second professional year) were collected using validated questionnaires, attitude towards mental illness (AMI), and attitude towards psychiatry (ATP) that assessed their attitudes to psychiatry and mental illness. Double data entry and validation were done using EpiData and analysis using Epi Info software.

RESULTS

Median AMI score was 54 (out of maximum 100) showing a neutral AMI. Median ATP score was 82 (out of maximum 150) also showing a neutral ATP. The theme-wise analysis showed that the attitude of students toward psychiatrist and psychiatry branch was relatively better compared to their AMI.

CONCLUSION

Undergraduate students have a neutral attitude to psychiatry and mental illness. More efforts are needed to change the attitude to favorable side.

Student Perceptions About Benets From an Extracurricular Curriculum: A Qualitative Study of the Underserved Pathway

Introduction

Too few medical graduates choose to care for underserved populations. This qualitative study explores medical student perceptions of the benefits of participating in the Underserved Pathway (UP), a 4-year extracurricular program designed to nurture interest in, and develop skills to serve vulnerable populations.

Methods

Fourteen of 28 graduating students in the class of 2013 who completed the UP were interviewed. Using conventional qualitative content analysis, an iterative process was used to code transcriptions until there was high concordance among the assigned codes. The research team analyzed the data for common themes, theme saturation, and unique perspectives.

Results

Four major thematic areas emerged: 1) the underserved curriculum scaffold, 2) influence on career choice, 3) influence on residency choice, and 4) capacity to match. Of all participants, 78.6% thought the UP influenced their career choice, 64.3% stated the UP played a role in residency choice and rank, and 85.7% thought participation in the UP would improve match success. No single curricular component of the UP was individually responsible for career or specialty choice, or as being most useful to student understanding of the underserved.

Conclusions

Students noted that participation in the UP provided them with a scaffold to support their interest in underserved careers, and influenced their specialty and residency choice. They also perceived it as making them more competitive as residency applicants. This study provides medical educators with insight into the importance of building robust frameworks, even extracurricular ones, to support student interests in serving vulnerable communities.

RAHI-SATHI Indo-U.S. Collaboration: The Evolution of a Trainee-Led Twinning Model in Global Health Into a Multidisciplinary Collaborative Program

RAHI–SATHI presents an innovative twinning model of global health academic partnership, resulting in a number of successful research activities, that features trainees or students as the driving force, complemented by strategic institutional support from both sides of the partnership. Others can promote similar student-led initiatives by: (1) accepting an expanded role for trainees in global health programs, (2) creating structured research and program opportunities for trainees, (3) developing a network of faculty and trainees interested in global health, (4) sharing extramural global health funding opportunities with faculty and trainees, and (5) offering seed funding.

Background:

In recent years there has been a surge in the number of global health programs operated by academic institutions. However, most of the existing programs describe partnerships that are primarily faculty-driven and supported by extramural funding.

Program Description:

Research and Advocacy for Health in India (RAHI, or “pathfinder” in Hindi) and Support and Action Towards Health-Equity in India (SATHI, or “partnership” in Hindi) are 2 interconnected, collaborative efforts between the University of Massachusetts Medical School (UMMS) and Charutar Arogya Mandal (CAM), a medical college and a tertiary care center in rural western India. The RAHI–SATHI program is the culmination of a series of student/trainee-led research and capacity strengthening initiatives that received institutional support in the form of faculty mentorship and seed funding. RAHI–SATHI's trainee-led twinning approach overcomes traditional barriers faced by global health programs. Trainees help mitigate geographical barriers by acting as a bridge between members from different institutions, garner cultural insight through their ability to immerse themselves in a community, and overcome expertise limitations through pre-planned structured mentorship from faculty of both institutions. Trainees play a central role in cultivating trust among the team members and, in the process, they acquire personal leadership skills that may benefit them in their future careers.

Conclusion:

This paradigm of trainee-led twinning partnership promotes sustainability in an uncertain funding climate and provides a roadmap for conducting foundational work that is essential for the development of a broad, university-wide global health program.

Ensuring the Health, Safety and Preparedness of U.S. Medical Students Participating in Global Health Electives Overseas

Global health electives based in resource-poor countries have become extremely popular with medical students from resource rich ones. As the number of such programs and participants increase, so too do the absolute health and safety risks. It is clear from a number of published reports that many institutions provide little or no meaningful preparedness for students and do little to ensure their health and safety. These deficiencies together can affect students, their foreign hosts, and sponsoring institutions. The School of Public Health at the State University of New York, Downstate Medical Center, and its predecessor, the Department of Preventive Medicine and Community Health, have sponsored a 6-8 week global health elective for fourth year medical students since 1980. The purposes of this elective are to provide students with an opportunity to observe the health care and public health systems in resource-poor countries, provide medical service, and have a cross-cultural experience. Over the course of the past 35 years, 386 students have participated in this global health elective in more than 41 resource-poor countries. Recent annual applications for this elective have been as high as 44 out of a class of 200 students. Over the past 10 years, annual acceptance rates have varied, ranging from a low of 32 % in 2007-2008 to a high of 74 % in 2010-2011 and 2013-2014. Careful screening, including a written application, review of academic records and personal interviews, has resulted in the selection of highly mature, adaptable, and dedicated students who have performed well at overseas sites. Appropriately preparing students for an overseas global health experience in resource-poor countries requires the investment of much professional and staff time and effort. At the SUNY Downstate School of Public Health, these resources have underpinned our Global Health in Developing Countries elective for many years. As a result, the elective is characterized by meticulous organization, extensive preparedness measures for students, and continuous monitoring of site and country safety. The health of students is ensured by one-on-one assessment of immunization needs, anti-malarials, and the provision of a five-day supply of post-exposure HIV prophylaxis. Students sign agreements regarding the legal issues, immunizations, and anti-malarials recommended as well as HIV post-exposure prophylaxis. They are also required to obtain medical evacuation insurance provided by the university, and medical care insurance valid overseas. Student travel plans are also approved as is in-country lodging. The focus of our 6-8 week global health elective is not clinical medicine. Rather, it is to enable students to learn about the health care and public health systems in a resource-poor country. Through that focus, they also come to understand the causes of health and health care disparities that exist in the country to which they are assigned. Our students are greatly advantaged with regard to cross-cultural understanding since our school is located in New York City's Borough of Brooklyn, where 40 % of the population was born outside of the U.S. Our comprehensive effort at risk management for this global health elective includes a thorough debriefing for each student upon his/her return. Special attention is given to ascertaining illness or injury while overseas, and, when necessary, immediate referral is made to an appropriate university clinical department where a student can be appropriately case managed. Meticulous oversight, careful selection of safe overseas sites, and attention to preparing students have resulted in significant risk reduction and successful experiences for the majority of our 386 students. This article describes the model we have developed for ensuring the health, safety, and preparedness of students participating in our global health elective.

Increasing Medical Trainees' Empathy Through Volunteerism and Mentorship

BACKGROUND

Within medical education, there have been recent calls for increased understanding and exposure to poverty to increase trainees' empathy toward the underserved. Students participating in Michigan Cardiovascular Outcomes Research and Reporting Program research program volunteered at World Medical Relief (WMR) in Detroit, Michigan, a nonprofit organization which recycles medical equipment for developing countries and within greater Detroit. Participants' perceptions of the underserved were measured before and after the experience.

METHODS

Preliminary questionnaires were given to participants prior to and after exposures at WMR. Questionnaires examined participants' attitudes toward the underserved, knowledge of medical supply reuse, and their perceived ability to impact change. P values of <.025 were considered significant.

RESULTS

A total of 39 participants completed the survey, 77% previously volunteered, 33% had volunteered internationally. Participants were >4× more likely than previously to have knowledge of the variety of recycled medical supplies at WMR. Prior to volunteering, 48.7% of participants gave little thought to how excess medical supplies could be collected versus 0% after exposure. Participants were 1.5× more likely to agree that the experience was enhanced working with their peers and 2.7× more likely to consider starting their own organization/intervention for medical supply donations. Those participants that never previously volunteered were 1.3× more likely to do so with encouragement from a mentor.

CONCLUSIONS

Encouraging exposure to such service programs resulted in enhanced knowledge of community resources and increased motivation to participate in outreach and belief of individual responsibility to care for the underserved. Incorporating volunteerism into traditional education programs offers the opportunity to build awareness and interest in students reaching out to the underserved.

Medical student attitudes toward the medically underserved: the USU perspective

This study examined a cohort of students attending the Uniformed Services University regarding their attitudes toward medical care in underserved populations. Using the previously validated Medical Student Attitudes Toward the Underserved (MSATU), repeated measures analysis of variance showed that student attitudes toward care in underserved populations was less favorable than limited national data at entry and declined over time (Mean MSATU total score Year 1: 46.2 [SD 10.95]; Year 4: 41.7 [SD 12.3] p < 0.01). Differences in medical school debt, exposure to underserved populations, and the definition of "service" in the context of active duty military status might explain some of our findings. Providing broad service learning opportunities within the curriculum could increase student exposure to underserved populations and strengthen the social contract between community and institution.

The Heroic and the Villainous: a qualitative study characterising the role models that shaped senior doctors' professional identity

BACKGROUND

The successful development and sustaining of professional identity is critical to being a successful doctor. This study explores the enduring impact of significant early role models on the professional identity formation of senior doctors.

METHODS

Personal Interview Narratives were derived from the stories told by twelve senior doctors as they recalled accounts of people and events from the past that shaped their notions of being a doctor. Narrative inquiry methodology was used to explore and analyse video recording and transcript data from interviews.

RESULTS

Role models were frequently characterised as heroic, or villainous depending on whether they were perceived as good or bad influences respectively. The degree of sophistication in participants' characterisations appeared to correspond with the stage of life of the participant at the time of the encounter. Heroes were characterised as attractive, altruistic, caring and clever, often in exaggerated terms. Conversely, villains were typically characterised as direct or covert bullies. Everyday events were surprisingly powerful, emotionally charged and persisted in participants' memories much longer than expected. In particular, unresolved emotions dating from encounters where bullying behaviour had been witnessed or experienced were still apparent decades after the event.

CONCLUSION

The characterisation of role models is an important part of the professional identity and socialisation of senior doctors. The enduring impact of what role models say and do means that all doctors, need to consistently reflect on how their own behaviour impacts the development of appropriate professional behaviours in both students and training doctors. This is especially important where problematic behaviours occur as, if not dealt with, they have the potential for long-lasting undesirable effects. The importance of small acts of caring in building a nurturing and supportive learning atmosphere at all stages of medical education cannot be underestimated.

Medical humanities: a closer look at learning

The inclusion of medical humanities with medical curricula is a question that has been the focus of attention for many within the evolving field. This study addressed the question from a medical education perspective and aimed to investigate what students at Trinity College Dublin learned from participating in a short medical humanities student-selected module in their first year of an undergraduate medical programme. A total of 156 students provided a written reflection on a memorable event that occurred during their student-selected module. The reflections were analysed using the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT) and through qualitative thematic analysis of the written reflections. Evidence of learning from the REFLECT quantitative analysis showed that 50% of students displayed higher levels of reflection when describing their experience. The reflection content analysis supported the heterogeneous nature of learning outcome for students, with evidence to support the idea that the module provided opportunities for students to explore their beliefs, ideas and feelings regarding a range of areas outside their current experience or world view, to consider the views of others that they may have not previously been aware of, to reflect on their current views, and to consider their future professional practice.

Current Practices in Global/International Advanced Pharmacy Practice Experiences: Home/Host Country or Site/Institution Considerations

International outreach by schools and colleges of pharmacy is increasing. In this paper, we provide current practice guidelines to establish and maintain successful global/international advanced pharmacy practice experiences (G/I APPEs) with specific recommendations for home/host country and host site/institution. The paper is based on a literature review (2000-2014) in databases and Internet searches with specific keywords or terms. Educational documents such as syllabi and memoranda of understanding (MoUs) from pharmacy programs were also examined. In addition, a preliminary draft was developed and the findings and recommendations were reviewed in a 90-minute roundtable discussion at the 2014 American Association of Colleges of Pharmacy Annual Meeting. Recommendations for the host country include travel considerations (eg, passport, visa, air travel), safety, housing, transportation, travel alerts and warnings, health issues, and financial considerations. For the home country, considerations for establishment of G/I APPE site (eg, vetting process, MoU, site expectations) are described. The paper is a resource for development of new G/I APPEs and provides guidance for continuous quality improvement of partnerships focusing on G/I pharmacy education.

A global health elective for US medical students: the 35 year experience of the State University of New York, Downstate Medical Center, School of Public Health

The School of Public Health at the State University of New York, Downstate Medical Center has sponsored a 6–8 week global health elective for fourth year medical students since 1980. The purpose of this elective is to provide students with an opportunity to observe the health care and public health delivery systems in low-income countries, provide medical service and have a cross-cultural experience. Over the course of the past 35 years, 388 students have participated in this global health elective in more than 41 low-income countries. The most popular sites include the Dominican Republic, Guatemala, India, Kenya and Thailand. Overall, interest in this elective has persisted throughout the course of time, sometimes temporarily increasing or decreasing with outside factors, such as the events of 11 September 2001 and the outbreak of Severe Acute Respiratory Syndrome in Asia. Recent annual applications for this elective have been as high as 44 out of a class of 200 students. Over the past 10 years, annual acceptance rates have varied, ranging from a low of 32 % in 2007–2008 to a high of 74 % in 2010–2011 and 2013–2014. Careful screening, including a written application, review of academic records and personal interviews has resulted in the selection of highly mature, adaptable and dedicated students who have performed well at overseas sites. Student rated satisfaction levels with this elective are almost universally high, with most rating it the best experience of their medical school years. Students undergo extensive preparation prior to their travel overseas, including a review of individual health and safety issues, travel and lodging, and the nature of the host country culture, health care system and assignment site. Downstate medical students are especially experienced in cross-cultural understanding because of the unusual diversity of the patient population in Brooklyn, and the diversity of local hospital staff and the medical school class. The Alumni Fund of the College of Medicine has steadfastly supported this elective with both a philosophical commitment and financial grants to help defray costs since the very early years. The Dr. Michael and Lona B. Kennéy Endowment, the Joshua H. Weiner endowment, and the LSK Foundation have also provided financial support for this elective. Throughout the course of this elective, overseas preceptors have willingly given of their time and institutional resources to make these experiences available and meaningful for our students.

The benefits of working abroad for British General Practice trainee doctors: the London deanery out of programme experience in South Africa

BACKGROUND

The value of international health experience for doctors from developed nations is well recognised. Provisions have been made for medical staff in the United Kingdom to embark on work experiences abroad during their careers in the National Health Service. The London Deanery and Africa Health Placements provide an Out of Programme Experience for British General Practice trainee doctors wanting to work for a year in rural hospitals in South Africa.

METHODS

A qualitative study was conducted among fifteen British General Practice trainees who participated in the programme. The research aim was to understand the perceived benefit and value of their experience and their opinions about the structure of the programme. The data was analysed using thematic analysis.

RESULTS

Their experience provided an accelerated year of learning and development that contributed to their professional and personal development. In addition to their general development, their improved ability to work in resource limited settings, enhancement of soft skills, a greater appreciation for the National Health Service and a better understanding of working within foreign health care systems were important gains. The timing of the experience, the security of re-employment on their return, assistance with administrative requirements of destination countries and the opportunity to gain varied, hands-on experience were highly valued components of the Out of Programme Experience.

DISCUSSION

The value and benefits derived from the doctors' experience in South Africa are discussed in relation to another evaluation of the Out of Programme Experience, as well as issues of transferability of skills and competencies and future impacts on career decisions.

CONCLUSION

This study provides evidence to suggest programmes such as the OOPE have the potential to create substantial benefits for trainee doctors, both in terms of their medical skills and competencies and through the development of softer skills. This programme, through the supply of scarce skills, further benefits the host country and specifically the health facilities and communities served by these trainee doctors.

Student perspectives on the value of rural electives

Background

Medical students in the Faculty of Health Sciences at the University of the Witwatersrand (Wits) in Johannesburg have the opportunity to do electives at the end of the first and third years of a four-year graduate-entry medical programme. Upon their return they are required to write a short portfolio report. Over the period 2005 to 2011, 402 students chose to do rural electives.

Aim and setting

To understand the value of rural electives from the perspective of medical students in the Faculty of Health Sciences at Wits, as derived from their assessment reports.

Methods

A review was conducted of 402 elective reports. Common themes were identified through repeated reading of the reports, and then content analysis was undertaken using these themes.

Results

Major themes identified were the reasons for choosing a rural facility for the elective, including going to a home community; benefits of the elective, especially in terms of clinical skills and personal growth; relationship issues; the multiple roles of the rural doctor, who is often a role model working in difficult conditions; and the challenges of rural electives.

Conclusion

The electives were overwhelmingly positive and affirming experiences for students, who developed clinical skills and also learnt about both themselves and their chosen career.

Validity of Medical Student Questionnaire Data in Prediction of Rural Practice Choice and Its Association With Service Orientation

PURPOSE

The validity of medical student projection of, and predictors for, rural practice and the association of a measure of service orientation, projected practice accessibility to the indigent, were investigated.

METHODS

West Virginia (WV) medical student online pre- and postrural rotation questionnaire data were collected during the time period 2001-2009. Of the 1,517 respondent students, submissions by 1,271 met the time interval criterion for inclusion in analyses. Subsequent WV licensing data were available for 461 in 2013. These 2 databases were used to assess for validity of projection of rural practice, for predictors of rural practice, and for student projected accessibility of the future practice to indigent patients.

FINDINGS

There were statistically significant associations between both pre- and postrotation projections of rural practice and subsequent rural practice. The most significant independent predictors of rural practice were student rural background, reported primary care intent, prediction of rural practice and projection of greater accessibility of the future practice to indigent patients. For scoring of practice access, there were trends for higher scoring by rural students and rural practitioners, with greater pre-post increases for those with urban hometowns.

CONCLUSIONS

This study demonstrates the utility of medical student questionnaires for projections of numbers of future rural physicians. It suggests that students with a rural background, rural practice intent, or greater service orientation are more likely to enter rural practice. It also suggests that students, particularly those with urban hometowns, are influenced by rural rotation experiences in forecasting greater practice accessibility and in entering rural practice.

Antecedents of philanthropic behavior of health care volunteers

Purpose

– This paper aims to propose a conceptual model of philanthropic behavior of volunteers in the health care sector.

Design/methodology/approach

– This study is based on an extensive review of past research on philanthropic behavior. To conduct the literature review, keywords such as philanthropy, philanthropic behavior, giving, donating, competencies, volunteering and social network in health care were identified.

Findings

– From the literature reviewed, three groups of antecedents of philanthropic behavior among health care volunteers (HCVs) were identified, viz., individual factors, social factors and organizational factors. This paper proposes social network as a mediating variable in linking the three groups of antecedents with philanthropic behavior. The paper offers a number of propositions which explain the proposed model of philanthropic behavior of HCVs.

Practical implications

– Further research is suggested to test and validate the framework to provide empirical evidence. Upon model validation, the paper could offer practical interventions for human resource development (HRD) managers to assist philanthropic-based organization toward developing and managing philanthropic behavior of HCVs. The paper highlights the importance of social network to promote individuals to engage in philanthropic actions.

Originality/value

– The paper yields a new approach in theorizing philanthropic behavior among HCVs by integrating the theory of planned behavior, social identity approach and organizational support theory. The proposed social network as a mediator could provide new insights to the HRD practitioners on developing philanthropic behavior among HCVs subject to model validation. The research contributes to literature in philanthropy, HRD and community development.

Ethical considerations of physician career involvement in global health work: a framework

Examining the ethics of long-term, career involvement by physicians in global health work is vital, given growing professional interest and potential health implications for communities abroad. However, current literature remains heavily focused on ethical considerations of short-term global health training experiences. A literature review informed our development of an ethics framework centered on two perspectives: the practitioner perspective, further subdivided into extrinsic and intrinsic factors, and community perspectives, specifically that of the host community and the physician's home community. Some physician factors included cultural/linguistic differences, power imbalances, and sustainable skills/competencies. Receiving community factors included resource limitations, standard of care disparities, and community autonomy. Home community factors focused on the opportunity cost of an unavailable physician who was trained and supported by the local community. Descriptive review permitted comparison with existing short-term literature, noting similarities and differences. Our framework provides a basis for further research and critical analysis of ethical implications of career-long physician global health work.

Teaching corner: raising the bar: ethical considerations of medical student preparation for short-term immersion experiences

Short-term international medical outreach experiences are becoming more popular among medical students. As the popularity of these trips grows, participants, scholars, and institutions have become more aware of the potential pitfalls of such experiences. Loyola University Chicago Stritch School of Medicine (SSOM) has an approximately 20-year international service immersion (ISI) program that has sent more than 1,400 participants to more than 30 countries. Recently, ISI programming has been adjusted to provide students more formal sessions exploring the ethics of the ISI trips. Students are required to attend both pre- and post-trip educational sessions covering a wide range of relevant global health topics as well as participating in in-country reflections and post-trip debriefings. This recent adjustment has evolved further to become the foundation for the SSOM's four-year Global Health Honors program that not only encourages an ethical foundation for the student's ISI experience but also hopes to provide a foundation for students as they look toward a future career in global health.

Scaling up short-term humanitarian surgery: a global surgery elective for senior medical students

OBJECTIVES

The proportion of US medical students participating in global health has increased by 24%. These experiences are generally self-directed and lack a formal educational component. This article describes a structured, comprehensive, community-driven global surgery elective for senior-year students.

DESIGN

"Surgery and Global Health" is a monthlong elective during which students shadow in the university hospital, lead discussions of an assigned text, attend lectures, and participate in a clinical rotation in rural Haiti. The first week is didactic and takes place in Atlanta, GA. Weeks 2 through 4 are clinical and are conducted in Haiti. Urological and general surgery procedures are performed during weeks 2 and 3, while the final week is reserved for follow-up care. This experience was institutionally supported.

SETTING

Emory University Hospital, Atlanta, GA; L'Hôpital St. Thérèse, Hinche, Centre, Haiti.

PARTICIPANTS

Emory University School of Medicine students, years 2 through 4, supervised by faculty from the departments of Urology, General Surgery, and Anesthesiology. Senior-year students spent 21 days in central Haiti working in a rural clinical setting.

RESULTS

Students participated in all facets of surgical care including preoperative clearance, postanesthesia care, discharge planning, and follow-up. Students felt a level of supervised responsibility that was not afforded at their home institution and were able to take on more advanced clinical roles.

CONCLUSIONS

Students planned and executed this innovative experience with multidisciplinary, departmental, and institutional support. Stateside components introduced students to Haitian culture, global surgery ethics, and humanitarian surgical trip logistics. Structured global health experiences such as this give students practical skills and incentive to pursue careers involving global surgery.

Effective strategies for global health research, training and clinical care: a narrative review

The purpose of this narrative review was to synthesize the evidence on effective strategies for global health research, training and clinical care in order to identify common structures that have been used to guide program development. A Medline search from 2001 to 2011 produced 951 articles, which were reviewed and categorized. Thirty articles met criteria to be included in this review. Eleven articles discussed recommendations for research, 8 discussed training and 11 discussed clinical care. Global health program development should be completed within the framework of a larger institutional commitment or partnership. Support from leadership in the university or NGO, and an engaged local community are both integral to success and sustainability of efforts. It is also important for program development to engage local partners from the onset, jointly exploring issues and developing goals and objectives. Evaluation is a recommended way to determine if goals are being met, and should include considerations of sustainability, partnership building, and capacity. Global health research programs should consider details regarding the research process, context of research, partnerships, and community relationships. Training for global health should involve mentorship, pre-departure preparation of students, and elements developed to increase impact. Clinical care programs should focus on collaboration, sustainability, meeting local needs, and appropriate process considerations.

Unchallenged good intentions: a qualitative study of the experiences of medical students on international health electives to developing countries

BACKGROUND

Irish medical students have a long and proud history of embarking on international health electives (IHEs) to broaden their experience in the developing world. Although there are many opinions in the literature about IHEs, there is a dearth of empirical research that explores the experience and the value of these experiences to medical students. Most students who participate in these IHEs from Irish medical schools are members of student IHE societies, which are entirely run by students themselves. There are varying levels of preparation and interaction with the medical schools in planning these experiences. This study explores the experiences of a sample of students who completed IHEs in 2012.

METHODS

This qualitative study used anonymized one-on-one interviews with medical students in Irish medical schools who completed IHEs to developing countries in 2012. Students were recruited using online noticeboards of student societies and e-mail. Purposive sampling was used to find students from different medical schools, some who had travelled with medical student IHE societies and others who had travelled independently. Seven male and seven female students participated. Interviews were conducted until saturation was reached. Data were then analyzed thematically.

RESULTS

The main themes identified were the perceived benefits of IHEs, the difficulties experienced with the distribution of charitable donations, the emotional impact on the students of participating in the IHEs, awareness of scope of practice by students, and issues with the current structure of IHEs.

CONCLUSIONS

The informal relationship that currently exists between student societies and the medical schools results in poor accountability and reporting requirements on IHEs. Clearer guidelines and identification of learning outcomes for students would be helpful. The findings are relevant to medical students internationally.

To the point: obstetrics and gynecology global health experiences for medical students

This article, from the To the Point series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides educators with an overview of considerations for obstetrics and gynecology global health experiences for the medical student. Options for integration of obstetrics and gynecology global health into undergraduate medical curricula are discussed. Specific considerations for global health clinical experiences for medical students, including choosing a clinical location, oversight and mentorship, goals and objectives, predeparture preparation, and evaluation, are reviewed.

Electives in undergraduate medical education: AMEE Guide No. 88

This Guide outlines the scope and potential roles an elective can contribute to undergraduate medical training and identifies ways to maximize learning opportunities, including within global health. The types of educational activity available for electives range from meeting individual educational need through to exploration of potential career pathways, with many factors influencing choice. Key areas of organization underpinning a successful elective before, during and after the placement include developing clarity of the intended educational outcomes as well as addressing practicalities such as travel and accommodation. Risk management including the implications for the participating schools as well as the student and their elective supervisors is crucial. This Guide would not be complete without some discussion around ethics and professional conduct during an elective, with consideration of the impact of elective placements, particularly in low-middle income countries.

Western medical students' experiences on clinical electives in sub-Saharan Africa

CONTEXT

Electives commonly represent a valued, enjoyed and formative part of medical training. However, there is little empirical evidence about students' preparedness, practices and perceptions of medical electives in resource-poor settings. Exploring what students do, why and under what circumstances is therefore worthwhile.

OBJECTIVES

This study aimed to evaluate students' views on the processes, outcomes and impacts of medical electives in three low-income countries.

METHODS

A qualitative study using purposeful sampling and semi-structured interviews was conducted. Participants were 29 Western students on medical electives at seven host sites in sub-Saharan Africa. A framework approach was used to analyse 872 minutes of audio-recorded data.

RESULTS

Students were highly positive about their experiences and seemed aware of their clinical limitations. Pre-departure training offered by some institutions was beneficial, but the content was perceived to be of little clinical relevance. Language barriers were the main challenges faced by students, even in places where English was the second language. Students who stayed longer, were nearer qualification or were based in rural units (rather than teaching centres) contributed more to patient care. Supervision was considered adequate but this appeared to be judged in a local context. Deliberate inappropriate practice was not encountered, but on occasion misunderstanding arose over the student's status.

CONCLUSIONS

Students who undertake electives in resource-poor countries appear to have clearly thought out and positive intentions, but current systems cause concern with reference to student activities and staff time, and require improvement. Instead of focusing on education benefits alone, students (and their sending institutions) need to consider other approaches through which host communities can more clearly benefit. Effective pre-departure preparation should become a requirement.

The correlation between global health experiences in low-income countries on choice of primary care residencies for graduates of an urban US medical school

This study sought to determine whether medical students who participate in a global health elective in a low-income country select residencies in primary care at higher rates compared with their classmates and US medical graduates in general. Given the projected increase in demand for primary care physicians, particularly in underserved areas, understanding possible factors that encourage training in primary care or enhance interest in the care of underserved populations may identify opportunities in medical school training. The authors used data from the Office of Student Affairs, SUNY Downstate College of Medicine and the National Residency Matching Program to compare rates of primary care residency selection from 2004 to 2012. Residency selections for students who participated in the SUNY Downstate School of Public Health Global Health Elective were compared with those of their classmates and with residency match data for US seniors. In 7 of the 8 years reviewed, students who participated in the SUNY Downstate School of Public Health Global Health Elective selected primary care residencies at rates higher than their classmates. Across years, 57% of the students who completed the elective matched to primary care residences, which was significantly higher than the 44% for the remainder of Downstate's medical student class (p = 0.0023). In 6 of the 8 years, Downstate students who participated in the Global Health Elective selected primary care residencies at rates higher than US medical school seniors in general; rates were the same for both Downstate Global Health Elective students and US medical school seniors in 2009. Students who participated in a global health experience in a low-income country selected primary care residencies at higher rates than their classmates and US medical school graduates in general. Understanding how these experiences correlate with residency selection requires further investigation; areas of future study are discussed.

The temporal decline of idealism in two cohorts of medical students at one institution

BACKGROUND

A number of studies have indicated that students lose idealistic motivations over the course of medical education, with some identifying the initiation of this decline as occurring as early as the second year of the traditional US curricula. This study builds on prior work testing the hypothesis that a decline in medical student idealism is detectable in the first two years of medical school.

METHODS

The original study sought to identify differences in survey responses between first-year (MS1) and second-year (MS2) medical students at the beginning and end of academic year 2010, on three proxies for idealism. The current study extends that work by administering the same survey items to the same student cohorts at the end of their third and fourth years (MS3 and MS4), respectively. Survey topics included questions on: (a) motivations for pursuing a medical career; (b) specialty choice; and (c) attitudes toward primary care. Principle component analysis was used to extract linear composite variables (LCVs) from responses to each group of questions. Linear regression was then used to test the effect of the six cohort/time-points on each composite variable, controlling for demographic characteristics.

RESULTS

Idealism in medicine decreased (β = -.113, p < .001) while emphasis on employment and job security increased (β = .146, p < .001) as motivators of pursuing a career in medicine at each medical school stage and time period. Students were more likely to be motivated by student debt over interest in content in specialty choice (β = .077, p = .004) across medical school stages. Negative attitudes towards primary care were most sensitive to MS group and time effects. Both negative/antagonistic views (β = .142, p < .001) and negative/sympathetic views (β = .091, p < .001) of primary care increased over each stage.

CONCLUSIONS

Our results provide further evidence that declines in medical student idealism may occur as early as the second year of medical education. Additionally, as students make choices in their medical careers, such as specialty choice or consideration of primary care, the influences of job security, student debt and social status increasingly outweigh idealistic motivations.

Primary care residency choice and participation in an extracurricular longitudinal medical school program to promote practice with medically underserved populations

PURPOSE

In 2006, the University of Washington School of Medicine (UWSOM) launched the Underserved Pathway (UP), an extracurricular longitudinal experience supporting student interest in caring for underserved populations. This study examined the association between UP participation and residency choice.

METHOD

The study population was 663 UWSOM graduates who matched to a residency from 2008 to 2011; 69 were UP participants. Outcomes included matching to primary care residencies (family medicine, internal medicine, pediatrics, or medicine-pediatrics). The authors calculated graduate rates and odds of UP participants versus nonparticipants matching to primary care residencies overall and to residencies in individual primary care specialties. This analysis included all graduates and 513 graduates who had dual interest in primary care and underserved care at matriculation. Of 336 graduates matching to primary care, the authors calculated rates of entering the individual specialties with respect to UP participation.

RESULTS

UP participants matched at significantly higher rates than nonparticipants to primary care (72.5% versus 48.1%, adjusted odds ratio [OR] 2.2) and family medicine residencies (33.3% versus 15.0%, adjusted OR 2.9). Of graduates with dual matriculation interest in primary care and underserved care, 73.4% of participants versus 53.5% of nonparticipants matched to primary care (adjusted OR 1.9), and 31.2% of participants versus 18.0% of nonparticipants matched to family medicine (adjusted OR 2.1). Of primary care matched graduates, 46.0% of participants versus 31.1% of nonparticipants entered family medicine.

CONCLUSIONS

Supporting student interest in underserved careers is associated with higher rates of graduates entering primary care residencies, specifically family medicine.

Students' experience of prison health education during medical school

BACKGROUND

Social responsibility and accountability can be important core values in medical education. At the University of British Columbia, undergraduate medical students engage in prison health community service-learning opportunities in regional correctional facilities.

METHODS

To describe the impact of prison health exposure on pre-clinical medical students, in-depth individual interviews were conducted with individuals who had participated in a prison health medical education program. All interviews were transcribed verbatim, and interpretive descriptive methods were used to inductively derive thematic findings to describe students' experiences.

RESULTS

Major themes emerged as students reported how (1) exposure to incarcerated populations increases students' insight into issues that diverse marginalized sub-populations encounter; (2) positive interactions with the incarcerated individuals enhances relationship building; (3) collaboration reinforces teamwork skills and (4) community placements garner important learning opportunities within the medical school curriculum.

CONCLUSIONS

Our findings demonstrated that pre-clinical exposure to incarcerated individuals and prison health education provided a unique setting for medical students to develop an increased sense of social responsibility and accountability.

Reducing the stigma of mental illness in undergraduate medical education: a randomized controlled trial

BACKGROUND

The stigma of mental illness among medical students is a prevalent concern that has far reaching negative consequences. Attempts to combat this stigma through educational initiatives have had mixed results. This study examined the impact of a one-time contact-based educational intervention on the stigma of mental illness among medical students and compared this with a multimodal undergraduate psychiatry course at the University of Calgary, Canada that integrates contact-based educational strategies. Attitudes towards mental illness were compared with those towards type 2 diabetes mellitus (T2DM).

METHOD

A cluster-randomized trial design was used to evaluate the impact of contact-based educational interventions delivered at two points in time. The impact was assessed by collecting data at 4 time points using the Opening Minds Scale for Health Care Providers (OMS-HC) to assess changes in stigma.

RESULTS

Baseline surveys were completed by 62% (n=111) of students before the start of the course and post-intervention ratings were available from 90 of these. Stigma scores for both groups were significantly reduced upon course completion (p < 0.0001), but were not significantly changed following the one-time contact based educational intervention in the primary analysis. Student confidence in working with people with a mental illness and interest in a psychiatric career was increased at the end of the course. Stigma towards mental illness remained greater than for T2DM at all time points.

CONCLUSIONS

Psychiatric education can decrease the stigma of mental illness and increase student confidence. However, one-time, contact-based educational interventions require further evaluation in this context. The key components are postulated to be contact, knowledge and attention to process, where attending to the student's internal experience of working with people with mental illness is an integral factor in modulating perceptions of mental illness and a psychiatric career.

Decline of medical student idealism in the first and second year of medical school: a survey of pre-clinical medical students at one institution

BACKGROUND

Idealism declines in medical students over the course of training, with some studies identifying the beginning of the decline in year 3 of US curricula.

PURPOSES

This study tested the hypothesis that a decline in medical student idealism is detectable in the first two years of medical school.

METHODS

We sought to identify differences in survey responses between first-year (MS1) and second-year (MS2) medical students at the beginning (T1) and end (T2) of academic year 2010 on three proxies for idealism, including items asking about: (a) motivations for pursuing a medical career; (b) specialty choice; and (c) attitudes toward primary care. Principle component analysis was used to extract linear composite variables (LCVs) from responses to each group of questions; linear regression was then used to test the effect of on each LCV, controlling for race, ethnicity, rural or urban origins, gender, and marital status.

RESULTS

MS2s placed more emphasis on status/income concerns (β=0.153, p<0.001), and much less emphasis on idealism as a motivator (β=-0.081, p=0.054), in pursuing a medical career; more likely to consider lifestyle and family considerations (β=0.098, p=0.023), and less likely to consider idealistic motivations (β=-0.066, p=NS); and were more likely to endorse both negative/antagonistic (β=0.122, p=0.004) and negative/sympathetic (β=0.126, p=0.004) attitudes toward primary care.

CONCLUSIONS

The results are suggestive that idealism decline begins earlier than noted in other studies, implying a need for curricular interventions in the first two years of medical school.

Undergraduate medical students' attitudes towards psychiatry: an international cross-sectional survey between India and Japan

Undergraduate psychiatric education has an important role in developing psychiatric knowledge, decreasing stigma towards mental illness, and promoting psychiatry as a career choice. The attitudes and beliefs of medical students towards psychiatry have not been well understood, especially in non-western countries. To clarify this aspect, we have conducted a cross-sectional study between India and Japan. This study, conducted at two centres, one each in India and Japan, used a semi-structured questionnaire to evaluate the attitudes and beliefs of third-year medical students towards mental illness and psychiatry; such as emotions experienced dealing with psychiatric patients, aetiology and treatment of psychiatric disorders, and psychiatry as a career choice. A total of 79 medical students from India and 77 from Japan participated in the present study. Significant differences were observed in the emotions experienced by the medical students while dealing with psychiatric patients. Most medical students (> 90%) from both study sites favoured psychiatrists for treatment of psychiatric illness. Psychiatry as a carrier choice was significantly related to the nationality of the medical students. The findings of the current study provide insight in to the attitudes of third-year medical students from India and Japan towards psychiatric patients.

Student objectives and learning experiences in a global health elective

International health electives offer unique experiences for medical students to develop clinical skills and cultural competencies in unique and diverse environments. Medical students have been increasingly pursuing these learning opportunities despite the challenges. However, their goals in pursuing these opportunities and the relation between their learning objectives and actual experiences have not been studied adequately. It is important to assess these programs based on student objectives and whether those objectives are met. Thirty-seven medical students from five cohorts at a US medical school completed pre-post questionnaires regarding their global health elective objectives and learning experiences. The questionnaires included mostly open-ended questions and a Likert-scale rating of their overall experience. Qualitative thematic analysis involved inductive coding and followed a content-driven immersion-crystallization approach. Quantitative program evaluation measures yielded descriptive statistics. Five general objectives and four types of learning experiences were identified. Student objectives were: (1) to observe the practice and organization of health care in another country; (2) improve medical/surgical skills; (3) improve language skills; (4) learn about another culture; and (5) deepen knowledge of infectious diseases. All of their objectives were achieved. Moreover, one learning theme, "self-reflection and personal growth," was not a student objective. Quantitative assessment showed that most students had a favorable elective experience. Program challenges were also identified. Students in a global health elective were able to fulfill self-identified learning objectives, while also gaining other unexpected yet important lessons. Students' learning objectives also should be considered in evaluating learning experiences in international health electives.