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Global Lessons

INTERNATIONAL ROTATIONS AND ELECTIVES CAN OFFER A WEALTH OF EDUCATIONAL EXPERIENCES.

The New Physician September 2004
On the first day in her new hospital, fourth-year Alexia Moutsatsos walked onto her floor and saw medical students and residents rushing from place to place. Unsure why they were behaving this way, Moutsatsos went about her business and waited to begin rounds as she had always done. “I enjoyed a cup of frappé, thinking, ‘This is going to be so easy.’ I went up to the nurse asking for some labs, and she looked at me like I was crazy,” she says.


After muttering something under her breath, the nurse stormed off to deliver medications to her numerous patients. Bewildered by the reaction, Moutsatsos tracked down her resident for an explanation. The resident’s response was simple: “Here we draw blood, run it to the lab, and do anything else like EKGs, vitals, suctioning, write a note…. Have you done anything this morning? Well, what do you do in the U.S.?”


It wasn’t exactly how Moutsatsos, a soon-to-be graduate of Georgetown University School of Medicine, wanted to start her international elective at Athens Laiko Hospital in Greece. Nonetheless, it was the beginning of an unforgettable educational experience. And she learned lesson No. 1 well: “An international rotation is not meant to be a vacation,” she says.


Of course, that is exactly what some future physicians hope for from an international rotation, casually going on some rounds while making plans for the next sightseeing trip. Meanwhile, for some naïve first- and second-years, an international medical experience may instead conjure up visions of exotic locales with themselves acting as “super-physicians,” providing care to desperate and ever-grateful locals.


None of this is the reality, though. Not for most medical students, anyway. International rotations and electives are as diverse as the nations of the world, and offer lessons more valuable than any sightseeing trip could possibly provide.


THE POWER OF PERSISTENCE


One of those lessons is the value of hard work and persistence. And learning this often begins long before students enter foreign lands, as Dr. Daniel Park, an internal medicine intern at the University of Alabama-Birmingham, discovered while planning his overseas experience.


The then University of North Carolina (UNC) at Chapel Hill School of Medicine third-year had set his sights on Angola, a country that has been torn apart by civil unrest for most of the past three decades. Inspired by an Angolan family he met before medical school, Park was so determined to do a rotation there that, even if he had to take a year off and received no academic credit for it, he would do it. “My career goal entering medical school was to do international relief work. Going to Angola was a way for me to have an international experience in a war-torn country so that I could see what this type of work was really like, to test myself and see if I could handle the challenges of working under difficult circumstances,” he says.


UNC provided some financial assistance for his travel, but he says he was left to his own devices for figuring out how to get there.


“There were not many organizations willing to have a med student volunteer, mostly because it was an unstable environment [with tremendous] risks and costs of taking on volunteers,” he says. “I e-mailed and wrote many letters to all the [nongovernmental organizations (NGOs)] and individuals, churches, etc., that I could find on the Internet and through personal contacts before finally contacting Catholic Relief Services, who directed me to a Catholic mission hospital that agreed to have me come. They had never done this before, and it was not easy to get the documents done to get a work visa. It took a lot of perseverance and rejections before I finally got lucky.”


“Luck” led Park into Angola blindly. “I had no direct contact with the sisters [who run the mission] because they were isolated, and it was logistically difficult to have communication. So I basically committed without knowing exactly what to expect. Because of this, I had to do things with flexibility, accepting that things would be made up as we went along instead of planned out well,” he says.


Fortunately, Catholic Relief Services helped process his travel documents, provided transportation in Angola and assisted with communicating to friends and relatives back in the United States. It could also get money to him when necessary.


Dr. Daniel Clinchot, the associate dean for clinical education and outreach at Ohio State University (OSU) College of Medicine and Public Health, says students should try to affiliate themselves with an organization established in the foreign country.


“You really have two sets of students. You have a set that…either goes on the Internet or knows of an organization, and that organization has some of the same goals and objectives of the student, and the student links on with that organization…,” he says. “Then you have students, who on their own, will seek out and do some international electives, and really have to consider [all of these logistical issues] and set that up themselves.” The latter, he says, is much more difficult.


For students making their own rotation arrangements, most begin by going online, as Park did. “The biggest advice I could give would be to utilize the Internet and to e-mail relentlessly,” says Cully Wiseman, a second-year at the University of Texas Medical Branch (UTMB) at Galveston. “If you are starting from scratch, pick an area where you are familiar with the language, and start looking on the Internet for NGOs or medical groups that work in the region.”


Using these methods, Wiseman has arranged educational trips for himself in Australia, Guatemala, Peru, Tanzania and South Africa. “[Use the Internet to] find e-mail addresses, physical addresses, phone numbers, and contact these people as much as you can. If you e-mail 50 people, 10 are likely to write you back. If you only contact three people, you aren’t likely to get anywhere.”


And start this planning well in advance. “I think the biggest thing that students don’t usually understand is the time it takes to organize something like this,” Clinchot says. “I mean you don’t just decide you want to do an international elective and go do it.”


Besides finding a rotation and financial support, students need to get immunizations, visas and passports. And the longer a student waits, the more expensive transportation costs can be. “Not only may it take four months just to get a reply, but international plane tickets are much cheaper when purchased far in advance,” says Dr. Jennie Howland, a first-year medicine–pediatrics resident at Tufts University Baystate Medical Center.


As a fourth-year at the University of Massachusetts Medical School, Howland took electives in Nicaragua, Swaziland and Tanzania. It was a stint in Tanzania that posed some of her greatest challenges. “I had started a medical rotation at a remote hospital I had randomly contacted over the Internet. Unfortunately, there were no doctors in practice and a very sporadic patient load,” she says.


Luckily she also met a group of locals in the village of Nyamswa that was creating a community-wide development project. “I could see their main limitations were financial, but when I asked them what they needed, they asked for volunteers and technical assistance as well,” she says. So with some guidance from the International Federation of Medical Students’ Associations (IFMSA), Howland founded the Malaika Project, a student-run organization that not only provides medical rotations in Nyamswa but also coordinates other projects, including agricultural development, sanitary improvements and business promotion. Now, medical students and other future health professionals can go through the Malaika Project to volunteer their time in Nyamswa.


ORGANIZATIONAL BENEFITS


In fact, many wannabe international travelers turn to student organizations for assistance. “Most students go through AMSA, the American Medical Student Association, specifically the branch that is here for the international health interest group,” Clinchot says. “We have a very active international health interest group here, and they have sent students all over, and helped students find funding and make connections with people who are going.”


Dawn Mautner, AMSA’s global health education and opportunities coordinator, says some local AMSA chapters sponsor discussion panels that allow students to hear about classmates’ experiences. Also, chapters are often able to direct future physicians where to look for grant money offered by their medical schools or by community organizations.


On the national level, Mautner says AMSA’s international health Web page (www.amsa.org/global/ih) provides financing tips in “The Creative Funding Guide for International Electives,” an online handbook compiled by AMSA and the International Health Medical Education Consortium (IHMEC). “Funding the trip is often the stickiest part of getting out of the U.S. for many of us as students,” she says. And when debating where to go, students can turn to AMSA’s searchable database of international health opportunities.


Future physicians can also seek assistance from IFMSA, as Howland did. “For students looking for international work or education, IFMSA students can link them with projects, other medical student leaders and information in whatever they may be interested…,” says Jessica Evert, an OSU fourth-year and executive vice president of IFMSA-USA. “For example, IFMSA-Spain coordinates a project at an HIV orphanage and clinic in South Africa [in which] any IFMSA member from around the world can participate. Medical student members of IFMSA-USA run several village projects consisting of clinical and public health endeavors in Ghana and other developing countries.”


In particular, IFMSA can assist those who are financially strapped. “If price is not an issue, arranging an international experience is not that difficult. There are several organizations that can get you abroad if you want to pay several thousand dollars,” Evert says. “IFMSA is unique because their programs are available for minimal cost—i.e., like $100—so they are more accessible to medical students in the U.S. and abroad.”


Students can also organize themselves to share resources and find financial assistance. That’s what Wiseman did when he launched SIGHT—Students Improving Global Health Together— in 2003 at UTMB at Galveston. “SIGHT started on the back of some neuroscience notes I was working on last spring. I had had the idea in the back of my mind for a long time, but started writing them down on a piece of paper when I should have been studying brain lesions,” he says.


What may have seemed like procrastination turned out to be much more after Wiseman sent an e-mail to classmates, who he says made the idea a reality. Now, SIGHT has more than 100 members, who hold regular meetings to share their international experiences. They also recently compiled a guide for overseas educational opportunities. And SIGHT was even able to convince Dr. Stanley Lemon, the dean of the UTMB medical school, to provide $10,000 annually to the organization for financial assistance to students doing rotations or research abroad. “We had over 20 students apply for scholarships this year, and awarded scholarships to nine, [who are] going to India, Nicaragua, Togo, South Africa and Bolivia,” Wiseman says.


THE MONEY ISSUE


Not surprisingly, finances are a major concern. AMSA estimates that a six-week elective costs an average of $2,500. And in some cases, students end up paying those expenses with their school loan money.


However, like the scholarships offered by SIGHT, help is available. “Very rarely do students have to pay out of their pocket. The sources of those funds, though, can be varied,” Clinchot says. “Sometimes students will link up with a specific organization…. Other ways students can get financial assistance is grants [through their medical schools], but also the international health interest groups can help students raise funding, be that through local philanthropic organizations or groups that have an interest in a specific component of health care in the region where the student wants to go.”


AMSA’s and the IHMEC’s “Creative Funding Guide for International Electives” directs students to investigate sources ranging from the Christian Medical and Dental Associations to the Academy for Educational Development to the Rotary Foundation. In particular, it suggests future physicians may want to seek financial support from religious groups. “Many religious organizations are becoming more active in their support of service-related projects with an international focus,” the guidebook says.


Similarly, Howland advises students not to avoid an organization or missionary service just because it may conflict with their religious views. “If you are not religious, don’t shy away from mission hospitals. Missions often provide the majority, if not the highest quality, of health care in many countries, and their mission is to serve impoverished people, not necessarily to evangelize,” she says.


And depending on where the medical student wants to go, a religious organization may provide the best avenue to get there, as was the case for Park working with Catholic Relief Services for his Angola elective.


WHERE TO GO?


How does one decide where to do a rotation or elective? “You need to be motivated and interested. But there are a number of issues to be concerned with,” says IHMEC president, Dr. Andre-Jacques Neusy, who’s also the director of the Center of Global Health at New York University School of Medicine.


First off, if a student hopes to receive academic credit for the rotation, he’ll want to meet with the medical school’s office of international education—or the equivalent—to determine if it’s available for the desired rotation. Many administrators are willing to cooperate, as is the case at OSU, which recognizes international rotations as fulfilling students’ community project requirements. However, schools may not recognize rotations in certain countries. For example, OSU does not recognize rotations in Cuba or other countries under U.S. embargo. “Those countries we try to discourage students from going there for their own personal safety,” Clinchot says.


Of course, safety and health are concerns for anyone planning an international rotation. “Take care of your personal health, and go in with a realistic understanding of risks involved,” Park says. (See “Health and Safety Abroad,” p. 30.)


Language should also be considered. “I highly recommend going to a country where you have some basic communicatory skills in the native language,” Moutsatsos says. “I spoke solely in Greek. Though [I struggled] with unfamiliar medical terms, they respected the fact that I tried my best at being ‘Greek’ and was volunteering my time in the country of my ancestors.”


However, other future physicians say language barriers can be overcome if translation services are available. “At Raleigh Fitkin Memorial Hospital in Swaziland, none of the doctors spoke the local language,” Howland says, “but the translation worked well in the clinical setting, and I learned more in my three months there than I had in my entire first three years of medical school.”


Clinchot says students can also arrange for a translator, in a sense. “For example, we had a student this past summer who went to India, and he did not speak the native language. So he made plans with one of the other students who did, and they both went on the experience, and one was able to be translator for the other. So it worked out well,” he says. “But students definitely need to [consider language barriers]. I mean, it’s very difficult to communicate, especially medical issues, to a population that doesn’t necessarily understand medical terminology when you are not speaking in their native tongue.”


LESSONS TO BE LEARNED


While language, safety, cost and academic credit are essential considerations, so, too, are the location’s educational benefits. “I think the most important thing is finding a place where you’ll get the sort of training you are looking for,” Howland says.


Clinically, students are sure to see conditions they would almost never see in the United States, particularly if their rotations are in developing nations. “[T]hey get exposed to illnesses and disease processes that are preventable and rarer in the United States,” Clinchot says, “and they learn how simple measures of infection containment can make a big difference in different communities.”


However, Neusy believes future physicians should investigate opportunities that will directly benefit their medical practices in the United States. “In my view, the main focus should be to go to countries that are really relevant to your immigrant communities. So if you are going to see patients from Bangladesh or from West Africa in the place where you [are practicing medicine] here in the States…, then we think there is a benefit in going to those places,” he says.


Nevertheless, Clinchot and Neusy agree that future physicians have a great deal to learn simply by seeing how health care is delivered in other parts of the world. “It is very important for students when they go to the field to really be in these countries and be sensitive to these cultures, to the way people view health, to understand this is not a North American-centric model that they have to bring there, and they really have to be open to those experiences,” Neusy says. “And ultimately it will make them better physicians. It is not only to look at exotic pathologies—which they will find and that they will actually find back in the States when people come here—but it is more important to see that the health model that people have differ….


“They will come back here certainly more enriched by the experience, and I am certain they will actually be better clinicians.”
One way to encourage this is for students to immerse themselves in the culture. “Once in a foreign environment, being open and making friends with the people around you, especially the local people, is the key to having a good overall experience,” Howland says. “They can also teach you about the language and culture, and share a different view of the world that can challenge your assumptions. They can take you places that might not be in your tour book.”


And Park advises adopting the mindset of a visitor. “Understand that you are there as a guest and be grateful for the opportunity. You are receiving more than you give,” he says.


If future physicians are willing to receive these valuable lessons, the gifts of the overseas elective or rotation could have lasting effects. “International experiences have been the most life-transforming periods of my life,” Howland says. “I would highly recommend to everyone to take advantage of the opportunity you have to provide some service, experience a different way of life and change your way of perceiving the world forever.


“Even if you have to use your own loan money, $1,000 to $2,000 is a small price to pay in the grand scheme of your medical education for a learning experience, which will last a lifetime and from which you will continue to learn for years to come.”
Scott T. Shepherd is an associate editor with The New Physician. Direct comments about this article to tnp@amsa.org.