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Bringing lessons from the heartland to the homeland

From the October ACP Observer, copyright 2007 by the American College of Physicians.

By Stacey Butterfield

While American medical students explore health care through programs in the rest of the world, their foreign counterparts are lining up for the chance to borrow their spots at U.S. medical schools.

The opportunities that international students find vary from full clerkships to observations of the workings of a hospital. Some students pay fees, room and board, while others have all their expenses covered. And there is competition for slots even in the more expensive, less hands-on programs, according to medical school administrators.

Why the push to study here?

"I believe that's an easy question. It's every scientist's dream to come study and then practice medicine in the USA," said Ioannis Angelidis, a Greek medical student who spent a month on a surgery rotation at Brown University in Providence, R.I.

Not every visiting student is hoping to practice in the U.S., although all that were interviewed for this article expressed interest in at least pursuing further study here. "There's definitely a cohort who wants to practice here," said Suzanne C. Sarfaty, ACP Member, director of international health programs at Boston University School of Medicine.

Students from countries with advanced health care, such as in western Europe, have good residency options at home and are often just interested in seeing a different system, but those visiting from countries with less-developed systems are often hoping to make the connections needed for a residency in the U.S., she said.

Yu Chun Shen, a student on a psychiatry clerkship at Yale University in New Haven, Conn., plans to use her study-abroad experience both to get a U.S. residency position and to improve care back home in China. "It is my hope that after the residency, I will go back to serve my motherland," she said.

Amazing technology, limited access

Technology is a top attraction for many students visiting the U.S. Bruno Dubeux spent part of his last year of Brazilian medical school studying surgery at Emory University in Atlanta, Harvard Medical School in Boston and the Mayo Clinic in Rochester, Minn. "The infrastructure is amazing. In every single corner, you find a computer," he noted.

Dr. Dubeux said that before he started his rotation at Grady Memorial Hospital in Atlanta, American students warned about conditions at an inner-city public hospital. "They said, 'Oh, you're going to be scared at Grady.'"

He laughed, "It was very good compared to the hospital I was being exchanged from. At Emory Hospital, Massachusetts General and the Mayo Clinic, it was like being in a hotel."

In some cases, the foreign students found the facilities in better shape than the patients. Charles M. Wiener, FACP, who leads a program for foreign students at Johns Hopkins in Baltimore, said students often are surprised by the complexity and acuity of patients and the magnitude of their social problems.

"They are totally unprepared for that. Most of those countries have health care systems that are a lot more inclusive than ours," he said. "It makes them feel better about their own countries."

Alejandro Martin-Gorgojo, a medical student from Spain who visited Emory agreed. "There are certain features of the U.S. health care system which I believe make it not universally accessible and somewhat inequitable."

He explained that he's seen patients whose late diagnoses created severe problems, but who received excellent care when they were finally treated at a hospital. "I have found that this is a magnificent society, but full of complexities and paradoxes," he observed.

Respect for students

Foreign students are also often struck by the relationship between students and attendings. "I remember missing an appointment with Dr. Selbst, the chief of pediatrics, and I was so amazed that he checked with me to see if there was anything wrong," said Orhan Bican, a Turkish student who visited Jefferson Medical College in Philadelphia.

"They're amazed that students can talk to attendings and attendings talk to students," said Dr. Wiener.

European medical students generally get less contact with patients as well as attendings, according to Mr. Martin-Gorgojo. "I believe that medical schools in Spain, and in Europe in general, teach abundant theory but offer fewer opportunities for medical students to practice skills under the guidance of teaching physicians until they obtain a high level of proficiency," he said.

Chinese students were also impressed by the respect that medical students received from patients. "In China, some patients feel they are customers in a hospital for service and therefore have less respect for clinical staff," said Ms. Shen.

Her classmate at Yale, Derek Gard Ching Ying, explained further, "China is currently undergoing a reform in our health care system, which means increased medical expense on an already hefty burden for the majority of civilians. This results in a very strained relationship between patients and doctors."

By contrast, in his U.S. experience, he found that neither health care costs nor cultural differences created conflict between patients and providers. "Before I came, I thought conflicts were supposed to arise from differences in cultural background, ethnicity and needs. In the U.S., people of different backgrounds can work peacefully. I feel this is partly due to a better patient-doctor relationship."

Schools gain, too

In addition to taking away knowledge, the foreign students bring benefits to the schools that they visit, administrators noted. Students from Latin America, Africa and the Middle East, in particular, add differential diagnoses that would never occur to most American students and physicians, said Dr. Wiener. "Their knowledge of infections that are obscure to Americans is tremendous. With the Peruvian students, you can't teach them anything about TB because they've seen TB in every manifestation."

Many foreign students are also more accustomed to diagnosing patients without extensive testing, noted Paul M. Hassoun, MD, who works with visiting French students at Johns Hopkins. "They are actually clinically stronger. They rely less on technology—X-rays, CAT scans—and more on clinical findings."

All of the administrators were enthusiastic about the benefits of cultural exchange for both students and universities, but noted that issues of cost and logistics prevent such opportunities from being offered to more students.

At Brown, many exchange programs began with faculty members interested in taking U.S. students abroad.

"When they retire or move on, usually what happens is Brown students don't go to these countries, but the foreign students keep coming. Because we waive tuition, it gets to be a one-way street," said Julianne Ip, MD, associate dean of medicine. Brown has had to limit its tuition-free programs to students from universities where Brown medical students go on exchange. Interested students from other universities are now invited to participate in Brown’s elective clerkships on a tuition-paying basis.

Insurance and visa issues also restrict whether foreign students are allowed to touch U.S. patients. Foreign students require complex paperwork and, as Dr. Sarfaty noted, hands-on programs have been cut back because rotations are already crowded by visiting U.S. students. "Unless you have a full-time person juggling all this, it's a lot harder to work these kinds of programs," she said.

She noted the situation can seem unfair; U.S. medical schools establish programs around the world to send American students but restrict the number of foreign ones allowed. "It's really hard to say that our school is going to create affiliations with this school and that school and not agree to take their students."

However, the international students who do visit U.S. medical schools consider themselves lucky and have very few complaints. "The hardest part was the weather, really. I have never been in cold like that," said Javier Zaiek, a student from the Dominican Republic who experienced winter in Nebraska while studying at Creighton University.

Yet, he is prepared to brave the cold for another chance to study or practice in the U.S. "Yes, I will come here again," he wrote in his review of the Creighton program. "If there is an opportunity, just let me know."

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