Global Health Immersion Programs

Hooray for Jessica Evert, MD! Thank GOD for a voice that isn’t just blowing the same direction as the wind. Twenty five years ago (gee, that makes me feel old) we were on the upside of this uphill battle… and push, push PUSH- is what I and many similar students did to get what was then known as ‘international health’ on the radar screen at our medical schools. And make no mistake about it, student energy IS STILL the vital source of change. But we ‘gray back’ professors of medical education~ should be also be willing to proactively champion Global Health though our positions of influence at institutions and regulatory bodies and PULL these sluggish bureaucratic organizations along.

Our medical schools are often asked to answer to board content, licensure requirements, and professional consensus. I support Jessica’s call for meaningful action from these powerful organizations to incorporate global health competencies into undergraduate medical education.

Thanks for this post Jessica, it is timely. Medical students should not be left to design their own global health education when the latest statistics show that 43% of medical students are completing international electives (AAMC data, 2010).

Why hasn’t global health really “happened” in these accreditation and licensing bodies yet? Why are they just starting to happen now? Is it just because they have become so laden with slow, bureaucratic process? Is the slowness because of thoughtfulness and deep consideration, or is it just the system itself? How might these systems respond more quickly where there is a clear need to address a topic within medical education?

A group of us have indeed advocated for years to get predeparture training into accreditation (and into the lives of students), with positive results so far… but the effort has been enormous. How many changemakers can continue to invest the type of intense energy it takes to make this happen?

Thanks again for bringing this topic into the spotlight.

Brava Jessica! Thanks for putting into a compelling and coherent manner what has been discussed now for years.

I agree with Evaleen and Kelly. I think that we have to also look at the consequences of moving this forward. While we want there to be some Global Health competency for US health professionals, we must also be careful not to impose US “standards” on other sovereign healthcare systems and medical education systems.

The pursuit of more Global Health requirements should not mean that all Global Health Education sites in other countries need to be cut from the same mold as US rotation sites. If we do this, by placing too many specific policies and standards on sites in other countries, Global Health will look more and more like US Health and that is not the aim. We are not in the business of franchising McDonald’s. We want students to have an authentic experience of the differences of healthcare in different countries and different cultures. Therefore in our efforts to require Global Health knowledge of our students, let’s be careful to tread lightly on the host cultures and host institutions so that they can preserve as much of their identity and uniqueness as possible and not be forced to follow a long list of US standards.

Hey Dr. Evert,
I attended your talk at the recent AMSA conference and I really love the work you’re doing… it’s really inspired me right now in a time where I am really disillusioned with the one-track education I’m getting that seems to be so close-minded. I’m from Kenya, and ever since I started learning, I think of everything in terms of the whole world, but it’s so hard to relay this mode of thinking to people who haven’t been exposed to global influences and can only think within national borders. Thank you for being a voice of reason and for caring so much about this really important issue! Imagining how different my medical education would be if global health was a priority makes me sad about its current state and hopeful for the future if your work continues on in a positive way… thanks again!

I would like to also mention that :

A terrific example of an amazing ‘grayback’ who is now pulling higher institutions along is Michele Barry, MD, FACP, recently appointed Senior Associate Dean Director, Center for Global Stanford School of Medicine. Indeed, she is to be congratulated for her outstanding performance in ‘corralling’ the entire campus including graduate school of business engineering, medicine and law under one umbrella – using global health as a lens through which medical and higher education can take place.

~most importantly… she’s brought in real money that can make things happen- she is generous and open to creative thinking- she is finding money that others can use to voice their perspectives and opinions in a collegial manner and helping junior faculty and students fund more constructive activities abroad.

I invite Dr. Barry and other Dean’s dealing with these same issues to join this discussion and help is think about where we go from here.

To add my two cents, I have to agree with a previous comment on the blog post. While I obviously care about global health, I’m not sure “global health” per se has a dedicated mandatory role in medical education. I think a greater awareness of the social issues of medicine could certainly be emphasized as well as service to underserved populations (just like an earlier email you sent making the point that “third world” conditions exist right here in the US). Sending students abroad without the right attitude or preparation is a recipe for disaster if you ask me…

I want to thank everyone for their comments, specifically Sherya who brings up important cautionary arguments. I think it’s important to differentiate between global health education/competencies which can be taught within US medical school curriculum and rotations or immersion programs abroad. They are not the same. I agree with Shreya that unprepared students going abroad is a recipe for extracting resources from already stretched communities and clinics, ethical mis-steps, and doing more harm than good. Many medical schools are allowing students to go abroad without any preparation (which is why LCME’s requirement for post-departure training is so important). Often these activities are done with a service rather than educational mission. If I may paraphrase Kelly Anderson’s comments in an to-be-released documentary called “First Do No Harm” (about the issue of students going abroad and the issues that it raises) “when service becomes the goal of international rotations, rather than education, humility is lost….good intentions are not good enough motivations for working abroad.” I think many of our institutions and individuals are sending the message to students of “Change the World” through going abroad, rather than “Let the World Change You” (CFHI’s motto). The latter is an important contrast to the former. Especially for initial visits to locations, during short-term engagements, or when you are not fully trained (to any extent; these rules even applied to full fledged doctors), it is important to be an observer, a learner, and hold the local practitioners as the experts of own realities- rather than swooping in and trying to paternalistically save people. Thus, I do think there needs to be a clear distinction between the curricular reform I am advocating for- it is NOT a requirement that all students go abroad. In addition, our medical schools need to be more diligent in their oversight of global health rotations, often part of this diligence is recognizing the inherent limitations in our medical schools to cultivate sustainable just partnerships (for a variety of reasons including unreliable funding streams, staff/faculty turnover, and an inherent bias for self-interest, and risk adverseness that causes them to pull out of partnerships when the weather isn’t fair, as well as agendas that focus more on research and capacity building than education- not necessarily a bad thing, but education sometimes takes a back seat). To address these limitations it’s important that medical schools consider partnerships with NGO organizations, such as CFHI- who can advocate for communities, guarantee reciprocity (why is it that physicians and health workers in developing countries are expected to teach US students for free??), execute meaningful pre-departure training and professionalism training, have 24/7 effective support when students are in country, and have the flexibility to stay with partners even when the state department says otherwise. At NEGEA Michel Dodard did a keynote address, afterward he attended the curriculum workshop which I led. He emphasized the important synergy between Medishare and University of Miami to this end. In conclusion, I think the distinction between global health curriculum (basic knowledge of what’s going on in developing countries and on the global health landscape) integration into medical school curriculum and international rotations- international rotations are much trickier and should not be a requirement. In fact, I think they should be only undertaken with great care, preparation, and partnership.

Glad to have looked at this blog website, and I am glad to be a participant of CFHI. Looking forward to my April experience. Great work, guys, and I will check this website frequently.

I would like to commend Jessica Evert for all the work she and colleagues have done over the past few years to respond to the kinds of problems she describes in her blog.

First as a student and then resident she worked to promote the programs of the US Chapter of the International Federation of Medical Student Associations, later helping to merge IFMSA with the American Medical Student Association. In her current position as medical director of Child Family Health International program she is helping the students overseas placement program to “walk the talk” in global health. She and a colleague, Jack Chase, co-edited of a multi-authored guidebook for the design, development, management and selection of residency programs that offer a global health track. The second edition of this guidebook, published this month, represents a major expansion and refinement of the first one that she edited and published in 2008.

GHEC warmly supports her plea for the introduction of global health concepts and content into the curriculum for all health professionals and especially those enrolled in medicine. Whether practicing their profession at home or abroad, 21st Century health professionals need to have a good understanding of both the global threats to health and of the diverse ways these threats are addressed.

— Thomas L. Hall, MD, DrPH, Executive Director, Global Health Education Consortium

Thank you Jessica for your honest and powerful post, and for the work you do.

In my opinion, a major hurdle to ‘global health’ being a meaningful component of medical school curriculum is a misunderstanding that it is foreign and other. As a profession, medicine has gradually evolved to move past teaching pathophysiology of disease, to understanding disease in the context of the patient, and to understanding disease in the context of society (public health, ethics); medicine will move to understanding disease in the context of communities and of the world as a whole, with the recognition that the word HEALTH in any other language has the same value and importance. As Jessica described with her feelings of being cheated by her own medical education, in my own MD degree I was not given a proper context of suffering as it relates to marginalized communities in Canada and around the world, and I am left to piece this together on my own. To echo the sentiments of Jessica, Kelly and Shreya, it is worrying that after medical school we can practice medicine in any community or context we like without having had the proper training to prepare us for this.

Although the LCME has not yet adopted the proposal to implement predeparture training as an essential component of service learning, we continue to advocate for this important component of student, patient and community safety. I will join the call for updated LCME requirements to reflect the realities of global health. Thank you Jessica for this important discussion.

I really appreciated your blog! I could not agree with you more.

It’s important for all citizens of the world to have some kind of curiosity and interest in one another, that we learn together and appreciate each others struggle. Most importantly, as the geographic boundaries are blended through movement of people from one community to another, it is our duty as physicians to have the skills to be able to meet those needs. Not only from a medical standpoint, but culturally as well.

International medicine education needs to be developed passed Instructors simply presenting their own work in a far away community. It needs to be integrated into our everyday learning.
Thank you for bringing attention to this subject!