VALUE OF INTERNATIONAL HEALTH ROTATIONS
FOR MEDICAL STUDENTS
AT THE UNIVERSITY OF COLORADO SCHOOL OF MEDICINE
Candice Lyn Miller
BA.., University of Colorado, 1970
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Administration, Supervision and Curriculum Development
1996 by Candice L. Miller
All rights reserved.
This thesis for the Master of Arts
Candice Lyn Miller
has been approved
Miller, Candice Lyn (M.A., Education)
Value of International Health Rotations for Medical Students at the University of
Colorado School of Medicine
Thesis directed by Associate Professor Paul Bauman
Each year, University of Colorado medical students participate in elective
international health rotations as part of the Medical Student International Program at
the University of Colorado School of Medicine. This study looks at 76 of these medical
school graduates who participated in international health rotations from 1990-1996
inclusive. Specifically, this qualitative study looks at value derived from the graduates
international health rotations. The guiding hypothesis of this thesis is that these
graduates derived value from their overseas rotations. J
A four-page survey that evaluated the academic and the potential long-term
medical value of such rotations was distributed to all students receiving credit for
international rotations between 1990 and 1996. Findings are based on a 90% response.
Responses confirm the hypothesis, demonstrating value in specific medical skills, general
problem solving skills, character building, and perspective broadening. Cumulatively,
respondents visited 34 countries and report observing and treating a wide variety of
infectious, non-infectious and congenital diseases, injuries, traumas, and malnutrition.
A literature review was completed, and interviews were conducted with leaders
in academic health centers nationwide to determine if and to what degree international
health rotations had value for medical students. With several notable exceptions, there
are few studies that survey medical student programs in the United States and that
measure the value of these programs from a medical student perspective.
Research findings indicate that the hypothesis of this work, that international
health rotations have valuewhether defined as skill improvement, character building,
perspective broadening, learning diversity of health care systems, or seeing diseases run
their full course uninterrupted in a developing country settingwas reinforced. Results
indicated that 100% of the respondents recommended an international health rotation
to medical students, and that there was no significant opportunity cost for the
experience. Further longitudinal study is recommended, in order to overcome the
limitations of a one-time qualitative survey.
This abstract accurately represents the content of the candidates thesis. I recommend
This thesis is dedicated to the individuals who learn and work daily in the field of
international health so that millions of individualsmostly childrendo not have to die
of preventable diseases.
And for Kevin.
Foremost, I wish to thank the graduatesnow Interns, Residents and
physicianswho contributed to this study. In their busy schedules, each one set aside
time to complete their survey and to write narrative so that this study might succeed.
As medical students, these physicians were the inspiration for this thesis.
I wish to thank my professors throughout my degree process, since each of
them contributed positively to my professional and intellectual growth. I wish to thank
Paul Bauman, PhD, my thesis advisor, who supported this project development and
gave unselfishly of his time and suggestions over the past three years. I wish to thank
my thesis committee, comprised of Paul Bauman, PhD; Robin Harvan, EdD; and Calvin
Wilson, MD, who provided succinct recommendations that impacted positively on the
quality of this work.
John C. Cobb, MD is the father of the Medical Student International Program.
Jocks vision, wisdom and practicality gave life to this program. I wish to thank Jock
and Holly, long-term partners and promoters of international health.
Through her knowledge of key international health issues, sense of dignity and
sense of humor, Miriam Orleans, PhD inspired me. Mims teaching, especially relating
socio-economic issues to health, and her input regarding the survey format, were
I wish to thank John E. Repine, MD, who mentored me for the past nine years
in the areas of medical student advocacy and research, and who always gave me valuable
and perfectly timed professional advice.
Over the past five years, Michael C. Mozer, PhD gave me insights into the
process of developing and making meaningful the results of research. Mike also kept
me laughing with his notable sense of humor.
My family, especially my parents Darlene and Alan Miller, was constantly
supportive. They gave me frequent encouragement, as they have done throughout my
life. I wish to thank Karen Miller for her strong support and loyalty, as well as my
brother Gregg, not only as family, but for allowing me to have my beautiful nieces
Petra Eve Miller and Jana Danielle Millerin my life weekly. As I read about millions
of children worldwide who die of preventable diseases, I was reminded of the miracles
of modem medicine and was thankful for the health of these children.
Dona Urquhart, my daily walking partner, has been a fine sounding board and a
trusted friend throughout this process, giving wisdom and advice when needed. In
addition, numerous faculty, students, administrators and staff at the University of
Colorado Health Sciences Center have given me moral support and encouragement.
Finally, I wish to thank an extraordinary friend and partner, Kevin Markey,
whose doctoral process was apparently so inspiring that I decided to trade the honors
and have my husband participate in my thesis process! I always held Kevins standards
for research in front of me. His commitments to research excellence and to invention
have been a model for me. Kevin gave selflessly of his time, energy, and expertise
specifically with the database developmentto support this thesis. He also maintained
a sense of humor throughout, for which I shall always be grateful.
1.1 Medical Education in the United States.....................................1
1.2 1978: Alma-Ata.............................................................2
>"1.3 Primary Care Physician Training............................................4
1.4 Medical Education: Motivations for Overseas Electives......................5
1.5 Problem Statement..........................................................8
2. What is Already Known?.......................................................9
2.1 The Literature Review......................................................9
2.2 Distinctions............r.................................................. 10
2.3 Value in International Medicine...........................................11
2.4 Medical Education Reforms.................................................13
2.5 Models: Hamburgers, Shish-kabob, Tacos and Pizza..........................18
2.6 Literature Review: There is No Value in an Overseas Rotation..............19
2.7 Major Players.............................................................22
S 2.8 Academic Health Centers...................................................24
2.9 Closing the Gap Between What We Know and What We Want to Know............28
2.10 Expansion as an Indicator of Demand and Value.............................31
3. Presentation of Research Methods and Research................................33
3.1 The Survey.............................................................. 33
4. Summary of Findings..........................................................36
4.1 Demographics (Questions 1-4)..............................................36
4.2 Background (Questions 5-7)................................................37
4.3 The Rotation (Questions 8-13).............................................40
4.4 Diseases and Conditions Observed..........................................41
4.5 Assessment and Implications (Questions 14-23).............................45
4.6 Research Interpretation...................................................49
vj 5.1 Possible Implications for Practice of Medicine.............................56
5.2 Recommendations for Longitudinal Study...............................57
5.3 Final Summary........................................................59
A. Kerr Whites Box........................................................61
B. International Health Forum Schedule................................... 62
C. Survey Questionnaire....................................................63
D. Survey Cover Letter.....................................................67
2.1 International Rotations by U.S. Medical Students by Year in School .......24
4.1 Number of Respondents by Year of Graduation...............................36
4.2 Reasons for Selecting Site and Country....................................37
4.3 Ranked Reasons for Going on an International Medical Rotation.............38
4.4 Ranked Reasons for Participating in International Medical Rotation........39
4.5 What Was of Value?........................................................40
4.6 What Was Not of'Value?.................................................. 40
4.7 Diseases and Related Conditions Observed by Respondents...................42
4.8 Respondents Reporting Skills Improved Due to Rotation.....................45
The transformation of the worlds entire population into one ecological and
health entity, and the growing mosaic of cultures, ethnicities, and languages that define
U.S. society point to the urgency of creating a health care system which is responsive to
the growing needs of a single interconnected civilization (AMSA Summary Report,
1994, p. 1).
1.1 Medical Education in the United States
Medical education in the United States has not changed radically in one hundred
years (Petersdorf, 1995). However, with the turn of the millennium, we can expect to
see fundamental changes in medical education. Some of those seeds are sown. For
example, we have seen an increased number of primary care core (required) courses
appear in the United States medical school curricula, as well as in more problem-based
learning and community-based elective and required courses.
One of these specific changes in medical education is increased training in
primary care. This change is not only instrumental for training medical students in the
basics of primary care who will never set foot outside of the United States, but it is also
instrumental for training them in primary care for their practice of international
medicine overseas, whether for a short or extended period of time. Before looking at
documentation regarding the expanding student interest in international health training,
it is useful to look at an historic benchmark which motivated primary care.
1.2 1978: Alma-Ata
Looking back to lend historical perspective, there is a clear turning point. From
September 6-12,1978, at Alma-Atacapital of Soviet Kazakhstanover 700
representatives from all over the world met for the first time in history to convene The
International Conference on Primary Health Care. The theme of this conference was
to protect and promote the health of all people of the world. One major result of
this conference was the Declaration of Alma-Ata, (WHO, 1994) which defined, with
international consensus, Primary Health Care for the first time.
Why was this significant? There are numerous reasons. One reason why Alma-
Ata was significant is that nations took responsibility for global health instead of simply
protecting the health of ones own. This had, and continues to have, major
implications on health policy, health politics, and health practitioners.
Alma-Ata was significant as a declaration that began a process. This declaration
brought attention to a well-known fact within the international health community: that a
majority of the worlds population needs mostly primary health care to survive.
Although medical education has trained pre-doctoral students for the 20th century in
the more sophisticated, technologically-oriented tertiary and quaternary medicine, some
of the effects of Alma-Ata filtered down to medical education in the form of increased
primary care training. Alma-Ata also heightened awareness about the discrepant resource
allocation where a large percentage of the worlds resources go to relatively small
percentage of the worlds population (Cohen, 1995). Because of Alma-Ata, in-depth
discussions resulted worldwide that would have an impact on medical education.
In the early 1990s, the American job market for physicians became relatively
saturated with medical specialists and sub-specialists. Occurring simultaneously, due in
large part to Alma-Ata, was the growing recognition that more primary care training was
needed and necessary to meet the actual needs of the American population. This
recognition impacted medical education.
Finally, for the purposes of this thesis, Alma-Ata was significant because it
generated the worldwide Health for All (HFA) by the Year 2000 initiatives. Although
it was seen that each country would interpret and adapt differently to meet theHealth
for All targets, HFA was key in identifying a baseline^ below which no individuals in
any country should find themselves (Mahler, 1983). The World Health Organization
established a global strategy to support the Health for All targets.
Alma-Ata, then, helped not only to define primary health care or primary care
(PC), but it also began a process still in motion today, involving global strategies to
define and deliver health for all. Clearly all the goals will not be met by the year 2000, as
had been hoped. However, Alma-Ata was key in articulating a consensual definition of
primary care, gathering intellectual expertise, and accelerating efforts in that direction.
1.3 Primary Care Physician Training
Since primary care physicians (trained in Family Medicine, Internal Medicine,
Pediatrics and sometimes Obstetrics/Gynecology) are now the first and often the only
point of contact of western medicine, medical training and retraining has a different
profile than in the past. In the current managed health care system in the United States,
these individuals not only treat patients, but also refer patients when appropriate.
In Colorado, the Generalist Initiative addresses primary care medical
education training, and recommends strongly that 50% or better of all medical school
graduates have a primary care Residency by the year 2000. As members of a health care
system and as medical educators, we are becoming more and more aware that the
medical education and health care system are training future physicians for tertiary
hospital care when only a relative fraction of the population utilizes it.
Larry Green, MD, Chairman of the Department of Family Medicine at the
University of Colorado, demonstrates this graphically with an educational tool entitled
Kerr Whites Box. (Appendix A). That is, for every 1000 adult population who are at
risk in the United States, the following holds true:
1000 Adults At Risk
750 adults report one or more illnesses or injuries
250 adults go to a consulting MD one or more times
9 adult patients are admitted to a hospital
5 adult patients are referred to another MD
1 adult patient is referred to a university medical center
This is not a health policy discussion per se; however, Kerr Whites Box does
lend perspective to the fact that 99% of adults only need basic health care (White,
Williams & Greenberg 1961). Some variation of this fact can be found in every country
in the world.
Primary care training can contribute and broaden medicine to serve a broader
population than can tertiary care medicine. How can primary care broaden medicine?
First, it forces us to look at society: the problems, the needs, the
diversity, the cultural variations, and the differences in values. Second,
primary care focuses our attention on what is common: the problems,
the concerns, the personal. Third, the curriculum of medical education,
now attempting to educate more generalists, must address the problems
that are common in order for medicine to meet its obligations to society.
To help inform medical education is the challenge (Connelly, 1995).
1.4 Medical Education: Motivations for Overseas Electives
Because of the Generalist Initiative, (and medical education policy), more
students will be trained in primary care in an American setting than ever before.
Primary care is becoming integral in modern medicine and medical education, and there
are currently core primary care courses for first-, second- and third-year medical
students at the University of Colorado School of Medicine.
According to the International Health Medical Education Consortium
(IHMEC), as of the Fall of 1996, in twenty four (24) of the 126 United States accredited
medical schools (20%), medical students are actively self-selecting to be trained in
primary care medicine in an international setting (personal communication, 1996).
David Altman, MD, former Vice President of the Association of American Medical
Colleges (AAMC), illustrated this growing interest at the IHMEC Conference at
Harvard Medical School, October 1994.
In order to go overseas for a clinical elective rotation, some medical students
nationwide are willing to go more deeply into debt for medical school and defer
graduation 3-12 months. Nationwide, there are a variety of motivations for medical
students to complete an overseas rotation.
Because of population mobility, traveling and the spreading of diseases without
borders, as discussed extensively by Jonathan Mann, MD, Francois-Xavier Bognoud
Professor and Professor of Health and Human Rights at the Harvard School of Public
Health, this student motivation is practical. According to Mann, it is naive to continue
to think as we have in the pastthat diseases will stay national, that there is a disease
geography, if you will, beyond which diseases will not go (October 1994, conference at
Harvard School of Public Health). We must become more sophisticated in these days
of the rapid spread of contagious disease. From the American Medical Student
Association (AMSA, 1995):
The need for health professionals with an adequate understanding of
international health issues is evident where the global AIDS epidemic is
concerned. The permeability of borders to contagious disease is a
challenge that will require multinational resource allocation in which the
U.S. interest in increasing future health care providers knowledge and
involvement with international efforts should be unquestionable (p. 1).
Part of the expansion of students international medicine training is due to this
kind of awareness. In discussions with faculty at academic health centers mentioned
later, some increased medical student motivation is due to the promotion of
opportunities through peers or, through global communication. For example, one need
only surf the Internet to discover intriguing international clinical opportunities for
medical students. According to discussions with some of the University of Colorado
medical school graduates, some motivation is due to increased collaborations, and/or
due to the desire to explore unusual clinical conditions as well as simply serve ones
fellow human being.
According to the AAMC and IHMEC, expansion of international medical
student rotations is also motivated in part by changing demographics, such as students
desire to learn and practice Spanish, since they are aware of the growing Hispanic
population and knowledge that Spanish-speaking abilities will be an asset. This is a
realistic goal since, according to projected U.S. Census Bureau demographics, by the
year 2030, 20% of the United States population will be Hispanic and, by the year 2050,
25% will be Hispanic. Clearly, not all will be Spanish-speaking, but many (including an
increasing number of immigrants) will have been raised in a particular tradition and will,
therefore, have a belief system that is not necessarily one which fits neatly into the
western medical model.
Finally, but not exhaustively, medical students are motivated to train and practice
international medicine due to a growing interest in multiculturalism and diversity, as
reported specifically by University of Colorado graduates. This includes learning about
multiculturalism, as well as seeing some alternative cultural medical practices
incorporated gradually into western medicine and western medicine reimbursement
packagessuch as acupunctureand thus taking advantage of opportunities to
immerse oneself in a cultural and medical setting other than ones own.
Whatever the motivation, according to David Altman, formerly at the AAMC,
an increasing number of medical students are interested in international medicine, and
that interest is demonstrated by an increasing number of student-selected overseas
1.5 Problem Statement
But what is the value of an international rotation? Inspiration and motivation for
this thesis derives from this question. That is, as the Director of the Medical Student
International Program for eight years, this author observed medical students before and
after international rotations. These observations led to the notion of apparent value
that the international health elective rotations seemed to have for medical students. If
that notion was true, it would also hold that these rotations had value for medical
Because casual observations and value measurement are distinct, the intent of
this thesis is to ask and answer the specific question, (1) What is the value of an
international health rotation to a medical student, (a) who received elective academic
credit for such rotations, (b) through the University of Colorado School of Medicine, (c)
from 1990-1996 inclusive, and (2) what are the possible implications of those rotations
for their practice of medicine? The first part of the question relating to value is the
work of this thesis. Possible implications of this thesis and will be discussed later.
2. What is Already Known?
In order to explore this question, this author completed both a literature survey
and a literature review. This literature survey revealed that unexpectedly few writers
have studied and reported issue(s) of value with regard to an international medical
student rotation. Even fewer had studied their own medical student populations.
The literature review revealed a majority point of view that an international
medical rotation during medical school produced value for the students medical
education. Virtually nothing was found on the impact of international rotations on
residencies or physicianship. This chapter addresses the results of the literature review
and current academic health center perspectives about this topic, as well as some
relevant agency perspectives, such as that of the International Health Medical Education
2.1 The Literature Review
Since very little has been written on this specific topic where value was addressed,
and databases have been established and tracked, this author expanded key words of the
literature search beyond international medical education to include international
medicine, curriculum in medical education, medical education, and primary care. Few
empirical studies were published. Those published were completed by Heck and
Wedemeyer (1991 and 1993), Pust (1992), and Taylor (1994). These were separate
studies from three different medical schools. Of those, topics of career choice,
curriculum planning and quantitative course offering surveys were more prevalent than
Of the nearly eighty articles reviewed, a clear majority emphasized the value of
international educational experiences. Overall, the literature review revealed that the
authors who wrote of the value of international medical rotations looked at the topic
through seven distinctions, or in seven categories. Whereas the writers in these specific
categories will be cited shortly, the basic categories encountered in the literature follow.
These seven categories were: (1) the perspective that international medical
rotations partially fulfill a training physicians role in social accountability and humane
service (the moral imperative), (2) the value of the global physician, with transferable
skills who demonstrates international standards of care (3) the importance and, in some
cases, the criticality of medical school preparation and training to go on an overseas
rotation, (4) review of the effect(s) of international rotations on specialty career choice,
(5) the perspective that international rotations are part of health reform, as in Health
for All by the Year 2000, (6) the study of various models in international health
rotations and, finally, (7) the linkage or clear potential linkage between these
international experiences and pursuant impacts in health care in the United States (for
example, cost containment).
In addition, some writers in the literature addressed the uses of international
training to study different healthcare systems but did not address medical education
specifically. A separate group of writers were skeptical but still open-minded group.
Finally, several writers felt that the international rotations had no value.
Of the above seven categories seen in the literature and mentioned above, the
first, third and last categories will be addressed as relevant since these are basically the
pros and cons of the value of international medical training.
2.3 Value in International Medicine
In the literature review, of those writers who focused on the specific value(s) of
international education and international medical education, the most passionate and
adamant perspective was that of the moral imperative of international medicine, and the
concomitant responsibility of serving the poor. In this body of literature, international
medical rotations are seen as a privilege, an opportunity to learn, and as a social
Despite remarkable progress in the medical sciences in recent decades,
the burden of disease on the planet remains substantial... .Among
developed nations, the United States has been conspicuous in its meager
contribution to international medical education.. .growing awareness
that an important moral obligation is being neglected... .Interest in
international health has been increasing once again among medical
students (Boelen, p. S21).
This addresses the concern for the whole, and demonstrates an awareness of the global
burden of disease.
Carl Taylor, MD, DrPH, is a professor emeritus of international health at Johns
Hopkins University. Because Taylors work covers all of the above seven distinctions in
one tightly packed article, his comments are used as a kickoff point. Taylor (1994) sees
an overseas clinical elective rotation as both an opportunity to impact and improve
health care in under-served communities, but also as an opportunity to compensate for
the negative impact most medical education has on altruistic attitudes. He argues that
the impact of overseas rotations for medical students lies in three basic domains: the
cognitive, skills building, and as an experience impacting the affective and values.
In the first regard, he emphasizes that knowledge gained on these rotations is
tremendous, in part because students learn about diseases not often seen in the
United States, but that they see the causal chain leading to a disease. Finally, he argues
that exposure to different cultures and lifestyles can and does allow the student to build
new conceptual frameworks from which to learn and practice medicine.
Taylor (1994) argues that learning to work with different kinds of people is a
critical skill for a good physician, and that these rotations build that skill. He notes that
this is true in part because the overseas experience trains one in flexibility, cultural
diversity, the opportunity to transfer skills to an unfamiliar setting and make great strides
in developing better problem-solving skills. He characterizes the United States health
care system as one that promotes dependency, not self-reliance. He contrasts that with
the need to instill self-sustainability in overseas work when he states that students
should learn that a major responsibility of health workers is to teach people to solve
their own problems (Taylor, 1994, p. 633). Implied in this extension of social
responsibility is the responsibility to get in, help and get out without instilling patient
Finally, Taylor (1994) argues that international medical rotation experiences
impact the affective domain. He believes that an important part of being a physician is
acquiring appropriate values and attitudes. He recounts his extensive experience
observing'students and physicians go overseas and return having experienced dramatic
shifts in values. The result? They went overseas, their eyes opened, and they could
see the needs at homein this case, in the ghetto near Johns Hopkins. In essence,
these students redefined their framework of health needs by means of their growth in
Taylor (1994) states directly that the benefits to American health care from
overseas training of students should be recognized and supported. He concludes by
citing a longitudinal study illustrating how Johns Hopkins medical students overseas
training prepared and motivated them to work with the poor at home.
2.4 Medical Education Reforms
Spearheading an ambitious American initiative in medical education reform is
Charles Boelen, MD, DPH, MSc. Dr. Boelen is chief medical officer for educational
development of human resources for health, Division of Development of Human
Resources for Health at the World Health Organization (WHO). In 1992, WHO
mounted a global initiative entitled Changing Medical Education: An Agendafor Action, to
facilitate the transformation of medical education into a more relevant and effective
enterprise in how it responds to societys health care needs (Boelen, 1992). Part of the
purpose of this initiative is to synthesize innovations in medical education from around
the world (for example, problem-based learning, community-oriented primary care,
population medicine and community partnerships).
In addition, Boelen (1992) addresses the nature of work in schools as we prepare
to rebuild medical education into a more socially responsive resource: Education helps
society achieve its goals. (p. 746). He proposes a model that will be included as part
of the penultimate distinction mentioned above. But here Boelens (1992) contribution
is simple: to tie reforms in medical education to reforms in health care. Calling for
more research, his group wants to better understand how medical schools can be
fundamentally reoriented to best serve society. Boelen (1992) concludes with equity vis-
a-vis the need for global action:
Human rights and the quest for equity and quality in health care are
universal values. Thus, efforts to reorient health systems, social systems,
and educational systems toward the achievement of a better state of
individual and collective well-being deserve attention on a global scale.
Change in medical education takes an even greater significance if seen
within that perspective (p. 749).
Other writers who view international medical education in the context of the
social/moral imperative include Barbara Gastel (1995), Heck & Wedemeyer (1995) and
President Emeritus of the American Association of Medical Colleges (AAMC), Robert
Petersdorf, MD (1995). PetersdorPs (1995) argument goes beyond the above when he
states that, when medical schools fail in their mission, it is often because of their
disregard for societys needs.
The second distinction seen in the literature, closely linked with the
perspective of social accountabilitywhether as a motivator or as a result of an overseas
medical rotationis the distinction that we are going in the direction of the global
physician, and that international medicine supports this. Gastel (1995), Hamilton
(1995), Boelen (1995), Blizard (1991) and Suwanwela (1995) all address this. Gastel
(1995) summarizes the findings of a July, 1995 international conference entitled
Toward a Global Consensus on Quality Medical Education: Serving the Needs of
Populations and Individuals: Summary of the Consultation. M. Roy Schwarz, MD, of
the American Medical Association, previous Dean of the University of Colorado School
of Medicine, gave the Closing Remarks.
At this international conference cited above, Schwarz synthesized conference
input by envisioning the physician for the year 2050. He saw a global physician certified
in universal core competencies, who also had competencies specific to the practicing
locale. He saw outcome of care feedback and community needs recycled back into
medical education, both during medical school and for lifelong learning. Finally, he
envisioned a worldwide communications network among medical schools for
collaboration in education, research and patient care (Gastel, 1995).
Hamilton (1995) states that a key for medical education must be the study of
cultural awareness in populations as we move into a more primary care-oriented health
care system. International medicine is one way to gain experience in this area. Boelen
(1995) summarizes this perspective in arguing that In the long term, medical schools
may be judged against basic indicators of quality identified by the world community.
A third distinction in the literature is that formal preparation and training
are critical for medical students to derive significant value in their international health
rotation. In a Lancet Anonymous editorial (1993), in Heck and Wedemeyer (1991), Pust
and Moher (1992), Heck and Pust (1993), and Taylor (1994), the simple fact is
emphasized that value added from overseas rotations is largely a function of the quantity
and quality of formal training medical students receive prior to departure. This
preparation, however, is not a simple matter. Due to the low priority in medical school
curricula for this type of workand thus acutely limited resources directed to itand
due to the complexity and variety of topics available to teach, formal preparation can
include everything from cross-cultural and transcultural training (critical factors), to
language or infectious disease, to pathophysiology, epidemiology and geography.
Heck and Wedemeyer (1995) surveyed all accredited American medical schools
regarding the existence of overseas elective offerings and preparation. Based on these
data, they summarized dominant and recommended topics for teaching medical
students in order to prepare them for overseas rotations. For example, in their survey
of American medical schools, the following priority of subject categories in international
health courses was documented for 35 medical school programs which offered
preparation training courses. Educators gave primary health care courses top priority,
with public/community health courses second, research third and tropical medicine
courses fourth. However, because of the special requirements of working in health
care settings abroad, training in international health may be most effectively taught as a
comprehensive, integrated program for students who have had previous experiences in
direct patient care during clinic and ward clerkships (Heck and Wedemeyer, 1995).
The fourth distinction was a look at the impact of international health
rotations on specialty career choice. This is predominantly reviewed in detail by Heck &
Wedemeyer (1991 and 1995), Pust & Moher (1992), and Taylor (1994).
Although more research needs to be done in this area, consensus is that an
international health rotation not only impacts specialty choice but it impacts choice of
setting for health care delivery as well. Pust (1984) also discusses possible cost savings
implications of those primary care trained physicians who know how to problem-solve
with few resources.
The fifth distinction found in the literature was that of health care systems and
health care delivery which, it was suggested, would require international system
restructuring, both in education and health care delivery. This discussion occurs several
times in the context of Health for All by the Year 2000 initiative. Although this was not
a major category, it was clearly specified in several articles including Baum and Sanders
(1995), Boelen (1992), and Godinho (1990).
2.5 Models: Hamburgers, Shish-kabob, Tacos and Pizza
The sixth distinction found in the literature is an outgrowth of the
restructuring of ideas. That is, these writers reviewed and recommended several medical
models. Although this does not address directly the value of international health
rotations on the practice of medicine, these alternate medical models emerged from
discussions of successful international models of health care delivery. These models
have major possible implications not only for preparing students to go overseas, but in
reviewing our own health care systems for possible restructuring in the emerging
managed care setting.
Boelens (1992) hamburger model emerged; this consists of top bun
(participation in improving health care organization), the hamburger (relevance and
efficiency) and the lower bun (involvement in quality assurance and technical
Inspired by the hamburger model, several other models emerged during that
international conference. These included the shish kebob model with many layers of
health care, the taco model, mixture of therapies from the developing world, and the
pizza model, a solid base of agreement with variations in toppings and spices added to
the health care delivery versions (Gastel, 1995). Abramovich (1995) presented an
interesting idea: now that the European Economic Community is underway, he
suggested that the physician who is being produced for at least a continent be studied
and efficacy observed. Blizard (1991) suggests that no international model can or will.
exist, but that we could clarify national models and share the best of those as
collaborations. The call for new and ongoing collaborations pervaded these articles.
Finally, the seventh category of the literature review looks at the linkages or
potential linkages between these international educational experiences and the likely
impacts on American health care. Those who covered this topic included Barry and Bia
(1986); Nora el al (Daugherty, Goodman, Nora, Mattis-Patterson and Stevenson, 1994);
Petersdorf (1995); Pust and Moher (1992); Pust (1984); Heck and Wedemeyer (1995)
and Taylor (1994). Overall, their review is that there is direct linkage between the
overseas experiences, skills developed, growth in cultural awareness sophistication,
growth in compassion and ability to meet health care where the rubber hits the road
with the basicsboth with patient and population medicine.
2.6 Literature Review: There is No Value in an Overseas Rotation
Though of lesser volume, there were several writers who argued that there are
negative motivations or results from medical students going overseas. These writers
comments may seen as the following distinctions, and seen by us as cautions for our
own work: (1) confusion through differences in cross-cultural logic and in cognitive
perceptions; (2) internationalism not realistic; (3) the familiar sin of modernization
equals westernization; (4) supervision at a distance does not work; and (5) make an
effort to ensure adequate conceptualization of experience.
Although Shaughnessy (1995) looks at international commercial ventures, his
comments hold an important caution for international educational collaborations:
Mistakenly, many companies still believe that the essence of successful collaboration
management is a quick course in cultural training (p. 10). As we consider the value of
linkages, the following can also easily be generalized to a clinical, educational setting: ..
.all aspects of an international joint venture have to be managed with a vengeance
because of the inherent wish to assume that a shared commercial ethos will protect the
deal (p. 11). Shaughnessy elaborates on the fundamental error of assuming a venture is
protected by a mystical commercial logic (p. 11). Linguist and Berkeley Professor
George Lakoff (1996) covers this in his new work, Moral Politics, where he cautions the
reader to beware of what we consider common sense since what we call common
sense is culturally relative. Further, he argues that complex, numerous, often
unconscious, assumptions underlie all human reasoning (Lakoff, 1996).
A more negative point of view is seen in Stevens (1995) and Ninkovich (1995),
who see international education as elitist, demonstrating American naivete.
Acknowledging that medical practice has and does embody a cultural component,
Stevens (1995) argues that there are strong links between national dominance and
perceived medical superiority. In this piece, she traces colonialism worldwide, which she
claims is by its nature, condescending (p. S13). She quotes Ivan Bennett (1984), past
professor of medicine at New York University, who wrote that When we speak in
terms of international comity through health, and urge that health transcends politics, I
believe that we are whistling Dixie (p. 33).
Stevens (1995) believes that quality is defined by the most powerful nations, that
to expect the imminent coming of a global medical program, or even one standard of
medical education, would be foolish (p. S17). Finally, and more consistent with other
writers who see value in taking medical education overseas, she states that cultural
competencetrue understanding of medicine in a different cultureprobably will
always require a stint in a country of interest (p. S17).
In Requiem for Cultural Internationalism, Frank Ninkovich (1986) reviews
M.B. Bullocks book on an American transplant, wherein the Rockefeller Foundation is
reviewed vis-a-vis largesse to the Peking Union Medical College. Issues such as
appropriate technology, elitism, the western scientific model are all discussed, as an
indictment of Rockefeller philosophy as it is entwined in politics. Bullock (1980)
represents the point of view which is by now the familiar sin of equating
modernization with westernization (p. 251). Boulder and Wallace (1974) saw that
supervision at a distance was one of the key disadvantages for achieving value in an
Robert Northrup (1991) is skeptical about the value of overseas rotations but
open-minded. He acknowledges that such an experience can dramatically alter
(students) perceptions of health, health care and societal and personal responsibility,
and can even contribute to permanent career changes. Citing Heck and Wedemeyers
1991 survey of all American medical schools, Northrup (1991) acknowledges that the
majority of these students are not prepared for their overseas rotations. Heck and
Wedemeyer (1991) reported that only 22% of the US medical schools provide
preparatory training courses and that only 9-15% of the 2400 students traveling in 1989
participated in them.
Northrups skepticism relates more to the opportunities missedunprepared
students working with patients without much guidancethan to the value of overseas
rotations. However, he calls for medical schools to review current procedures, require a
structured report of the visit to ensure adequate conceptualization of the experience,
and define specifically supervision and tasks to be done (Northrup, 1991, p. 92).
2.7 Major Players
Armed with apparently overwhelming data in support of the value of overseas
medical education rotations, and the richness of potential future research in this area,
this researcher contacted key agencies involved in medical education to see if and what
trend(s) and reported value exist from the students point of view, as well as what
perceived value exists from the agency representatives point of view. This could clearly
be another thesis, and this summary is brief.
For the purpose of this thesis, the American Medical Student Association
(AMSA), the Association of American Medical Colleges (AAMC), the International
Health Medical Education Consortium (IHMEC) and leaders in the international
medical education programs at ten academic health centers in the United States.
Their international program began in 1990. According to the AMSA Final
Project Report, (1994), the collaboration between The AMSA Foundation and the
Pew Charitable Trust, which resulted in the nationally competitive, three medical school,
faculty and student exchange (intercambio) included medical schools in Rochester,
Boston and Colorado with Latin American countries. According to AMSA, this
International Health Partnership Project was on the cutting edge of medical education
at the time. This program not only gave medical students direct experience with
community-oriented primary care in settings where this is already well tested, but it also
provided faculty new learning and teaching opportunities as well. The AMSA Final
Project Report gives us ideas for future international rotations as they apply to medical
Its essential feature is the integrated assortment of knowledge that it
stimulates through the conglomeration of varied personal and
professional experiences. In a sense the international partnership is the
natural extension of the teacher-student, teacher-school and student-
student partnership that already occur within existing medical schools to
the global scale (1994).
Donald G. Kassebaum, MD, Vice President for the Division of Educational
Research and Assessment for the AAMC in Washington DC, represented the
Association of American Medical Colleges (AAMC). Dr. Kassebaum forwarded
Summary Reports from 1994 and 1995, which included consolidated input from all
students who completed their senior AAMC questionnaire from every accredited
medical school in the United States (Association of American Medical Colleges, 1994,
1995). The 1996 Summary Report is pending.
These reports, summarized in Table 2.1, include a number and percentage for
medical students who participated in an international health rotation, reported separately
for years one through four of medical school. Due to the structure of medical
education, most medical students take their electives overseas during their fourth year.
Year four national participation in overseas rotations increased 17% in absolute terms
(or 13% in relative terms) between 1994 and 1995.
Table 2.1. International Rotations by U.S. Medical Students by Year in
School (Association of American Medical Colleges, 1994,1995)
Year 1994 1995
N % N %
1 239 1.9% 228 1.7%
2 275 2.1% 259 1.9%
3 169 1.3% 183 1.4%
4 950 7.4% 1114 8.4%
According to Caroline Stuck of the International Health Medical Education
Consortium (IHMEC) this trend continues. The IHMEC was formed in 1991 and
already has a 64-school membership (both individual and institutional), is a direct
acknowledgment of the expanded medical education institutional interest in resources
and programmatic experience/lessons learned related to medical students international
2.8 Academic Health Centers
Finally, American academic leaders in the medical education international health
community were contacted. This is not an exhaustive list, but the remarks from these
individuals certainly underscore the observable trend toward increased international
health rotations by our American medical students to learn to practice medicine
overseas. Recognizing that different individuals might provide a different list, it is
believed that the following schools contacted represent a strong sampling of the United
States accredited medical school international programs.
These individuals and schools include (listed alphabetically by institution):
Donald Wedemeyer and Thomas Daniel of Case Western Medical School; Joan May of
Cornell University Medical College; Audrey Bernstein of Harvard Medical School, and
the Universities of Arizona College of Medicine (Ronald Pust); Cincinnati College of
Medicine (Jeffery Heck), Colorado School of Medicine (William Robinson); Johns-
Hopkins Medical School and Graduate School (Carl Taylor); Silvia Bird from the
Rochester School of Medicine and Irwin Cohen from Tulane Medical School. In
addition to these, Cynthia Haq, MD, national faculty advisor for the AMSA
international partnership program, responded from the University of Wisconsin School
The three questions asked of these academic health center contacts were: (1)
what trends have you noticed in medical student demand for international health
rotations in the past ten years? (2) what value do you think these rotations have for your
students? and (3) what do you think might be the possible impact(s) for their practice of
medicine? The responses for each question were consensual.
For question number one, regarding trends noticed over the past ten years,
these individualsall of whom have spent a good deal of their professional lives
studying and/or participating in overseas workresponded as follows. They have
noticed that there is an increased student-driven demand for overseas rotations,
especially when the students have some knowledge of primary care, community oriented
primary care and/or cross-cultural health knowledge. These individuals noted that,
although institutional support (both at home in their academic setting and overseas in
larger institutional agencies) does not necessarily reflect student interest, students have
learned to take the initiative to make their own way. That is, students find funding,
complete necessary logistics and make a rotation happen if they want one.
Another trend noted was that student interest grew steadily in the late 1980s
and that this interest peaked in the early 1990s. However, it was also noted that, even
though student interest is not increasing at the same rate in the mid-1990s, there is still
a steady stream of students who wish to participate in these electives. One faculty
member noted that his students are leaner and meaner, in the sense that they learned
overseas how to get a lot done with few resources and they have learned to apply this
skill back home.
In question two, these individuals were asked what value they thought these
overseas rotations had for their students. We heard the same answers again and again.
The consensus was that students came to realizations about discrepant resources used in
the United States and abroad. That is, the students felt that they saw wastefulness of
health care resources in the United States as compared with health care workers meeting
a majority of health care needs with few resources. These individuals also reported that
they thought their students learned independent thinking and gained more personal
independence through these experiences. In addition, they felt that students developed
strategies for success under difficult conditions and developed through-sightedness, or
the ability to see things through.
In addition, these individuals reported that their students strengthened their
cross-cultural sensitivities such as developing a willingness to hear about an illness or
symptom through another belief system than their own. Finally, these individuals
reported that students strengthened their second language, and that they developed a
positive perspective of the United States health care systems enormous resources
compared with the rest of the world. In other words, they no longer took our health
care for granted.
In question number three, we asked these individuals in academic health centers
what they thought might be the possible impact(s) or implication(s) of these student
overseas rotations for the students practice of medicine. Responses included the
students growth in the sense of tolerance, that these rotations engage the students
humanity, teach them to build team and collaborate with an interdisciplinary group of
diversely trained health care workers, become more skilled at the history and physical,
and come to see a more universal concept of medicine. Importantly, these individuals
reported that students grew in their ability to see the connections between socio-
economic status, health care received, and resultant health in the community. In other
words, they felt that students learned to see the role of family and community directly as
it impacted patients treatment and healing process. Other comments reflected the
students beliefs that they obtained their Residency of choice based on their overseas
If the above comments from preeminent physicians, leaders in the field and
those experienced in international health have validity, international health elective
experiences for medical students may not only hold value for the students medical
education, but also for their practice of medicine long-term.
2.9 Closing the Gap Between What We Know and What We Want to Know
Based on what we know, what is the value of an international health rotation? In
order to look more specifically and in-depth at the University of Colorado School of
Medicine student rotations, it is necessary to review the mechanism through which
students launch their rotations at the University of Colorado School of Medicine: the
Medical Student International Program (MSIP). Nearly thirty years old, at the current
average of 10-15 per year, at least 300 and possibly as many as 450 medical students have
gone overseas for elective credit through the MSIP.
John C. Cobb, MD, Professor Emeritus and former Chairman, Department of
Preventive Medicine at the University of Colorado School of Medicine, originated the
Medical Student International Program in 1966. It was developed programmatically
over the next two decades by Drs. James Kurowski, Christopher Patterson, and Jerome
Stromberg, scientists at the University of Colorado Health Sciences Center (UCHSC), all
of whom had direct international clinical and/or international research experience.
From 1985 until 1989, Nancy E. Nelson, MD directed and expanded the program. This
author has directed the MSIP program from 1989 to the present.
The purpose of the MSIP was and is to provide a formal structure within which
medical students can work in an underprivileged area overseas, or in a poverty area or
Indian reservation or Eskimo village in the United States. Students may go to
developed countries, but the vast majority select developing country sites.
By the Rules of the CU School of Medicine, medical students may receive
elective academic credit for up to four months rotations overseas, provided that they
are in good academic standing, and that their study project is supervised in situ by a local
physician competent in the discipline giving credit, as well as managed by a UCHSC
Deferment of graduation to permit an ever larger overseas experience has been
chosen by as many as three students per year. A number of students have undertaken
small-scale research projects, health surveys, or daily clinical duties and village calls, some
of which have been submitted to medical journals. Receiving credit for the rotation
includes follow-up after the completion of the rotation: either writing a paper for the
MSIP files, which has a file for every country in the world as well as scholarship and
language school opportunities, and/or giving a slide presentation at a traditional
International Health Forum to peers and faculty (Appendix B).
According to some of our medical students, this Forum is helpful in their
professional development. They have reported that it is a format from which to inquire
about opportunities, broaden perspectives regarding the relationships (arguably
correlation) between wealth and health (income and outcome) in developing and non-
developing countries. In addition, an overseas rotation gives medical students an
opportunity to apply acquired medical knowledge after their first year, in their fourth
year of medical school, or in a year set aside for a rotation where graduation is deferred.
Although this program is not highly funded or a crucial priority in the context of
the School of Medicine, faculty, students and staff have kept the program alive and have
raised funds to pay for small scholarships, books, slides and pizza for small gatherings.
A combination of factors combined to produce the current healthy MSIP program,
expanded interest groups, and international exchange fellowships from the American
Medical Student Association (AMSA) in collaboration with the Department of Family
Medicine. Because of student demand, in the spring quarter of 1997, an international
primary health care elective will be offered to all University of Colorado Health Science
Center students through the Department of Family Medicine.
Growing interest and growing programs feed upon one another, but it is true
that both are growing. Locally, at UCHSC, collaborations expand through fundraising,
a developing database of faculty and sites, word-of-mouth, faculty recruitment, and
volunteer time and energy on the parts of faculty, students and staff. For the first time
in the history of CU School of Medicine, during the summer of 1996, an International
Health Care Program (IHCP) was formed with representatives from the Graduate
School, Schools of Nursing, Pharmacy, Dentistry and Medicine as well as the Allied
Health Programs of Child Health Associate/Physicians Assistants (CHA/PA) and
Physical Therapy. The goal of this IHCP is to form interdisciplinary clinical and
research team collaborations for projects both in the United States and overseas.
2.10 Expansion as an Indicator of Demand and Value
This thesis argues that these student-driven, expanded international programs
both nationally and at the University of Colorado Health Sciences Centerare
indicators of demand and, by implication, of value. It is also important to note that
medical students who participate in this program self-select to participate and that
between 10-15% each year typically participate. Because of this, there is an unavoidable
selection bias with this population. That is, international rotations are not core
curricula, and participation is based entirely upon student choice.
If medical students express interest in registering for an elective international
rotationusually an elective in Internal Medicine, Family Medicine, Pediatrics, or
Emergency Medicinesuch interest is encouraged. Students are asked general
questions, and then directed to resources. When their plan for their rotation takes
shape, they are referred to potential faculty advisors to assist them in designing a
Logistics of CU medical students international rotations have proceeded
relatively smoothly. However, we felt that a qualitative study was important in order to
determine the value of these rotations. Therefore, we conducted a study in order to
determine specifically the valueboth kind and degreeof an international health
rotation to a medical student at the CU School of Medicine.
3. Presentation of Research Methods and Research
Given the nature of the thesis research question, that is, what is the value of an
international elective rotation and what are possible implications for their practice of
medicine? we determined that collecting the historic database, designing a useful
survey, contacting the maximum number of graduates from the University of Colorado
School of Medicine for this and future purposes, building a solid response database,
then answering the research question, were the goals of this thesis.
Every attempt was made to locate and survey 100% of the graduates who took a
Course Work Away Outside the United States elective rotation between 1990 1996
inclusive. These data artifacts were found in the Office of Admissions and Records,
Central Administration, and taken directly from original source documents signed by an
Admissions staff member who works individually with each student as they formulate
3.1 The Survey
The survey instrument (Appendix C) incorporated questions that emerged over
eight years from this authors observations, as well as from students, faculty, and survey
questions found in the literature, such as did you have any health consequences from
This survey was two pages double-sided, and designed to included four
categories of questions. In addition to asking for basic demographic information, broad
variables considered were reasons for going, factors they considered of value (asked
several different ways), and procedures and skills improved. Interpretation of the
variable data will follow the sequence of the survey sections. That is, the interpretation
will look at (1) Demographicsage, sex and date of graduation; (2) Background
(where they went and why); (3) Rotation details (what specialty they chose for credit,
what they considered of value, diseases encountered, and procedures developed or
improved); and (4) Assessment and Implications (how it affected career choice, how
valuable in it was in their current practice of medicine, health consequences, and
Key questions regarding reasons for going and perceived value were structured
to allow for both confirming and disconfirming responses. That is, the survey had
choices for value received, and for no value received. Finally, respondents were
asked do you believe that your international rotation will make you a better physician?
Enclosed in the survey was a personalized cover letter (Appendix D) with
handwritten notes thanking them in advance for their support. Each mailing included a
self-addressed, stamped envelope for their convenience in returning the surveys. Three
sets of mailings were done and the return date was changed for each set of cover letters
mailed. All respondents had seven (7) days to return their survey, but generous
extensions were allowed and second surveys were mailed when necessary.
Thereafter, graduates were tracked by telephone calls. When a letter was
returned "address unknown, or had another address, every attempt was made to resend
and/or contact that individual by telephone. Fortunately, several graduates had
information about one another which could be tracked. Graduates were eager and
willing to provide information for this project, which facilitated the process of
contacting graduates. An extra copy of each survey response was made and kept in a
secure place in the unfortunate event that the survey responses were lost or destroyed.
4. Summary of Findings
Sixty-eight graduates responded to the questionnaire. This represents a ninety
percent (90%) response rate. Results were compiled with the help of a commercial
database software. Non-narrative responses were coded appropriate to each question.
Narrative responses were usually summarized; several were quoted.
4.1 Demographics (Questions 1-4)
The average age of these 68 graduates is 30.8 years. Of that, 27 (40%) are
female and 41 (60%) are male. Numbers of participating graduates and years of
graduation follow in the Table 4.1.
Table 4.1 Number of Respondents by Year of Graduation
Year of Graduation
Although these approximate a slight bell curve, there is no known reason for
this appearance. Of the responses to date, 14 (21%) deferred graduation and graduated
either in August, following the May graduation of their classmates, the following
December, or the following year. Only one student deferred graduation 12 months.
4.2 Background (Questions 5-7)
On their rotations, these graduates went to 34 different countries over the 1990-
1996 time period. Most of them visited a clinic setting but this can be defined variably;
that is, sometimes the clinic had a staff of three, sometimes 20, so I simply accepted
their interpretation of clinic. Several went to both a clinic and hospital setting.
The graduates reasons for selecting their particular site, survey question #6, is
varied and includes everything from because it was recommended to I had always
wanted to do that. Table 4.2 represents frequencies of response.
Those that received only one mention included: found the site information in
the MSIP files, there were known collaborators there, program offered financial
Table 4.2 Reasons for Selecting Site and Country
Stated Reason Responses
Love of that particular culture, region, or setting 24
Knew someone there 21
Language constraint 16
Specific research projects, specialty, or clinic type 11
Wanted to go there 10
Recommendation or school presentation 7
Established program (Jamaica) 7
Rural setting 6
Wanted to see third world setting 5
Timing, timeliness of response or arrangements 5
Through other schools or programs (AZ, UCSF, etc.) 4
See different system of medicine or health care 4
To see certain disease; e.g., tropical 3
Lived or visited there or family members lived or trained there 3
Country amidst dramatic change 2
Diversity of country, issues 2
Help was needed in that country. 2
Received grant or financial help (AMSA, MAP) 2
assistance, help was needed in that country, wanted to visit a particular indigenous
population, environmental health opportunity, and opportunities for active medical
practice. The top four reasons, then, were specific in nature: desire to see that specific
culture, person, language or specialty.
Question #7 asked about reasons for going on a rotation, as distinct from the
above, which asked for reasons they selected a particular site. This question asked them
to please rank your 5 most important reasons for going, with l=first and 5=fifth.
Among the top five reasons are intentions to broaden perspectives of medicine, culture,
disease or language; to repeat positive experience of international travel; and to satisfy
cultural curiosity or something they always wanted to do. This is summarized in Table
4.3. The responses represent frequency of responses, not numbers of persons. Four of
Table 4.3 Ranked Reasons for Going on an
International Medical Rotation
Broaden perspectives/medicine/culture/health systems
Had been overseas before and found valuable
To see disease not often seen in the United States
Have always wanted to do this
Interest in primary care
Wanted to trek/hike but mostly for international health
Other students inspired me
Prepare for career in specialty area
Study particular population or disease
Wanted to take a break
Useful for Residency resume
these reasons for going on a rotation reinforce reasons for choosing a specific site:
specific culture, language, disease or different medical system.
Unexpectedly few went due to recommendations, to study a particular disease,
to take a break, or for an expressed interest in primary care. The group that had been
overseas before had a strong predisposition to go on an overseas rotation. Recreational
pursuits were a secondary rationale; for fun was ranked fourth or fifth by most
students who chose it as a reason for going. The number of students and the relative
rank they assigned each rationale is tabulated in Table 4.4.
Table 4.4 Ranked Reasons for Participating in International Medical Rotation
Had been overseas before and found
Interest in primary health care
See diseases not often seen in USA
Prepare for career in specialty area
To trek/hike, but mostly for
Study particular population or disease
Other students inspired me
Always wanted to do this
Useful for residency or resume
Wanted to take break
Number of students and their
rank for each rationale
#1 #2 #3 #4 #5
12 7 10 6 5
15 7 7 10 5
2 0 2 1 1
2 5 4 4 3
3 8 4 9 7
5 0 0 1 1
1 3 3 1 4
0 2 0 1 2
1 2 1 1 4
1 4 11 4 8
5 5 4 10 6
0 0 1 1 0
1 3 2 10 11
15 17 16 7 3
0 1 0 0 2
5 4 2 1 1
4.3 The Rotation (Questions 8-13)
Most of the 68 respondents (34, 50%) went for Family Medicine elective credit.
Credit was also received for Internal Medicine rotations (10,15%), miscellaneous
unclassified specialties (21, 31%) such as Preventive Medicine, Surgery and Emergency
Medicine (5, 7%), Pediatrics (1) and Research (1).
The average rotation time was 8.6 weeks, with a minimum of just over three
weeks to a maximum of 52 weeks, where the student visited five sites with three for
Question #10 directly addressed value. It asked what do you consider of value
that you learned from your rotation? Among the responses, most confirmed the
hypothesis, as seen in Table 4.4 in rank order. A few responses not consistent with the
hypothesis are listed in Table 4.5 in rank order.
Table 4.5 What Was of Value?
Survey question Responses
Learned more about other health systems 58
Learned diversity of views about disease & cause 48
Developed more sensitivity to cultural perspective 48
Learned to diagnose illness with few resources 41
Learned to treat and manage without tertiary care 38
Practiced language 32
Became more creative in problem solving 32
Table 4.6 What Was Not of Value?
Survey question Responses
Not sure what value I got from rotation 2
Got much less value than expected 2
Didnt get any value out of it 0
There is some similarity between the reasons for going as discussed in questions
6 and 7. For example, these similar reasons include broadening of perspectives and
sensitivities to other cultures, medical systems, diversity of populations and diseases and
the practice of a second language. However, a vital new component is ranked highly:
learning to diagnose with few resources, learning to treat without tertiary care and
expanded creativity in problem-solving. Not only were some of the graduates key
expectations apparendy met, but this kind of on-site learning (diagnosing with few
resources and creative problem-solving) could have positive implications for their future
practice of medicine.
4.4 Diseases and Conditions Observed
When asked what diseases or conditions they encountered that they had not
previously seen, the responses were numerous and varied. Included were (1) infectious
diseases, (2) vector-borne diseases, (3) congenital diseases, (4) non-infectious illnesses,
(5) injuries/trauma, (6) malnutrition and related conditions, and (7) other. These are
summarized in Table 4.7 beginning on the next page.
Conditions encountered that related to scarce resources included dirty hospitals
with no sheets or running water, power outages, terrible conditions, systems in which
patients are required to purchase own medications, primitive conditions and a
desperate lack of resources. In addition, students reported conditions where they saw
a huge gap in societal resources reflecting various treatment patients received at
Diseases and Related Conditions Observed by Respondents
AIDS in heterosexuals
Hansons disease (leprosy)
Many sexually-transmitted diseases
Many skin infections
Multiple types of parasitosis
Neonatal & adult tetanus
Third degree syphillis
Tuberculosis, resistant tuberculosis & pulmonary tuberculosis
Dengue (hemorraghic) fever
Chromosome 13 pregnancy carried to term
Familial Mediterranean fever
Genetic abnormalities in prenatal diagnosis
Secondary congenital heart disease
Brights disease (nephrotic syndrome)
Table 4.7 (Continued) Diseases and Related Conditions
Observed by Respondents
Non-infectious diseases (continued) Groin abscess intractable myoclonus Lot of cholecystitis of pregnancy & complicated OB/GYN Lupus neuropathy Poisoning: organophosphate & typhoid Portal vein thrombosis Ruptured intestine Transverse myelitis Tropical ulcers Tuberons sclerosis
Injuries and trauma Turners syndrome Extensive trauma Battery acid bums to face Septic abortions Snake bites & crocodile bites
Malnutrition and related conditions Stabbings War injuries 30% mortality rate in site area Extreme dehydration with death of milliary children Malnutrition: kwashiorkor and marasmus Rickets Severe anemia
Other observations Almost everything was new since this was my first clinical experience. Reyes syndrome The natural course of many common illnesses such as wound infections and pneumonia
hospitals. This observation led several graduates to comment on the connections
between wealth and health outcome.
Graduates reported that they encountered conditions related to diverse medical
systems; for example, one graduate reported seeing an effective community-oriented
primary care in populations where I didnt expect. In addition, they reported social
medicine & much less advanced forms of medicine than seen in the United States, and
diseases that are culturally specific, even in countries that we think have similar medical
systems, like hook worm Kreislaufstorung. In Germany, this term refers to blood
Question #12 asked if students felt prepared for their rotation. Most (51, 77%)
graduates felt that they had been prepared for their international rotation. However, in
nearly all cases where they indicated that they were not prepared, they made notations
such as there is no preparation for this sort of experience, that they could have
studied and practiced their second language more before leaving for their rotation, and
I was not prepared for (such) disrespectful treatment against indigent women.
Another key question, #13, asked what procedures and/or skills did you
improve or develop as a result of this international rotation? The percentage of
students responding yes to each of several questions is presented in Table 4.6. The first
five items in this table reflect the confirming value and the last two- items in the table
reflect the disconfirming value.
Of the responses to date, no skills improved received only 8 affirmative, and
dont and know which skills improved received only one affirmative response. Low
scores for surgical skills was predictable since most of the rotations were not surgical
electives, and since most of the surgery practiced was simple suturing and laceration
repairs. However, some graduates performed more complex surgery. One reported
that he delivered babies, cut off legs, debrided wounds, fixed cleft lip and eye
problems, and learned dental procedures.
Table 4.8 Respondents Reporting Skills Improved Due to Rotation
Skills improved for History and Physicals 44%
Skills improved for Differential Diagnoses 51%
Improvement in Problem Solving skills 59%
Improvement in Surgical skills 38%
Improvement in any of the above four skills 88%
No skills improved 12%
Dont know how skills improved 1%
4.5 Assessment and Implications (Questions 14-23)
Most did not defer graduation (79%) to participate in an overseas elective. Of
the fourteen (21%) who did, 86% thought that the extra time was worth it. When asked
in question #16 if the rotation affected their career choice, 21 responded yes and 40
(66%) responded no. Most noted that the rotation simply confirmed,
strengthened, increased interest in or clarified their previous career choice, and
the rotation gave them tangible evidence to proceed with that choice. One of the two
graduates who did basic research (as opposed to a clinical elective) stated that It
impressed upon me the tremendous value of participating in the international research
community. Reaffirmed (my) desire for academic medicine.
In answer to question #17, To what degree do you believe that your
international health rotation has been valuable to you in your practice of medicine?
responses averaged 5.9 degrees of value on a 1-7 scale, with a minimum of 3 and a
maximum of 7.
Question number 18 asked If yes, can you describe the most important effect?
Responses were voluminous. Instead of presenting an exhaustive summary or
recitation, we summarized from a representative selection of comments drawn equally
from male and female graduates. These graduates responded that the overseas
experiences broadened their perspectives on how to interact with patients, expanded
their awareness of other health care systems, and gave them fresh perspective on the
American health care system. Several noted that these experiences gave them an
injection of enthusiasm or fresh outlook into clinical medicine. In that regard, several
reported on the wastefulness of health resource allocation in the United States. They
also noted that they developed skills in diagnosing and treating patients with scarce
Further, graduates reported that they learned different approaches to medical
problems. One aspect of this was their appreciation of the opportunity to learn and
practice a second or third language. Also related to learning different approaches,
several graduates noted that they learned to see the practice of medicine from a patients
perspective, and from patient(s) non-traditional (in the sense of non-western) ideas
about source(s) and symptoms of their own condition. Finally, graduates reported that
their increased appreciation of available American health care resources was a result of
going overseas and being able to compare resources. Finally, two graduates felt that
their overseas rotations contributed to them securing the Residency placement of their
Question number 19 asked if graduates had personal health consequences, and
19 did (28%). Of those who did, most reported travelers diarrhea, mild cases of
malaria, cholera, worms, and/or fever. Two graduates had consequences of concern or
potential concern. One had severe falsiparin malaria in Africa andbecause he
fortunately had emergency insurancehad himself flown to London. There, he
presented for emergency treatment and contacted his family who made further
arrangements. This case is the only known severe case of personal health consequences
in seven years. The other graduate who had a potential serious health consequence was
stuck with a needle in an active positive HIV patient setting. Three years later, she
reports no signs of positive HIV infection. No known permanent consequences have
resulted from any of these rotations.
Question #20 asked if the graduates would recommend an international rotation
to medical students, and 100% responded affirmatively. Several emphasized their
answer with exclamation points. When asked in question #21 if they thought a
transcultural or multicultural Colorado community elective should be required, 32%
responded yes, 43% with no with 24% uncertain or no response. Two did not
check an answer but responded I hope so, and elaborated; one stated that he felt it
was too early to tell.
Question #22 was another key question to assist us in determining value: In
summary, do you believe that your international rotation will make you a better
physician? Respondents overwhelmingly (94%) responded affirmatively.
Methodology for summarizing responses was in the same manner as in number 18,
above. Graduates reported overwhelmingly that their overseas rotation experiences
contributed positively and were contributing to the quality of their physicianship.
Specifically, these graduates noted that their experience fostered a basic character
change that I feel broadens my perspective and clinical intuition, informed their
problem-solving skills, and taught compassion.. Importantly, several had insights into
how socio-economic status affects health care. In different ways, several graduates
described howin a setting with scarce resources, no phones, electricity or the
comforts of homeshe had to learn to think.
The final question (#23) asked for comments and suggestions for future student
rotations. Again, methodology was identical to that for question numbers 18 and 22,
above. Graduate comments included their opinion that future students should read up
on the geographic site of choice, practice their second-language medical terminology,
and go for as long as possible. One graduate noted that international work is fraught
with uncertainties, and that future students must allow for this. Another graduate noted
that experience with other health modalities is essential, and that this familiarity will
be helpful considering that 80% of the USA patients use complementary medicine.
Graduate suggestions included recommendations to keep a daily journal, prepare
early, take medical manuals on the rotation, practice suturing in advance and read up on
obstetrics and gynecology. Finally, graduates suggested that future students should just
do it, that these rotations should continue to be encouraged, and that students should
maintain humility with regard to what you can do in the worlds perspective.
4.6 Research Interpretation
An overview of the work performed indicates that CU School of Medicine
students derived clear value from their international health rotations taken between 1990
- 1996 inclusive, and the data is rich enough to encourage further study. The following
looks at the interpretation of that statement and specific findings.
This is the first time this data has been collected at the University of Colorado
School of Medicine. It was important to collect basic information as well as value-
oriented information without having a survey that was overwhelmingly long. No
graduates identified serious omissions or oversights in the surveys subject matter or
Based on this authors casual conversations with medical students over the past
nine years, the medical student responses for why they wanted to go overseas, and
responses regarding the kinds of rotations they chose were expected. Similarly,
responses from those who deferred graduation and felt it was worth it were expected.
Finally, it was expected that graduates would state that their international rotations will
make them a better physician.
However, there were several unexpected responses. The first was the number
of countries visitedone fourth of the countries on earth! (UNICEF, 1995) The
responses to most questions were clearer than expected; that is, there were fewer dont
knows than expected. The graduates seemed not only clear about what they wanted,
but also seemed clear about the value they received. They also had solid
recommendations for the Medical Student International Program that can be
incorporated into the program. For example, there are already activities in motion to
improve academic preparatory training and to fund scholarships.
Given the numerous diseases encountered and treated, it was unexpected to find
that these graduates had no known permanent health consequences. This may reflect
their vigilance, their skill, their caution, their wisdom or all of the above. The simple
fact that they are safe and knew instinctively or, in fact, how to maintain their safety in
complex cultural environments endorses the quality of character of our medical students
and our medical education at some level. It also underscores the importance of
continuing to keep students safe overseas as we continue to expand international
Regarding reasons for going (#7), the reason that was barely mentioned was
financial assistance. Six students had major AMSA grants and one had a MAP
fellowship. In addition, several had financial support from family members and church
groups; none of these were mentioned. The lack of or the luxury of funding did not
seem to matter much; their focus was on other aspects of their experience. On the
other hand, one graduate was emphatic about the need for more than inconsequential
few hundred dollars appropriated by the School of Medicine for these activities. As
mentioned above, scholarship funding is in motion.
To see that 32% of the respondents felt a domestic, rural rotation should be
required was quite unexpected, since we did not think that the graduates would support
any additional requirement, regardless of how noble it might be. These graduates were
emphatic that we should not require an overseas rotation and that forcing students to
do this would be inappropriate for both some students and populations served. Two
graduates emphasized that they felt it would make some students angry. However,
the graduates saw clear value in requiring the rural rotations for many of the same
reasons they valued their overseas rotations (for example, to broaden perspectives, learn
about other medical and belief systems, and to learn and practice Spanish). There were
24% who said they did not know. The balance of the graduates recommended that
rural rotations not be required.
When graduates ranked reasons for going, the reason that ranked highest for
first, second and third choices was to broaden perspectives: medical, cultural or health
systems. This strong response is heartening in light of the presumed medical intent of
these rotations, as opposed to a possible responses of have fun, or take a break.
In this thesis, we looked at empirical studies performed and literature written in
areas related to the research question. There are few empirical studies and virtually none
that address the specific, self-reported value gained through an international rotation by
the graduate themselves. Most studies address preparatory curriculum, exchanges or
quantitative surveys (how many schools have courses in international health).
Therefore, this thesis provided a small building block in the literature that deals with the
value of international health rotations for medical students. We believe that similar,
specific studies could (and hopefully, will) be done to illuminate further specific student
population responses in the United States. We may discover that this study can be
generalized to a larger population and this could possibly be valuable for discussions on
From the work done, what can be concluded when we now ask What was the
value of an international health rotation for medical students who took elective credit at
the University of Colorado School of Medicine from 1990-1996 inclusive, and what are
the possible implications for their practice of medicine?
The emerging hypothesis is that there is value for medical students at the
University of Colorado to participate in international health elective rotations because it
gives them perspective on other cultural, disease and health systems. In addition, it
allows them to improve their language skills and other skillshistory and physical,
problem-solving, differential diagnoses, although not in an unequivocal wayand it
does not result in any major education deficits or personal safety sacrifices. Based on
the very positive response to do you recommend (100%) and do you believe that your
international rotation will make you a better physician? We believe that this study was
not only needed but necessary for future study of the impact of these rotations on the
quality of physicianship.
Since the question of value was paramount, the four questions that asked
specifically about value must be reiterated. That is, question numbers 10,17,18 and 22
dealt directly with this issue and looked at value from several different directions. Given
the unequivocal nature of the responses, we feel that we can build from this research.
Since these 68 graduates visited 34 countries, we believe that this survey
represents a good sampling of international health rotations, mostly in developing
countries but also in developed countries. It must be stated again that these students
self-select to go on these rotations, that they do so with considerable self-motivation,
and that some of them defer graduation in order to go overseas.
From the results, then, what can we conclude about how these results either
support or contradict the current literature on this topic? In the sense that students as a
whole did not feel academically well prepared and had some recommendations
(although recall that several felt there was no academic preparation for one of these
rotations), this thesis is consistent with the literature in the need to better prepare
medical students academically for overseas rotations. In our spring, 1997 planned
offering of an international health elective, the CU School of Medicine is attempting to
close some of this gap a bit.
In addition to the questions asked, graduates gave us some valuable input to
consider. For example, several reported responses are consistent with Carl Taylors
evaluation in Chapter One of this thesis: that international medicine allows medical
students to see the causal chain of disease where preventive treatment is not used as
intervention. In this way, students observe the continuity, the natural course of
diseaseallowing the pathophysiology of medicine to be more apparent for learning
purposes. Did these rotations build new conceptual frameworks from which to leam
and practice medicine as Carl Taylor suggested? In order to answer this satisfactorily, it
would be useful to do further study with this cohort when they have completed their
Certainly, international medicine supports medical students to learn aspects of
primary care and community oriented primary care. Because of the increased funding
and national recommendations in the direction of training more primary care physicians
in the United States, it seems apparent that international medicine gives medical
students a certain edge in this regard.
Although the graduates did not report their experiences in these words, one
conclusion is that they gained perspective of global disease. In their words, they saw
new relationships of disease and socio-economic factors as they relate to health. Being
overwhelmedone graduates wordby these realizations can have major
implications. They may have been overwhelmed from time to time, but these
individuals are now aware of the vast disproportionate allocation of resources, of the
fact that the majority of the world does not have access to sufficient health care, and
theyve hopefully come full circle to gain broader perspective on their own quality
training. Some will no doubt extrapolate this to broaden their sense of social
responsibility. This category of comment reflects the moral imperative distinction
mentioned in Chapter Two.
In terms of specific diseases, several graduates noted that they saw some degree
of manifestation of tuberculosis. With this disease on the rise in the United States, it is
valuable for students to see and learn the symptoms of and treatment for tuberculosis.
Finally, it is important to note that, in self-selecting these rotations, medical
students might give up other opportunities. However, most rotations are taken in
fourth year, which is almost entirely Residency interviewing, elective and vacation time.
No core requirements are replaced by students taking these rotations because CU
medical students are required to take their core requirements in the state of Colorado.
In other words, no value has been reported as lost because students chose to take
these rotations instead of selecting another way to spend a comparable portion of their
fourth-year time. Since 86% of the students who deferred graduation reported that it
was worth doing, we do not believe that these international rotations have a negative
cost in terms of the quality or continuity of their medical education.
5.1 Possible Implications for Practice of Medicine
Based on the responses above, these overseas experiences broadened their
compassion and humanity; in short, these international rotations strengthened skills
needed to become better physicians. Possibly, these skills can be generalized to
strengthen additional skills, such as learning the importance of patients belief systems,
specifically as they relate to perception of disease etiologies.
There was a singular graduate comment that stood out and brought the
discussion of international health back home. This graduate reported the following;
Learning to diagnose illness/disease with few resources was one of the
prime reasons I went, but found that we have a reliance on technology
partly because it helps get the right (respondents emphasis) diagnosis.
Much of my regret for how third world medicine is practiced has waned
and I realize that they are doing the best they can with limited resources
and have a lot to teach us, but much of the medicine practiced is very
(again, respondents emphasis) shoddy. I say this after many years of
experience doing this stuff. Even now in the northern Mariana Islands I
can say the same thing.
There are implications for graduates long-term practice of medicine in learning
to balance primary care training with sophisticated testing and not rely too heavily on
the latter. For example, several graduates mentioned that they learned more about how
to diagnose with only history and physical and how to problem-solve with few or
limited resources. These abilities could have implications for future medical cost
containment. Since some of these graduates developed alternatives to expensive test-
related patient evaluation, this kind of training may help medical educators and
practitioners learn to contain some health costs. These impacts could help us bring
international health care home. At this point, it is impossible to predict exactly how or
to what degree, but it is a valid topic for future study.
Some graduates reported that a four-week immersion in a culture barely
scratches the surface and may not contribute much other than emergency support. By
giving intense pre-rotation academic training with various learning exercises, it is
believed that students will be able to hit the track running and both give and receive
increased value for their time spent. The implication would be that perhaps more time
overseas contributes more value to both student and population.
Awareness of the value of international medicine has impact on the foreign aid
of the United States and, as such, is also good business. The challenge is to be aware
that a win/win is possible both in the moral imperative of international health and in
the economics of it, but the challenge is far from being met. Once a physician is aware
of the above, and of the criticality of sharing and conserving health resources, a
profound learning has occurred. The physician can then become one of the teachers.
5.2 Recommendations for Longitudinal Study
We recommend that this study be considered a baseline study at the University
of Colorado School of Medicine. Using this study as a baseline, we recommend a five-
year longitudinal study with more in-depth, specific questions related to the impact(s) of
international medicine experience on the practice of medicine in Residency and beyond.
Of our current cohort, 28 (41%) requested a copy of our study. Numerous graduates in
this current cohort expressed a willingness to participate and/or assist in a further study.
The issue of doing a lot with limited resources came up again and again. Since
the issue of cost containment is and will no doubt continue to be paramount in health
care circles for at least the next decade, we recommend that a study look at how
problem-solving skills and history and physical skills could contribute specifically to cost
containment for health care in the United States. This will require sophisticated
quantitative studies, and may reveal valuable results that have implications for health
Further study to encourage longer-term rotations to benefit both the in situ
population and the medical student is also recommended. The one student who spent
52 weeks overseas derived enormous value. At present, this physician is an
Otolaryngologist. He has designed his lifestyle to have sufficient income so that he can
take off several months each year, go overseas and perform pro bono cataract operations
for patients who have no access to this care. However, this physician had what most
students do not; he had funding, and had a very clear goal of doing international health
from the beginning of his medical school career. We can still learn from this physician
by staying in contact with him and following his work. He has volunteered to
participate in studies related to improvement and expansion of our international
A final recommendation is to do a pre- and post-study of students prior and
post international rotations. In this way, perhaps we can identify and measure specific
areaseither improved skill, perspective or additional positive impact(s)that result
from these experiences.
5.3 Final Summary
In the 1995 AMSA Project Summary, it is noted that there are impacts on the
individual, on medical education (the institution) and a wider impact. As with Carl
Taylors (Johns Hopkins) Sylvia Birds (Rochester) students and others, internationally
trained students develop a broader interest in the community, in public health and have
a wider view of health than those only trained in the western medical model. As AMSA
noted in the AMSA Final Summary Report (1994):
In early 1993, U.S. AID launched an initiative to bring lessons learned
overseas back to the United States, and one of the areas mentioned by
the U.S. officials as being vital was health care. In general the existence
of programs like the AMSA program have had a small part in the larger
wave of realization that our future medical professional will require
increased international understanding (p. 13).
Not only students benefit. The impact is much broader. As a representative
from any medical school that has participated in an international program or
collaboration will report, faculty, students, staff and community are altered, usually
positively, by the experience. Although these programs do bring additional stress upon
the workload and existing demands of academia, the satisfactions are great and the
networks broadened. Collaborations beget collaborations and cultural/medical
awareness begets the same.
Future directions? This area is not necessarily rich soil for quantitative analysis
in the same way that one can calculate health department statistics, because of the
complex web of cross-cultural issues involved. However, the soil is rich for research in
this area that is carefully conceived and thoughtful in its approach.
Our hope is that, in some small way, this thesis will help build a scaffolding so
that we as medical educators can engage in recommended studies, develop the potential
of these international health rotations, and apply that learning to health care at home
Appendix A. Kerr Whites Box
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Appendix B. International Health Forum Schedule
INTERNATIONAL HEALTH FORUM
WARD DARLEY READING ROOM, #1832
The International Health Forum is an informal gathering of students, faculty, staff and
medical community members interested in international health care. Presentations are
usually given with slides, about a recent medical rotation in an international (usually
developing country) setting.
WEDNESDAYS, NOON -1 P.M.
BRING YOUR SACK LUNCH AND BRING A FRIEND
9/18/96 Introduction to the Medical Student International Program:
Opportunities, Guidelines, and ResourcesCandice Miller
9/25/96 Rural Family Health Care at a Clinic in Pachacan, BelizeBruce Evans,
10/2/96 Community Medicine on the Onzole River of Ecuador-Cal Wilson, MD
10/9/96 General Medicine at The Glasgow Royal Infirmary, ScotlandFran
10/16/96 Pediatrics in Hospital Para Nina Poblano in Puebla, MexicoDavid
10/23/96 Matoso Clinic in Kenya: An Experiment in Sustainability &
ReplicabilityRobert Roark, CHA/PA
10/30/96 Chinese Medicine & Pediatrics at Xin Ahong Yi Yi Yuan, the New
Medicine Hospital, at Jing Sha in Hubei, ChinaAbby Bleistein, MSIV
11/11/96 Special Guest Speaker, Cynthia Haq, MD, faculty advisor for AMSA
International Fellowship Program and faculty, University of Wisconsin at
Madison. 21st Century Medicine: Bringing International Health Back
Home. Sponsored in part by a mini-grant from the Graduate School.
Pizza will be served.
Appendix C. Survey Questionnaire
July 1, 1996
INTERNATIONAL ROTATIONS: MEDICAL STUDENT SURVEY
University of Colorado Health Sciences Center
School of Medicine
Because you went on an international health elective during your medical school career
here at HSC, you were chosen to participate in this study. We wish to learn whether or
not an international health elective adds value to the practice of medicine. Your
participation in this study is important to help us assess what value, if any, 1990-96
international rotations had for HSC medical students. Would you please complete this
brief questionnaire within 7 days and return it to me in the enclosed self-addressed,
stamped envelope? To ensure confidentiality, results will only be reported in the
If you would like a brief summary of the results when you complete this questionnaire,
please check here:_________and provide your address. If you have any questions, or
would prefer to complete this study by telephone or email, my telephone is 303-270-
8262 and I will make arrangements to call you back. My email is:
I Please write in
1. Your name:___________________________________________________________
2. Present age:_______________________________.
3. Sex: F_____M_____
4. Date of graduation (please specify month and year):__________________
5. Where did you go?
5b) city, town or village___________________________________________
6. Why did you select this particular country(ies) and site(s)?
7. Please rank order your 5 most important reasons for going; (l=first, 5=fifth)
7a) _____cultural curiosity
7b) _____had been overseas before and found it valuable
7d) _____interest in primary health care
7e) _______see diseases not often seen in USA
7f) _____prepare for career in specialty area
7g) _____wanted to trek/hike, but primarily went for international health elective
7h) _____wanted to study a particular population or disease
7i) _____other students inspired me
7j) _____learn/practice language
7k) _____have always wanted to do this
71) _____useful for residency resume
7m) _______for fun
7n) _____broaden perspectives: medical/cultural/health systems
7o) _____wanted to take a break
7p) _____other; please specify:___________________
III The Rotation
8. In which specialty did you receive elective credit?
8a) _____Family Medicine
8c) _____Surgery (ER)
8d) _____Internal Medicine
8e) _____Other; please specify
9. For how many weeks were you on your clinical rotation?________weeks
10. What do you consider of value that you learned on your rotation:
10a) ______learned diversity of views about disease and disease causation
10b) ______developed more sensitivity about cultural perspectives
10c) ______practiced my Spanish or other language (write in_____________________)
lOd) ______learned to diagnose illness/disease with few resources
lOe) ______learned to treat and manage without tertiary care advantages
lOf) ______became more creative in problem-solving
lOg) ______learned about other health systems/cost structures
lOh) ______not sure what value I got from my international rotation
lOi) ______got much less value than I expected
lOj) ______didnt get any value out of it
11. Please describe diseases or conditions that you encountered, that you had not seen
12. Do you feel that you were well prepared for this rotation? Yes__ No______
12a) If not, please explain what preparation you needed.
13. What procedures and/or skills did you improve or develop as a result of this
13a) ______ability to do history and physical
13b) ______ability to develop differential diagnoses
13c) ______strengthened problem-solving skills. Please describe:
13d) ______developed surgical skills. Please describe:
13e) ______did not improve any diagnostic or procedural skills.
13f) ______dont know
IV Assessment and Implications
14. Did you defer your graduation to participate in this rotation? Yes__No______
15. If yes, was the extra time worth it? Yes__ No______ Dont know______
16. Did this rotation affect your medical career choice? Yes____ No_______
16a) If yes, how?
17. To what degree do you believe that your international health rotation has been
valuable to you in your practice of medicine? (please circle)
1 2 3 4 5 6 7
not at all very much
18. If yes, can you describe the most important effect?
19. Did you have any personal health consequences from the rotation? Yes_____No_____
20. Would you recommend an international rotation to medical students?
Yes____ No_________ Dont know________
21. Do you think that a transcultural or multicultural Colorado community elective
should be required for medical students? (eg, San Luis Valley, western slope, etc.)
Yes______ No________ Dont know_________ Please explain:
22. In summary, do you believe that your international rotation will make you a better
physician? Yes__________ No_______ Dont know_________ Please explain:
23. Do you have any additional comments or suggestions to offer that will be helpful to
us as we prepare students for these rotations or offer new ones?
Thank you for participating in this survey. Your input is appreciated!
Appendix D. Survey Cover Letter
As a participant in the Medical Student International Program at the University of
Colorado School of Medicine in the past six years, your timely feedback to the enclosed
survey is very important to the success of my Masters Thesis. These data will be used
in my thesis and will be kept on file with the Medical Student International Program for
future students use.
I am surveying all University of Colorado medical students who went on a Course Work
Away rotation outside the United States from 1990 through and including 1996, who
received elective credit. This information will be kept confidential and anonymous, and
reported in the aggregate. Since I worked personally with each one of you, I am very
interested in your responses.
Every response counts. Would you please complete this and return to me by October
11, 1996? Should you have any questions, please do not hesitate to contact me at 303-
Thank you in advance for helping me study the value of an international rotation for
medical students and for their practice of medicine. Best regards to you; I hope your
medical career is going well.
Candice L. Miller
Medical Student International Program
University of Colorado School of Medicine
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