American College of Physicians: Internal Medicine — Doctors for Adults ®


U.S. students find ways to broaden their horizons

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

By Jessica Berthold

It really hit Doug Olson, ACP Associate, that he was far from home when he watched his South African colleague nestle a vial of a patient's blood in his armpit.

It was 2006, and the fourth-year medical student was treating a woman who was hemorrhaging after her baby died in utero. The woman's home was an hour away and transportation was tough to find, so she had bled for several hours before reaching the hospital in Durban, South Africa.

"The problem seemed to be that she wouldn't clot, but we couldn't wait the amount of time it would take to confirm this with a lab test. So my coworker held some of the blood under his arm for 10 minutes as a way to test it. Sure enough, it wouldn't clot," said Dr. Olson, now a resident at Yale-New Haven Medical Center in Connecticut.

The woman lived. For Dr. Olson, the incident was one of several pivotal experiences during his six-week rotation abroad, half of which he spent in an infectious disease ward and half in an ob/gyn ward where all the patients were crammed together in a single room.

"Everything I had read about in ob/gyn textbooks in terms of pregnancy complications I either saw, or helped manage, or had to manage myself in those three weeks," Dr. Olson said. "Before Africa, I'd never even delivered a baby."

An increasing number of medical students view international experiences like Dr. Olson's as vital to their training. In 2006, more than 27% of graduating medical students reported having had an elective or volunteer international health experience during their schooling, compared with 14% in 1998, according to the Association of American Medical Colleges (AAMC).

"Young people today are much more exposed to the global nature of things, and are much less parochial," said M. Brownell Anderson, AAMC's senior associate vice president of medical education. "They recognize that when they go into practice in the U.S., they are going to have to be able to deal with cultures and beliefs that go beyond what they were raised with."

A different perspective

While some students go abroad because they want to study a particular condition or disease, such as malaria or HIV, in countries where it's more prevalent, most simply desire to broaden their personal and professional experience, said Robert Einterz, ACP Member, associate dean of a partnership program between Indiana University School of Medicine and Moi University in Kenya.

"Most of these students aren't planning careers in global health, but they come into medical school with a strong altruistic spirit. They want to do good, and they see a chance for that in developing countries," Dr. Einterz said.

Kerry Lynn Massman, ACP Student Member, a fourth-year student at the University of Missouri-Columbia Medical School, wanted to do an international trip from the day she got into medical school. She has a two-week trip to Ghana planned for this month.

"I think there is a lot to learn from going somewhere with a lack of medical infrastructure. I want to see what it's like to be in a place where the health system is very different from the U.S.," Ms. Massman said.

Medical students who participate in a cross-cultural experience return home with a better understanding of health care systems both in the U.S. and abroad, an October 2003 Academic Medicine study found.

Jaquelyn Coloe, ACP Student Member, made her own arrangements to work at a small Zambian hospital for six weeks between her first and second year of medical school.

Jaquelyn Coloe, ACP Student Member, made her own arrangements to work at a small Zambian hospital for six weeks between her first and second year of medical school.

Many of the international trips involve providing primary care in areas where even basic services are limited. Visiting students, accompanied by in-country hosts and sometimes a doctor or two from the U.S., set up makeshift clinics in schools, churches or tents. Villagers come from far and wide to be treated with antibiotics, pain relievers and prenatal vitamins.

Jaquelyn Coloe, ACP Student Member, who worked at a small Zambian hospital for six weeks between her first and second year at Ohio State University, said she struggled with the lack of resources.

"We had a lady who we were able to diagnose with cancer, but then we realized that was the end of it. There was no chemotherapy, no radiation available; we didn't even have morphine," Ms. Coloe said. "It's a very hard thing to wrap your mind around, when you're used to the U.S. system, that you can't do much more than keep a sick person comfortable."

For Heather Strah, MD, seeing patients wait for days in the emergency room in rural Brazil last winter gave her more patience for the U.S. health care system. So did the fact that all the doctors in the hospital where she worked were on strike.

"They were striking against the poor conditions of this government-funded hospital, which had been in the middle of a remodeling project when the government ran out of money and stopped working on it," Dr. Strah said. "Each doctor would come work in the ER for a couple hours and check in on the floors to make sure patients weren't dying, but otherwise, they weren't around or available, and the medical students were doing a lot of the management."

Her initial reaction was to feel that the doctors were abandoning their patients, but she changed her mind once she returned to the U.S.

"It was more like these patients had been abandoned by the government that had promised to care for them. And you see a lot of that with patients on Medicare or in the VA system, where as a doctor you feel you can't do what you need to for patients, because there is no money to get it done," said Dr. Strah, now a first-year resident at the University of Pittsburgh. "We are the richest country in the world, and we have the same sorts of problems as the poorest part of Brazil."

In addition to providing a different view of health care delivery, going abroad can increase students' familiarity with diseases such as tuberculosis that are relatively rare in the U.S. It can also change their approach to primary care.

"In Malawi, people are really good at physical exams and diagnosis, because tests are so expensive—if you can get them at all—and they take days to come back," said Christina Polyak, MD, a University of Washington first-year resident who went abroad last spring. "There's a lot of emphasis on really looking at the patients and talking to them, on trying to think of everything that could be wrong before you order tests. It's made me think twice about ordering tests in the U.S."

Research into the impact of studying abroad corroborates Dr. Polyak's impressions. A study published in 1999 in the American Journal of Tropical Medicine and Hygiene, for example, found that internists who had done rotations abroad during residency were more likely to value physical exams in diagnosing than were their colleagues who hadn't done rotations abroad. The study, based on a survey of internal medicine residents who studied at Yale University from 1982-96, also found an association between studying abroad and working with immigrants, HIV patients, substance abusers and people on public assistance.

Similarly, the 2003 Academic Medicine article found that students with international medical experiences had more compassion, a wider appreciation of the family's role in health care and greater skill at communicating with patients.

"Going to Zambia really changed my point of view more than anything," said Ms. Coloe. "It reinforced my desire to serve people who need it the most, and kind of got to the core of why most of us become physicians, which is to help people."

Going abroad can help clarify interests and career goals, as well. The American Journal of Tropical Medicine and Hygiene article found that residents who'd been abroad were more likely to switch to general medicine from subspecialty medicine than those who hadn't been abroad.

Dr. Strah refined her interest in pulmonary infections after she diagnosed a coughing patient in Brazil with tuberculosis and then realized she'd just been exposed to the disease.

"I'd been planning to specialize in pulmonary infections anyway, but was interested in the critical care part of it," Dr. Strah said. "Being around people with chronic infections, and having a personal experience, made me more interested in the research angle."

Making it happen

Traditionally, most students have gone abroad for a month or two during their fourth-year elective rotation, but more and more students are taking trips between their first and second years of medical school or during spring break, said Tanyaporn Wansom, a fourth-year student at the University of Michigan Medical School and the American Medical Student Association's Global Health Chair. Latin and South America are popular destinations, because students can learn Spanish terms that will come in handy back in the U.S., she said.

Of the 125 accredited, degree-granting U.S. medical schools, at least 80 offer international opportunities, according to the non-profit Foundation for Advancement of International Medical Education and Research (FAIMER).

"Some schools don't even want to be listed on FAIMER's Web site at this point, because they have so many students that want to participate and they can't accommodate all the requests," Ms. Anderson said.

Several schools have formal arrangements where students do rotations on a regular basis with foreign hospitals or universities that have been thoroughly checked out by faculty. The University of Minnesota Medical School, for example, has agreements with about 20 sites, including ones in India, Tanzania, Thailand and Uganda, said Phil Peterson, MD, director of the school's International Medical Education and Research Program.

The program, which sends medical students abroad for four weeks to a year, began in 1998, when the state began to see a large number of African refugees among the swelling ranks of its Hmong and Hispanic populations, Dr. Peterson said.

"The dean decided you couldn't be an adequately trained doctor in Minnesota if you didn't understand the impact of culture on health care, so the program was founded," Dr. Peterson said.

The University of Michigan Medical School also has agreements with seven universities in Sweden, China, Japan, Slovakia and Africa. But most students still end up arranging their own rotations, said Cheryl A. Moyer, research director for Global REACH, a university resource for students who go abroad.

"Some students like having something established, while others like the flexibility of doing something that's never been done before. A couple years ago, we had a student who floated down the Amazon on a boat, providing health care at various villages along the way," Ms. Moyer said.

Students who devise their own programs often do so with the help of faculty who are engaged in global health work, or by asking experienced friends. It can be easier at larger universities because students can find connections through other graduate programs, like schools of public health or business, Ms. Wansom said.

Ms. Massman looked beyond her school's walls for help with her October trip. Through Internet research, she found a nonprofit organization called Project C.U.R.E., which located two host physicians in Ghana for her and the five other U.S. students going on the trip. Once there, the students, two doctors and a nurse practitioner will meet with the Ghanan doctors and set up free, temporary primary care health clinics in the capital city and rural areas.

"I wanted to find an established organization, because to plan the trip independently is stressful and time-consuming," said Ms. Massman. "For $3,000 per person, Project C.U.R.E. does everything: They schedule the flights, find the in-country hosts, the housing, even the mosquito netting. They also supply us with $3,000 worth of medical supplies to distribute within Ghana."

Ms. Coloe and Joseph Simonetti, ACP Student Member, a student at Ohio State, know how tough it can be to arrange a trip entirely on one's own. The summer after their first year of medical school, they planned to take a 2005 trip to Swaziland with seven other students. Instead, they wound up in Zambia alone.

"Our contact just stopped returning our e-mails and phone calls about a month before we were to leave," said Mr. Simonetti. "Jackie and I started Googling names in Africa, then sent out a couple hundred e-mails. We heard back from the one physician who we eventually went to work with, and he ended up being great."

Limited funding

Demand for going abroad definitely exceeds the funding available to do so. Most students end up paying most or all of the cost themselves, Ms. Wansom said. A one- or two-month trip is about $2,000 to $3,000, depending on where it is, with much of the cost coming from the airline ticket.

Some schools do offer scholarships: Michigan, for example, gave $1,000 scholarships to each of its 55 fourth-years who did an international rotation last year. It also funded a portion of the travel for the 85 first- and second-year students who took research or humanitarian trips abroad, said Ms. Moyer.

National scholarships are available, but they are highly competitive. In 2006, there were 140 applicants for the 10 Benjamin H. Kean Traveling Fellowships in Tropical Medicine awarded by the American Society of Tropical Medicine and Hygiene, said Christopher Plowe, MD, a University of Maryland School of Medicine professor who is in charge of the fellowships.

"Every year we have to turn down at least 90% of applicants, most of whom are very well qualified and have set up great overseas rotations. I think the word is out that these are hard to get, and if there were more resources to fund more fellows, the applications would double or triple," said Dr. Plowe.

Still, even for those students who end up paying out of pocket, the experience is priceless.

"Until you see how the rest of the world does health care, you don't have the best sense of how it's done here," Dr. Polyak said. "To see how folks in another country live and to interact with them on a day-to-day basis ... it's life-changing."


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