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Learning without borders: Med students take on the world

More U.S. medical schools are offering overseas clerkships, and students are eager to go.

By Myrle Croasdale, AMNews staff. March 12, 2007.

They bounced along the rutted road to Eldoret, Kenya, with their patient lying across the SUV's backseat. One team member carried the woman, Ann, who was wasted from AIDS, into the emergency department. It was 2004, and Sonali Sakaria, MD, then a fourth-year medical student from Indiana University School of Medicine, walked alongside. She tried to not gag on the stink of feces.

Medicine in a developing nation brings a host of unexpected sights and smells, as well as more significant challenges, such as limited access to diagnostic tools like x-rays. But for medical students, a two-month stint in a developing nation can be the highlight of their training.

With this article   Getting ready to go   Global classrooms offer mutual benefits

"The patients were so appreciative," said Dr. Sakaria, now a second-year internal medicine resident at Emory University School of Medicine in Atlanta. "They made you feel proud to be in medicine."

U.S. medical schools such as Indiana University are making significant contributions to health care worldwide and in the process are giving medical students, residents and practicing physicians the chance to benefit personally and professionally as they share their expertise.

Ninety-six medical schools among the 125 members of the Assn. of American Medical Colleges offer medical students elective international rotations. At least half of the 23 osteopathic schools have overseas training. Data from past years are scarce, but anecdotally medical education leaders said there has been rapid growth in such alliances in the past decade.

Most of these relationships are philanthropic, like the IU-Kenya Partnership. A few are profit-oriented. Regardless, U.S. medical students are interested. Nearly 39% of U.S. medical students studied in other countries in 2002, according to the latest data from the AAMC, up sharply from 20% in 2000 and 6% in 1982.

"The students recognize that it's a very small world we're working in," said M. Brownell Anderson, the AAMC's senior associate vice president of medical education.

The experiences deepen students' sense of altruism and compassion, broaden understanding of public health, increase cultural competence and heighten awareness of the importance of communication. It also leaves them more open to volunteering in underserved communities, according to "Expanding the Boundaries of Medical Education: Evidence for Cross-Cultural Exchanges," a review of 42 studies of cross-cultural medical experiences in the Oct. 2003 supplement of Academic Medicine.

Dr. Sakaria's medical mission influenced her career choice. She selected a residency at Emory because of its strong infectious disease department and connections with the Centers for Disease Control and Prevention.

Empowering others

U.S. medical educators want to cultivate responses similar to Dr. Sakaria's, said Robert Einterz, MD, associate dean of the IU-Kenya Partnership. To create meaningful experiences for U.S. medicals students, there has to be a meaningful partnership with the other country, he said.

Indiana's effort began with four physicians who had worked in developing countries and wanted to find a way for others to have similar experiences. They also wanted a venture that would have an ongoing payoff for the physicians and the people of Kenya.

"We wanted to put the Kenyans in front: promote their writing skills, diagnosis skills; link them with the infectious disease subspecialists to develop content; and find ways to use the funds we were attracting to bolster their salaries so they wouldn't get sucked away to the United States or to international organizations in Nairobi," Dr. Einterz said.

In 1989, using funds from Indiana's internal medicine faculty, they helped start the Moi University School of Medicine in Eldoret. Today the school, one of two medical schools in the country, produces 60 to 100 Kenyan physicians a year.

The medical campus includes the Moi Teaching and Referral Hospital and 18 rural clinics in western Kenya.

The enterprise also includes job training and micro loans to promote income security. A nutritional arm feeds 30,000 people a week through a food program, and the partnership owns four farms that yield 10 tons of fresh produce a week. "We are Hoosiers, after all," Dr. Einterz joked.

In addition to exchanging faculty and students, the University of Michigan Medical School is revamping the medical curriculum at eight leading medical schools in China. The goal is to establish uniform national standards.

David Stern, MD, PhD, Michigan Global Research, Education and Collaboration in Health director, is leading the project. He sees the work as part of making the world healthier.

"The West Nile virus didn't take very long to go from the West Nile to the United States," Dr. Stern said. "If we don't help them address their health problems, they could become ours. We have an obligation to help."

Tackling the funding issue

Money to pay for global health initiatives, however, is proving to be scarce. Dr. Stern described the curriculum work in China as "budget neutral" and financing for smaller projects as "on a shoestring."

While cash can be a barrier for patients seeking care in developing nations, it also can be a barrier for U.S. physicians who want to provide care. Baylor College of Medicine in Houston has come up with a solution.

Mark Kline, MD, president of the Baylor College of Medicine International Pediatric AIDS Initiative, said that although their ultimate goal is to train physicians and other health care workers in Botswana, an estimated 100,000 children were expected to die of AIDS-related complications unless there were physicians on the ground immediately.

"I asked a lot of medical students and residents what it would take to get them to Africa," Dr. Kline said. "The student debt/loan issue was one of the principal barriers."

In response, Baylor has offered to pay off up to $40,000 in medical school debt for each year a physician commits to work in Botswana. With the pressure of debt eased, Baylor filled its physician slots for 2006 and 2007.

At the other end of the financial spectrum is the University of Pittsburgh Medical Center, which is making money as it works to improve the health of citizens in other countries.

"We've figured out to export what we do and provide exactly what we do on the ground overseas," said Chuck Bogosta, executive vice president of Strategic Business Initiatives at UPMC.

For example, Italy was sending a large percentage of its transplant patients to the United States at a cost of 175 million euros, Bogosta said. By paying UPMC 45 million euros to build a transplant center in Sicily and 90 million euros annually to run it, the Italian government has saved millions, Bogosta said. In addition, the profit margin for the university's overseas medical center has been "very good," he said.

"We are transferring technology and knowledge that they pay for that they couldn't get otherwise," Bogosta said.

Ultimately, UPMC officials want to train Italian medical professionals to run the center.

Although overseas relationships end, the impact often lasts a lifetime. It has for Dr. Sakaria.

Dr. Sakaria watched over the AIDS patient, Ann, during the woman's hospital stay. Ann was a skeleton in a wheelchair and needed lots of calories in addition to IV fluids and a regimen of antiretrovirals.

Dr. Sakaria dropped in between rounds, bringing Ann meals from the U.S. students' residence. She was there the day Ann started physical therapy and stood for the first time in weeks.

"Ann made me realize what I love about medicine and what I love about being a doctor," then medical student Dr. Sakaria wrote in a paper she turned in to her professors about the experience.

Ann and Dr. Sakaria exchanged e-mails, and the physician received pictures of Ann as she recovered. The last she heard Ann was doing great.

Dr. Sakaria may not return to Kenya, but she is hooked on international medical missions and plans to take time during her career to contribute to care overseas and to people like Ann.

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 ADDITIONAL INFORMATION: 

Global classrooms offer mutual benefits

Through partnerships with overseas facilities, U.S. medical schools are not only providing their own students with valuable experiences, they are also helping to develop services such as emergency systems and patient care centers in their host countries. Here are some of the international connections the schools have made.

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