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Choosing an International Elective

Created 02.06.11 by Alison Hayward, MD
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Originally published October 19, 2007

The international elective, whether done in the summer after first year or in an elective block during fourth year, has become a virtual staple of medical school. The rising number of medical students who participate in such experiences reflects an increased awareness amongst medical students of global health issues such as access to health care for under served populations.

Many students spend long hours researching such opportunities, since so many diverse types of experiences exist worldwide. Choosing one of these opportunities can be a daunting process, particularly for students with a newly minted interest in global health who are trying to find a meaningful first experience.

Types of experiences

There are a number of types of experiences that health and pre-health volunteers may seek, and they are quite different from one another. Here is a list of some of the most popular international options:

International elective in an industrialized country
This category would be for students who are seeking a clinical experience in a place such as Europe. As with any away rotation, the availability of such an elective is dependent upon finding a preceptor at an institution you would like to visit, and then arranging whatever paperwork your school requires to receive credit. If you have no connections at the institution or in the area, and you can locate contact information, sending e-mails to likely preceptors in the specialty in which you would like to rotate is an easy way to screen for potential opportunities.

This type of opportunity is a fascinating way to see how medicine is practiced in a system outside the United States, and the ways in which that practice differs both in terms of treatment of illness and in terms of administration of and access to healthcare. You may also elect to work on a research project rather than doing a clinical-only experience.

International elective in a developing country
This option also involves clinical or research work, but in a health care institution that is in a resource-limited or impoverished setting. This exciting opportunity allows medical students to work in an area where health care professionals are desperately needed, and to have an eye-opening exposure to what most of the rest of the world has for health care. It can be fascinating to realize how physicians function with minimal laboratory and imaging capabilities. You may gain a new respect for physical diagnosis, which may often seem to be a brief precursor for a battery of blood work and body scanning in technology oriented Western medicine.

The challenge faced by students who travel to developing countries, particularly for 4th year students, is that they are motivated by internal and external forces driving them to provide actual clinical care to patients in great need (i.e. being the person with the most medical knowledge and experience in a remote area with few or no physicians at all available). As students who have little experience with provision of direct clinical care, this is certainly an ethical dilemma.

Things to keep in mind

  • All countries have laws governing who can legally practice medicine. You must be aware of these laws and discuss with your mentor or preceptor the legal guidelines under which you will be working. If you have no mentor or preceptor, you should be aware of any legal ramifications of your actions while abroad.
  • Safety equipment, including gloves, masks, gowns, and clean needles may not be available or commonly used in some settings. Ensure that you have a supply of gloves and practice appropriate universal precautions, even if those around you do not. Risking your health is not courageous; it is foolish.
  • Some believe that “any medical care is better than nothing”. This is a fallacy. Western medical treatments often have side effects that are not benign. It is also unethical to imply that those living in poverty do not have a right to expect high quality medical treatment. Paul Farmer, an icon in global health, has been integral in advancing the opposite idea: a ‘preferential option for the poor’.
  • Many drugs that are only available by prescription in industrialized countries are over the counter in developing nations. Just remember, before you attempt to treat a patient who comes to you for help as a prestigious ‘American student doctor’ – even a simple antibiotic can cause anaphylaxis. In a place where few options to treat an adverse reaction, are you comfortable with that risk? It is a difficult question, exacerbated by the fact that American students are heavily trained in American health problems, such as heart disease and diabetes. This leaves us uniquely disadvantaged in a location where tropical infectious diseases cause the majority of burden to the population.

Other options for international volunteering

Partially due to the challenges addressed above, which are associated with clinical work, many students choose a public health-oriented project, particularly during the summer after first year. These projects are usually located in developing countries, and often involve health education/promotion and awareness-raising activities. They may also involve disease prevention campaigns or physical projects to improve community health such as building water wells.

Such opportunities are often highly rewarding, and give students the satisfaction of addressing underlying health issues in communities where treatment of disease can be futile without changing the sanitation, hygiene, and prevention strategies of entire communities. Again, as with research, it is often easy to find opportunities for clinical experiences and shadowing within such projects. For example, shadowing a doctor in Africa who is the only physician in a district of 200,000 inhabitants as he circulates through various area health centers is a priceless educational experience in the firsthand effects of the ‘brain drain’ of healthcare and other professionals from developing countries.

Tips for Success

1. Use a trusted resource guide to find opportunities.

Some schools and other Web sites compile lists of potential opportunities for health and pre-health students (You can find some of the most well-known listed below under ‘Resources’). However, these compilations are usually not reviewed by anyone and thus may contain opportunities that are not high-quality. These opportunities should be investigated with caution – let the buyer beware!

For this reason, students should look into programs that are endorsed by sources that have some sort of quality control, or are recommended by someone you know. This is your only way to ensure that you do not end up stranded in a remote corner of the world with a program that is not a good experience. There are also some databases of opportunities that include reviews from former participants. Unfortunately, these are usually restricted and not publicly available.

2. Consider the safety of the location.

The State Department has a list of travel warnings and ‘Consular Information Sheets’ which can be viewed by country. Please review available information carefully before planning your trip. Proceed with caution if the country in question has a current travel warning. It is advisable to do your elective with a friend if possible. You should know all the details about the safety of the place in which you will be living and sleeping as well as the place you will be working. Transportation is also important to consider, as many places in the world have public transportation with extremely varied levels of safety.

3. Be fluent in the local language.

You must speak the local language at least passably if you expect to see patients in anything more than a ‘shadowing’ type of experience. As anyone who has used a translator knows, interviewing patients in a different language is sub-optimal at best, completely misleading and confusing at worst. Do not assume that people in rural areas speak the national language.

4. Be ‘fluent’ in the local culture.

When you travel, be a good ambassador for the United States. Be polite and respectful of local customs, social mores, and dress. Do not wear revealing clothing, period. Be aware that in other countries, public displays of affection may not be appropriate. Know the place you are traveling to and in what ways you might offend people.

5. Have realistic expectations.

If you are a first year medical student or otherwise have little experience with patient care, do not expect to be involved in high-level direct care. Concentrate on learning, and remember that you have the rest of your medical career to treat patients. Know the details of what your program involves. Ask questions if the descriptions provided by the program do not give you a clear idea of what you will be doing. Not being sure what you are signing up for can lead to disappointment. Remember, things in other countries may move at a slower pace. You may need to adjust your type-A medical student mindset. Enjoy it and relax.

6. Find a good mentor.

The best mentors are local to the place where you will be practicing, but an acceptable option is a mentor who has traveled to the location in question and has a great deal of experience there. Of course, all mentors should be teaching and learning-oriented and good role models for safety, ethics, and evidence-based practices. If you cannot find a suitable mentor at your home institution, don’t despair. Finding one via the internet may take only a small amount of initiative. Many medical school faculty members travel abroad regularly and have a profile on their institution’s website that would turn up in a quick web search. If you are planning to travel to an under served area, you may want to consider a mentor who is familiar with health and human rights issues and has experience working in resource limited settings. Ideally, your mentor will be the main person with whom you work while traveling abroad.

Resources

– AMA: http://www.ama-assn.org/ama/pub/category/12675.html
– AMSA Global : http://www.amsa.org/global/ih/ihopps.cfm
– ARHP (Reproductive Health): http://www.arhp.org/files/InternationalDirectory/pdf
Idealist.org is a fabulous resource for interested volunteers of all ages and types

About the author

The author is a co-founder, former director, and current assistant director of the Uganda Village Project (www.ugandavillageproject.org), as well as a former member of the IFMSA-USA Board of Trustees.

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Comments

  1. Israel Andrews says:

    Or if you are more than just an “all talk Idealist” you can find a medical school that specializes in training and teaching International Health, Cross cultural awareness, and incorporates Global medicine, Preventitive medicine, disaster relief, and maternal health in all 4 years of school culminating in a 6 week clerkship in one of several Developing countries (Nepal, Peru, Kenya, Ethiopia, India, Vietnam etc)but I guess I only know one school like that where students are actually doing those things. I speak of the Ben-Gurion University, THE Medical School for International Health icw/ Columbia University Medical Center

  2. Ahmed says:

    Hi . Thanks for the nice input. In fact I’m an intern, just obtained my MD degree last June. I didn’t have the chance to do some overseas experience but I certainly would do it now. I’m not sure If this is the best place to post my question. Is it big difference being an MD? I don’t think I would be that much different from a fourth year medical student. I don’t know if agencies that help students to go overseas would welcome someone with MD certificate.. just wanted to know..
    Any light on that would be much appreciated.
    Thank you.

  3. bailey says:

    There are many medical schools in the US and abroad that support research and clinical work abroad, and do quite a fantastic job of education in cultural competency…not just the “one” listed above. This is great, because you will likely have wonderful opporunities wherever you go. Just as an example, two of my roommates are in South Africa for the next two months, the other was in Gabon for three, and I am in Mali for seven months. Look at the NIH Fogarty website, the American Society of Tropical Medicine and Hygeine, and various med school websites(many have funded connections). Also look at the CDC, the Schweitzer fellowship (gabon), etc.

  4. Jones says:

    I must second the first comment made by colleague Israel. As I am sure that many American med schools provide good cultural competence training. There really is nothing like experiencing medicine in the completely foreign environment that Southern Israel is. From day one we are experiencing global health first hand, whether it means going to a clinic in a Bedouin shanti town or trying to do and H&P with the myriad of immigrants who do not speak a word of English or even Spanish for that matter. I am currently a 3rd year and my experience has been priceless so far.

  5. Israel Andrews says:

    Yes Bailey, to true, however, there is only ONE MEDICAL SCHOOL where if you are TRULY interested in doing work internationally, and NOT just for your CV for residency applications (I choose not to delve in to Kant and “duty” at this point), you can apply to.
    Globalized medicine is becoming local medicine, diseases dont have boundaries anymore, unfortunately countries in Africa, Asia, South and Central America dont have 1 doctor for 390 patients, as they do in America, nor is the culutral diversity around the BIG Medical Schools in the states all that diverse. If you want to learn, eperience, and give and not just talk about it, or use it as a talking point on a CV I suggest you check out “THE ONE” Medical school where their business is not just making you a doctor, but teaching you global health to its highest degree!

  6. Anonymous says:

    Do all medical schools allow a fourth year elective to be abroad, or do some require US electives?

  7. Anonymous says:

    Sorry–that may be interpreted incorrectly–I meant do some schools require ALL the electives to be in the US?

  8. Thank you for your comments. I’m sure there are med school applicants out there who are interested to learn about the program at Ben Gurion which I also have heard very good things about.

    To Ahmed: The answer to your question is definitely yes! In fact, most of the organizations I have worked with would much prefer to have all volunteers/visitors be MDs – but are happy to have help from any interested party. Of course, MDs have a great deal to offer as volunteers, but keep in mind the cautions mentioned above about the fact that those trained in the USA are not trained for the diseases of other parts of the world.

    One thing that you can do if you truly want to treat patients with tropical diseases is to take part in a program which will give you an intensive course in tropical diseases. These programs exist at institutions like Johns Hopkins as well as Oxford University (the Diploma in Tropical Medicine program). I would highly recommend a program such as this if you are an MD who wishes to practice even temporarily in an area affected by tropical diseases.

    To Anonymous: I am not aware of schools that do not allow international electives, but I would not be surprised if some do exist. Importantly, some medical school offer far more support than others for travel expenses – be sure to investigate when you are applying! One thing I do know is that a number of residency programs do not allow international electives, citing the subsidized money that they receive from the government as the problem. So if you are interested in doing an elective internationally, be sure to ask about this in interviews.

    To Israel: I appreciate your comments but I would hesitate to categorize all medical students who do not attend Ben Gurion as ‘all talk idealists’ or people who only want to participate in international health activities for their CV. People have different motivations and personalities and not everyone wants to dedicate their career to international medicine, but many would still like to work abroad temporarily, or become interested later in their careers. In my experiences with work internationally, I have found it immensely rewarding and personally satisfying, but also highly challenging, frustrating, and emotionally draining at times. I feel that there are many different ways in which we can give and participate in the global community, even from inside the borders of the United States. I would suggest that there are many who lead amazing careers in international medicine and took a variety of paths to get there. The first step is to realize how privileged we are and how much we can share with those in need. I think it is more constructive to focus on ways we can improve the quality of electives and make the most out of these experiences. They can inspire people and change lives. I have seen so much cynicism in medicine – I don’t like to quash any idealism if I can help it.

  9. Israel Andrews says:

    agreed
    however in my international experience, which thusly has been vast, it is 9 times out of 10 the idealist that is overwhelmed and unprepared, and the realist that stays to tough it out regardless of what kind of situation he/she got themselves into
    again this is based on experience in the field, but is there not a saying
    “Idealists are the dreamers, Realists make the dreams happen”

    It is more dangerous to send unprepared individuals into a foreign country with a different religion, different way of life, different language, different political structure, different dress code, different everything than to not send anyone at all, its like ALCS the first thing you do is assess your own safety. It is better if you are prepared, and have worked with natives in a comfortable environment before submerging yourself in a way of life you dont or cant understand (again why a medical school for international health) would be the way to go if you are TRULY interested in making a difference. This is not to dissuade those who are interested in doing 1 month electives, but by the time you get to wherever you are going and gain the trust of the locals, you are already leaving.

    Ben Gurion focuses on the cross-cultural awareness that many medical schools dont have time to teach, yes granted our first year is from july to july (which is not so fun) regardless, we walk away with a confidence that is more than just a hunch of “how I want to help” we learn to plan things like disaster relief protocols, refugee camp management, triaging natural disasters, Emergency medicine in the field (i.e. boonies), and we don’t just treat African Americans, Mexicans, and Native Americans and call that diversity.

    As my colleague mentioned before we are knees deep in Ethiopians speaking Amharric, Russians speaking Russian, Thai speaking Thai, Ghanians, Palestinians, Bedouin, Philipino’s, the Sudanese, Indian, and of course the Israeli’s, and none of them speak English.

    That is cultural diversity.

    If you are interested in more than a visit, and would like to experience the real deal, I encourage all of you to check out our program, I even think we have externships for people who want to do electives with the locals here in Be’er Sheva, in the Bedouin Villages, and in the West Bank.

    Peace Out
    Izzy

  10. Bailey says:

    So all of the people who have done amazing things in the field of international health have come from Ben Gurion? Didn’t it just open a few years ago?

    If your experience was truly vast, you would have come across many working abroad and in their home countries (with projects related to international health) who come from all types of medical schools. Please, look at leading authors, clinical practioners, economists and researchers in the field of international health and development before you make such a claim. And then, look at all of the long-term employees and volunteers for organizations such as MSF (Doct w/out Borders), MDM, Partners in Health, etc. Many of them aren’t even physicians, and they do absolutely amazing things. And of those that are physicians, very few (if any) have graduated from your medical school. That is not to say it isn’t a wonderful place to commence your training, it’s just not the only one.

    As I stated earlier, many US and other medical schools offer year-long electives and opportunities abroad, as well as short-term ones. And training to work internationally does not end with graduation. There are many residency programs with global health tracks (Brigham and UCSF come to mind first), so you will have many opportunities in your future if this is your passion.

    Best of luck in your decisions.

  11. R2-D2 says:

    I have heard some great things about Ben Gurion, and it appears to more aggressively push international health. You need to really research a school’s reputation, a very large number of US medical schools have at least some IH program available, and even if they don’t you can set up stuff yourself, I would look at a list of the Fogerty fellowship recipients, there are alot of schools that typically produce students almost every year that get these fellowships, which in my mind indicates that they are helpful for such students. Some schools used to tout an IH reputation, like Boston University, but actually may not have an efficient or friendly system for doing IH work and may have scaled back their operations and plans for helping students go to developing countries for meaninful rotations, but will *allow* students to do a tourist month in greece or some place else . . . but don’t provide support.

  12. Israel Andrews says:

    Funny you mention BU, I actually went there because they touted International Clerkships and the like, much to my dismay, and many others I have spoken to (including those who have gone on school sanctioned clerkships to the developing world) their expereinces remained sheltered and limited in their function and what they could do or learn. Yes Bailey other schools do have programs, like University of Miami and its involvement with Circle of Health International, which sent 4 medical students to Tanzania to sit in a hut and WATCH midwives work for a few hours a day and the rest of the time was spent traveling, im sorry thats not international medicine….

    That was an example of the people I have come across, I have more horror stories should you care to hear them, I can provide an email address, and again I am not stating that International outreach never existed before our schools creation, I am stating that a schools creation based solely on the need for international outreach has never happened before, not to mention the purpose and the mission of our school which is to send ALL its students out into the countries of our global neighbors!

  13. Rose says:

    Ben-Gurion does seem to actively help its students to do Global Health activites in developing regions, part of this is due to the location of the school, but mostly to an underlying desire to actually serve and learn about Global Health in an international setting.

    BU has disappointed some of my friends interested in doing Global Health work, the school touts this alot, but in reality this just a marketing technique for the school, which is privately based, to get more good applications from optimistic undergrads, and to attempt to improve the image of the school, the international health experiences offered are superficial, maybe with the good example set by Ben Gurion schools like BU which talk the talk, but don’t walk the walk will be encouraged to be more supportive of their students pursuing international health . . .

  14. Sodra Altaf. says:

    Hi,
    I am a 4th year medical student in Pakistan.after completing my mbbs and without doing my internship,i have to go to dublin for 1 year for personal matter.as according to the rule of Irish medical council,i am not able to do my internship in Dublin.is this possible for me to do electives during that year?have some light on this.
    Thank you.

  15. Atif says:

    I agree with knowing the ‘local language’ bit among others. I joined this MBBS course in a top college in India and failed to realize that I didn’t know the language in that area. The first year was chill as there was no interaction with patients. From 2nd year, when my clinics started, I realized maybe I was in the wrong place. I tried to learn the language and can interact with the patients but only limited to the basic questions. I get frustrated at times.

    But, I just got to keep going. I’m in final year now and hopefully I wont be doing my internship from India – the reason being the language barrier , even though we have a wide variety of patients.

  16. Man says:

    I wanted to do an Interntational elective in cuba. But then Bush came into power and changed everything in politics… That friekin … I rather not get started..

  17. Patron says:

    Ben Gurion has suspended clerkships outside of Israel and the United States for U.S. citizens who receive U.S. government-guaranteed student loans.

    http://www.cumc.columbia.edu/dept/bgcu-md/ps/clinical_clerkships.html

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