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March 6-9, 2014

AMSA Global Health Ethics
Student Curriculum

In recent years, increasing numbers of US-based health professions students have traveled to low resource settings to conduct short-term research projects and participate in clinical electives. The content of pre-departure training can be highly variable, leaving students unprepared for the ethical challenges posed by these experiences. This is magnified by the lack of attention paid to the burdens and benefits for local staff, institutions, and patient well-being in the setting of disproportionate poverty and disease. This curriculum explores some of the ethical challenges posed by US-based students’ global experiences through a series of case studies based on the experiences of the students. The curriculum includes pre-departure training and post-return debriefing sessions, which may be implemented in 1.5 hours each in groups of up to 20 students. The sessions are designed to be facilitated by student leaders with faculty guidance.

Research Ethics Curriculum | Clinical Ethics Curriculum

Introduction to Global Research Ethics

Recently, interest in global health among US-based medical students has exploded, and increasing numbers of students are traveling to low-resource settings for clinical and research electives.1,2 One study showed that trainees who have such experiences are more likely to care for impoverished patients in the future and that some may have even changed the focus of their clinical training from sub-specialty medicine to general medicine as a result of their time abroad.3 Another study documented an increased interest in volunteerism, humanitarianism, and public health among students who participated in an international elective; however, more research is necessary to truly understand the effects of international experiences on medical trainees.4 Furthermore, although there is some evidence that these experiences positively contribute to the professional development of medical students, there is no evidence that the patients involved in research by these trainees derive any benefit from these programs. Sending students to developing countries for short-term research experiences brings additional layers of complexity to an already ethically fraught situation.

In this curriculum, we explore some ethical concerns that are raised by medical students traveling to low-resource settings for short-term research projects.

Curriculum Components

1. Pre-Departure Workshop


2. Post-Return Workshop

Introduction, Cases and Discussions adapted from Provenzano AM, Graber LK, Elansary M, Khoshnood K, Rastegar A, Barry M. Short-term global health research projects by US medical students: Ethical challenges for partnerships. The American Journal of Tropical Medicine and Hygiene. 2010;83:211-4

Research Ethics Curriculum Team & References in Sidebar

Introduction to Global Health Clinical Ethics

A recent Association of American Medical Colleges survey found that 30% of graduates of U.S. medical schools reported participating in global health experiences.1 Previous research has shown that international rotations foster cultural awareness, elicit a deeper understanding of poverty, and influence students to pursue careers caring for underserved populations.2-5 Despite considerable interest in global health education from students and its reported benefits, however, most schools have not integrated formal global health programs into their curricula.6,7 Only recently have formal ethical guidelines for global health experiences been proposed.8,9 The lack of an institutionalized framework for global health education has had important ethical and educational implications for medical students who pursue electives in resource-poor settings.

International research programs are governed by well-developed clinical guidelines, but global clinical electives carry with them many ethical challenges that have received relatively little attention.10 While international research programs contribute to the larger academic discourse and are subject to institutional review board approval and other ethical standards, clinical programs that involve students also impact the local community and thus require similar attention. In particular, the perspectives and needs of institutions that host and support foreign students at the international clinical sites in low-resource settings (“host institutions”) have been neglected. Electives have been described as a “one-way opportunity” that favor students who visit from wealthier institutions.11 Paradoxically, the disproportionate focus on the benefits for visiting students rather than for the host institution reinforces the same disparities in wealth and opportunity that global health programs seek to address.

The case studies presented here, based on the experiences of the students, provide a tool for pre-departure training of medical students preparing for international electives.

Curriculum Components

1. Pre-Departure Workshop


2. Post-Return Workshop

Introduction, Cases, and Discussions adapted from Elansary M, Graber LK, Provenzano AM, Barry M, Khoshnood K, & Rastegar A. Ethical dilemmas in global clinical electives. The Journal of Global Health. 2011;1(1): 24-27

Clinical Ethics Curriculum Team & References in Sidebar

Research Ethics Curriculum

Research Ethics Curriculum Team

References

1. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Academic Medicine: Journal of the Association of American Medical Colleges 2009;84:320-5.
2. Panosian C, Coates TJ. The new medical "missionaries"--grooming the next generation of global health workers. The New England Journal of Medicine 2006;354:1771-3.
3. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Program: the fifteen-year experience with Yale University's Internal Medicine Residency Program. The American Journal of Tropical Medicine and Hygiene 1999;61:1019-23.
4. Smith JK, Weaver DB. Capturing medical students' idealism. Annals of Family Medicine 2006;4 Suppl 1:S32-7; discussion S58-60.

Clinical Ethics Curriculum

Clinical Ethics Curriculum Team

References

1. Association of American Medical C. 2010 Medical School Graduation Questionnaire: All Schools Summary Report. Washington, DC: Association of American Medical Colleges; 2010.
2. McKinley DW, Williams SR, Norcini JJ, Anderson MB. International exchange programs and U.S. medical schools. Academic Medicine: Journal of the Association of American Medical Colleges 2008;83:S53-7.
3. Ramsey AH, Haq C, Gjerde CL, Rothenberg D. Career influence of an international health experience during medical school. Family Medicine 2004;36:412-6.
4. Shaywitz DA, Ausiello DA. Global health: a chance for Western physicians to give-and receive. The American Journal of Medicine 2002;113:354-7.
5. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Program: the fifteen-year experience with Yale University's Internal Medicine Residency Program. The American Journal of Tropical Medicine and Hygiene 1999;61:1019-23.
6. Izadnegahdar R, Correia S, Ohata B, et al. Global health in Canadian medical education: current practices and opportunities. Academic Medicine: Journal of the Association of American Medical Colleges 2008;83:192-8.
7. Panosian C, Coates TJ. The new medical "missionaries"--grooming the next generation of global health workers. The New England Journal of Medicine 2006;354:1771-3.
8. Crump JA, Sugarman J, Working Group on Ethics Guidelines for Global Health T. Ethics and best practice guidelines for training experiences in global health. The American Journal of Tropical Medicine and Hygiene 2010;83:1178-82.
9. Provenzano AM, Graber LK, Elansary M, Khoshnood K, Rastegar A, Barry M. Short-term global health research projects by US medical students: ethical challenges for partnerships. The American Journal of Tropical Medicine and Hygiene 2010;83:211-4.
10. Shah S, Wu T. The medical student global health experience: professionalism and ethical implications. Journal of Medical Ethics 2008;34:375-8.
11. Mutchnick IS, Moyer CA, Stern DT. Expanding the boundaries of medical education: evidence for cross-cultural exchanges. Academic Medicine: Journal of the Association of American Medical Colleges 2003;78:S1-5.