This article, from the To the Point series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides educators with an overview of considerations for obstetrics and gynecology global health experiences for the medical student. Options for integration of obstetrics and gynecology global health into undergraduate medical curricula are discussed. Specific considerations for global health clinical experiences for medical students, including choosing a clinical location, oversight and mentorship, goals and objectives, predeparture preparation, and evaluation, are reviewed.
Enthusiasm for global health experiences among physicians-in-training over the past 30 years has been well documented and discussed in medical education literature. In 2012, 30.4% of graduates of US medical schools reported having participated in a global health structured elective or volunteer experience. Benefits for the student participating in global health curriculum and experiences include increased cultural competency, a developed sense of social responsibility and idealism, enhanced enthusiasm for learning, increased self-awareness, enhanced clinical skills, and increased knowledge. Such benefits to the student can result in a workforce locally that is interested and invested in primary care, and dedicated to the underserved.
Despite the increased interest in global health experiences, in 2011 only 24% (32/133) of all US medical schools had evidence of a structured global health program that students could complete without extending their medical degree training time. In addition, only 40% of those schools included a global health clinical experience. This phenomenon is not unique to the United States. Izadnegahdar et al in 2008 surveyed Canadian medical schools and found that they vary widely in their approach to global health education, with little consensus regarding content or structure of the teaching or clinical experiences. There is currently not a global health standard for the Liaison Committee on Medical Education (LCME), and medical school global health experiences and curricula can vary largely. For example, schools may offer global health certificates, tracks, or concentrations that may or may not include clinical or outreach experiences and could span 1-4 years, or students may participate in isolated 1-week outreach experiences that may or may not include clinical components. Furthermore, global health may be an elective choice, or can be fully integrated as a core competency for student learning. Internet search using terms “global health,” “international health,” “obstetrics and gynecology,” “medical school,” and “medical student” as well as personal communication with Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee member institutions revealed examples of current obstetrics and gynecology global health experiences being offered ( Table 1 ). PubMed search using the same terms revealed examples of global health experiences cited throughout this article. Drain et al propose specific steps that medical schools could take to meet the global health demand, including integrating topics into core teaching, creating global health pathways and tracks, supporting an administrative position or office to aid students, forming international partnerships with institutions, and having international rotations as part of routine training.
| Institution | Brief description | Cost consideration | World Wide Web site |
|---|---|---|---|
| Albert Einstein College of Medicine of Yeshiva University, Bronx, NY | Seminar series for third- and fourth-years students at home institution; clinical and research experience in host country | Funding for airfare, room and board, and some project expenses available to students through fellowships | http://www.einstein.yu.edu/departments/obgyn/global-women-health-programs/educational-programs.aspx |
| Boston Medical Center, Boston, MA | Series of educational activities throughout the year for students, residents, and faculty interested in global health; provides a conduit for research, programmatic, and clinical opportunities for students | Stipends available for language classes; partial funding available to students through grants, although most programs require students to pay travel | http://www.bmc.org/obgyn/services/global-health.htm |
| Johns Hopkins University School of Medicine, Baltimore, MD | Resources to set up an individual scholarly project between first and second year; resources for third- and fourth-year students to set up individual electives overseas | Funding for global experiences and projects available to students through competitive grants; other global electives may be funded through the program director’s grant | http://www.hopkinsglobalhealth.org/ |
| University of North Carolina School of Medicine, Chapel Hill, NC | Clinical and research selectives and electives available for students interested in women’s health; intern program for rising fourth-year students that includes 1 year of research and clinical work with specific focus on maternal child health | The Office of International Activities (a branch of the Office of Student Affairs) provides funding opportunities and directs students to external funding opportunities; the Medical Foundation (a not-for-profit organization) also helps secure resources and funding | https://www.med.unc.edu/obgyn/global-womens-health |
| University of California, San Francisco, San Francisco, CA | Global health concentration includes a 3-month project with the majority of that time abroad; mentorship to obtain obstetrics and gynecology–specific experiences | Partial funding available to students through grants | http://meded.ucsf.edu/gh |
| Warren Alpert Medical School of Brown University, Providence, RI | Scholarly concentration in global health includes a summer experience between first and second year, global health seminars during second year, and a scholarly project completed in fourth year; mentorship to obtain obstetrics and gynecology–specific experiences | Partial funding available to students through grants | http://brown.edu/academics/medical/education/concentrations/global-health |
Clearly there is a gap in medical education in terms of global health. Many students whose schools do not offer structured opportunities to participate in global health are seeking those opportunities on their own. Student-directed experiences can be less than ideal, as they may have significant organizational and financial barriers associated with them. The lack of oversight and mentoring poses challenges for the medical student and can create safety and ethical concerns related to unsupervised learning and navigating vulnerable populations.
As obstetrics and gynecology physicians and educators, we are uniquely positioned to deliver global health training and experiences for medical students. Obstetrics and gynecology is a specialty rich in topics that are important, as well as abundant, in global health. These include maternal and perinatal morbidity and mortality; genital fistula formation; cervical cancer screening and treatment; family planning and contraception; sexually transmitted infection and human immunodeficiency virus education, detection, and treatment; gender-based violence; sex trafficking; and the public health interventions that positively address these issues. Medical students are unique learners, have the potential to make change, and have an untarnished sense of idealism. By creating obstetrics and gynecology global health learning opportunities for medical students, we have the ability to create high-impact experiences and the potential to generate positive change and outcomes for our specialty and women’s health worldwide.
Options for integration of obstetrics and gynecology global health into the undergraduate medical curriculum
At the medical school level, global health learning can be an elective choice for students with high-level interest or an integrated core competency for all students. It is important for obstetrics and gynecology educators to become familiar with established global health learning opportunities at their institutions. If a global health curriculum currently exists, obstetrics and gynecology global health learning topics can be integrated into that curriculum. Goldner and Bollinger describe a first-year medical student global health course at Johns Hopkins University School of Medicine, Baltimore, MD, that leverages technology to incorporate live video conferencing with partner institutions abroad. Obstetrics and gynecology faculty leaders at Johns Hopkins University School of Medicine and the partner institutions led the discussion focusing on maternal health learning objectives, including cases of high-risk pregnancy in Baltimore, MD, and Addis Ababa, Ethiopia. Alternatively, obstetrics and gynecology global health learning topics and opportunities for positive global change can be integrated into preexisting obstetrics and gynecology–specific curricula. For example, public health interventions, such as cervical cancer screening, which have such a strong impact on vulnerable populations globally, can be highlighted in the context of gynecology oncology didactic sessions. Barriers to obstetric care and resulting obstetric fistula can be discussed while students learn about reconstructive pelvic surgery and obstructed labor. These nonexperiential learning opportunities can serve as an introduction for students to basic concepts in global health.
Pfeiffer et al conducted 26 in-depth interviews with global health leaders in 2008 and 2009. Interviewees highlighted the importance of hands-on real-world experiences in the context of global health learning. Clinical experiences can enhance student learning in global health in ways that are difficult to achieve with classroom learning alone. These include acquisition of clinical skills, knowledge of other health care systems, understanding limitations in low-resource settings, appreciation of conditions and pathology unique to the area of travel, and awareness of the implications of power and privilege. Clinical experiences can be offered through isolated student electives, or integrated into the core clerkship experience. Many institutions offer these experiences in elective format, but Chin-Quee et al describe a collaboration between Emory University, Atlanta, GA, and Project Medishare in Haiti through which students complete a surgery rotation in rural Haiti to satisfy elective week requirements for the surgery core clerkship. Provision of an international site that satisfies clerkship requirements necessitates compliance with LCME Educational Directive (ED)-8, which discusses comparability of education experiences across instructional sites. Students who participated in this trip had specific learning objectives taken from the surgery clerkship and strong US physician oversight. Integration of a global health clinical component into a clerkship is a unique way to consider structuring experiences.
Considerations for global health clinical experience
Whether integrated into a clinical clerkship or offered as a stand-alone experience, educators invested in facilitating such clinical experiences in obstetrics and gynecology global health for medical students should keep in mind several important considerations ( Table 2 ). Familiarization or partnering with institutions offering obstetrics and gynecology global health opportunities may be of help when thinking about formalizing experiences.
| Determine type of experience offered |
| Elective choice vs integrated core competency |
| Establish mode of learning |
| Didactic vs clinical/experiential |
| Confirm comparability of education experiences across instructional sites |
| Identify feasible, safe, and ethically sound location for clinical experiences |
| Interinstitutional agreement |
| Appropriate oversight |
| Sustainability |
| Provide administrative oversight and faculty mentorship for students |
| On site or remote |
| Determine goals and objectives for experience |
| General and local |
| Individual and community |
| Service to community |
| Organize predeparture preparation under faculty supervision |
| Programmatic review |
| Safety considerations |
| Cultural competency |
| Ethical considerations |
| Establish a structured evaluation process |
| Individual evaluation |
| Formative and summative |
| Program evaluation |
| Impact measure |
Choosing a clinical location
Choosing the location for global health clinical experiences is perhaps the most important consideration. Identifying a location that can meet specific goals and objectives of an obstetrics and gynecology global health clinical experience in an ethically sound manner is fundamental. In addition, feasibility of the experience such as the economics and logistics of travel, and safety of the location, needs to be considered.
Partnership with the institution in the host location and placement of students at international programs should be based on interinstitutional understanding and cooperation. These are typically formal relationships, and can be strengthened by understanding ways in which each institution can help the other. For example, the home institution may indeed be able to train practitioners at the host institution, fund members to visit the home institution, or provide compensation to host faculty/mentors. Transparency, trust, and professionalism are cited as important elements to any interinstitutional agreement, and appropriate local oversight should be in place to assure this. Suchdev et al also cite collaboration as 1 of their 7 guiding principles to making short-term international medical trips. They suggest partnerships with a nongovernmental organization, government agency, or other local organization as starting points for global health clinical experiences. These organizations may understand and work within the infrastructure of communities and facilitate programs. For example, outreach to agencies or nongovernmental organizations focusing on obstetric fistula, maternal child health, or cervical cancer may facilitate obstetrics and gynecology global health clinical experiences for our students. In addition, such partnerships may assure continuity of care and program goals locally if global health experiences are intermittent throughout the year. Suchdev et al also cite sustainability as a guiding principle, meaning that global health clinical experiences occur in a single location to augment efforts on successive trips. This approach can further demonstrate a commitment to an ongoing relationship, and may allow for a greater impact on the health of a community.
Oversight and mentorship
Administrative oversight and faculty mentorship is essential for students to successfully complete global health clinical experiences. Administrative oversight is important for forming partnerships with agencies or institutions, facilitating experiences, establishing funding opportunities, and completing student and programmatic evaluations and reviews. On-site or remote faculty mentorship should help students navigate their cross-cultural experience, deal with external and internal conflicts as they arise, and give clinical guidance. Remote mentorship can be facilitated by technology, using modalities such as video conferencing, written electronic communication in real time, or e-mail. Adequate supervision can help alleviate clinical and ethical issues, making the global health experience positive for both the student and the partner institution. In addition, integration of a global health experience into a clinical clerkship necessitates compliance with LCME ED-25 and ED-25-A, which discuss supervision of medical student learning experiences by faculty members.
Goals and objectives
It is important that a global health experience for medical students be not merely a site visit or travel experience, but one with specific learning goals and objectives. Such objectives are often referred to as competencies, and different competencies have been suggested by several authors. Peluso et al suggested general and local core competencies in global health. General competencies were further divided into individual and community. Individual core competencies included cross-cultural competence, communication and linguistic skills, understanding geographic burden of disease, problem solving with limited resources, identifying social and environmental determinants of health, recognizing health inequities and their effect on individual health, teamwork and collaborative problem solving, professionalism and ethical behavior, and awareness of the requirements of global health workers. These competencies incorporate the understanding that global health training for students is not simply cleaning up after inequities, but understanding and addressing the social conditions that produce them.
Implicit in the goals and objectives for a specific clinical experience should be service to the community visited, addressing their priorities. Suchdev et al cited service as a guiding principle for making short-term international medical trips, stating that service involves providing public health interventions and sustainable clinical care that address community priorities. Once a location is chosen, a needs assessment of clinical services that can benefit that location should be undertaken, with an emphasis on those services included in the clinical learning objectives. Making these goals transparent to the student can be an important step to reduce student ambivalence concerning the value and effect of the global health experience to the community visited. Furthermore, emphasis on service-oriented goals and objectives will focus the student on clinical experience priorities and decrease the idea of the opportunity as an exciting “travel experience.” Dharamsi et al note that there is growing concern that students may perceive global health opportunities as forums to practice clinical skills, enhance resumes, and travel to exotic locales, sometimes referred to as medical volun tour ism. Predeparture discussion of service-oriented goals and objectives visited may help to reduce this. Further discussion of preparation is discussed below.
Depending on how the global health clinical experience is to be integrated into the obstetrics and gynecology curriculum, attention may be paid to specific learning objectives for the obstetrics and gynecology medical student and pertinent learning objectives could be integrated as appropriate. For example, for the group from Emory University that spent their surgery core clerkship elective in Haiti, learning objectives that satisfied the surgery core clerkship requirements were adapted for this experience.
The goal of some global health experiences for students may include engagement in clinical research. Although discussion of the student role in clinical research is beyond the scope of this overview, considerations of ethics, preparation, and oversight must be undertaken in these situations.
Preparation
Predeparture preparation is integral to global health experiences. Such preparation should include programmatic review, safety considerations, cultural competency, and ethical considerations and be performed under the direction of faculty mentors.
Predeparture programmatic review should include discussion of goals and objectives, as well as evaluation measures. Student expectations and motivations should be discussed to ensure they are appropriately aligned with program objectives. Discussing self-reflection and program evaluation will also prepare the student for these exercises once they return to their home institution, and may encourage such opportunities while still at the host institution.
In-depth safety considerations should be discussed with the student prior to departure, keeping in compliance with LCME Medical Student-20. The Centers for Disease Control and Prevention World Wide Web site ( www.cdc.gov ) is an excellent source for specific information, including endemic diseases, preventive measures and medications needed, required and recommended immunizations, and travel notices. Universal precautions should be reviewed and any questions answered for the student. Any supplies needed to maintain safety for the student, such as gloves or masks, should be discussed and supplied. If available, a local travel clinic with expertise in international travel should be consulted.
Cultural competency should be included in any predeparture preparation, and students can proactively learn about social, political, and cultural contexts of the community they are planning on visiting. In addition, students may benefit from discussing global health experiences with students who have already completed similar experiences. Specific medical and social language skills that will facilitate meaningful and respectful interactions should be reviewed. Students should be educated regarding communication barriers, and encouraged to openly discuss their language competency with faculty and mentors at the host institution.
The importance of ethical considerations in global health has been discussed at length in the literature. Dharamsi et al discuss a series of interactive workshops using case studies that were developed for teams of students and medical residents preparing to initiate global health projects in resource-poor settings. Authors note that participants believed adequate preparation and reflection were necessary to ensure ethical conduct. Lahey proposes a comprehensive curriculum that provides students with basic proficiency in the systematic recognition and resolution of the ethical pitfalls of global health outreach work, and proposes key components of such a curriculum. The proposed curriculum begins with understanding the ethical motivations for healing the sick and disadvantaged, which leads to a discussion of global health disparities and a survey of ethical global health outreach work. Such a conceptual foundation is meant to be paired with specific training to promote the ethical provision of global health outreach work.
Evaluation
As with any other learning experience, a structured evaluation process is necessary, both at the individual and programmatic level. This is also mandated by the LCME as specified in Medical Student-20.
Individual evaluation can be based on goals and objectives. Formative and summative feedback and evaluation can be completed both during and after the clinical experience, by local physicians or mentors or by those at the home institution. A written summary of the experience can also be used for student evaluation and may serve as a vehicle for important post-trip reflection. Reflection is indeed important to service learning, and Abedini et al comment that the act of reflection for medical students after global health experiences is essential for experiences to be truly meaningful. Vora et al describe an international health elective for second-year medical students, during which participating medical students were required to write a reflection essay and compose a photojournal presentation. Patient logs with physician verification were also required evaluation tools. Technology, such as World Wide Web–based blogs, can facilitate this type of reflection and record-keeping, as well as provide mentors at home institutions up-to-date information regarding the student experience.
Program evaluation can occur via systematic feedback from student and faculty participants at both the home and host institution. Periodic review of evaluations and changes based on these should occur as with any other educational program. Peluso et al also suggest that program success can be measured by participant performance on standardized examinations that measure knowledge of key global health concepts or on an objective standardized clinical evaluation that examines skills useful in taking care of patients in low-income settings.
The success of a program can also be measured by its impact. This could mean impact on the host institution and/or community, or on the participants. For example, impact measure might be the percentage of students who continue to work in global health or with underserved populations within their own country. Periodic reevaluation should occur to ensure that a program is benefitting participants and communities.
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