INTRODUCTION

Intellectual exchanges are part of the fabric of clinical medicine and medical education. For centuries, medical students have traveled internationally in order to enhance their educational opportunities. In the nineteenth century, American students brought clinical and educational advances back to the United States (US) from Europe.1 More recently, students have come to the US to avail themselves of clinical and research advances as well as advances in pedagogy.

Much has been written about the experiences of North American and European medical students abroad. Nearly 30% of US medical students participate in international rotations, mostly to lower- and middle-income countries.2 Less has been published about international medical students coming to the US for clinical rotations. One study found that 20% of US schools with global health programs did not allow reciprocal exchanges, and many that do create barriers through prohibitive costs and fees.3 A survey of AAMC schools found that only 58% allowed international medical students for clinical rotations. Respondents cited strains on learning spaces, faculty capacity, and funding as limitations to visiting student programs.4 International host physicians and medical trainees feel that exchanges need to be bilateral partnerships5 and, similarly, Bleakley et al. argue that existing power structures of global health education need to be reexamined or they risk being seen as educational “neocolonialism”.6

Available information on international students in the US largely comes from administrators and course directors. Aligning with the data above, our medical school dean’s office has observed increasing difficulty in accommodating international student visitation requests. This study explored the thoughts of a representative sample of US attending physicians who interact with affected students on various clinical services. Findings were anticipated to enhance understanding of this sector of medical education and potential improvements to it.

METHODS

Our study was performed at two academic institutions in the United States, the University of Pittsburgh (Pitt) and the University of Minnesota (UMN). Pitt is a research-focused medical school in the Northeast, while UMN is more clinically focused and is in the Midwest. Both have large educational missions and regularly host international trainees.

We conducted two focus groups (FGs) at Pitt and one FG at UMN. Participants were recruited through email solicitation of clinician-educator faculty members to achieve representation from a range of clinical disciplines and career stages within each FG. Each FG consisted of seven to eight participants, was conducted virtually, and facilitated by a professional qualitative study support service that also performed verbatim transcription. Each participant provided consent and received a $30 gift card as compensation.

The initial question skeleton was created by two investigators (BH and ME) and edited by the FG facilitator. The six questions addressed participants’ relationships to the visiting international student experience together with their perceptions of its value and purpose, impact on institutional missions, and status and importance at the institution. Questions were open-ended (e.g., What do you think about the value of medical student rotations and hosting international medical students? What memories, if any, do you have of hosting international medical students?) and sometimes followed by probes into specific facets of the externship experience (e.g., What impact do international medical students have on education at your institution? Examples of probes were: What about the teaching experience? learning experience for your institution’s trainees? reactions of patients? clinical productivity?). After each FG, one investigator (BH) coded the transcript using open coding methodology and a second investigator (HT) reviewed the transcript and confirmed the codes. The third investigator (ME) also reviewed these data and adjudicated any disagreement between the other investigators. In an iterative manner, all investigators discussed emerging themes and enhancement of the question skeleton for the next FG. Specifically, the theme of the student’s experience and effects of their individual qualities on others emerged in FG #1 and was deliberately addressed in subsequent FGs. Three participants reviewed Table 2 and confirmed the themes.

All participants provided consent. Pitt’s Institutional Review Board approved the study.

RESULTS

All 22 participants were engaged in clinical practice and the teaching of US medical students, and specialized in internal medicine (general internal medicine and subspecialties), family medicine, pediatrics, emergency medicine, neurology, or surgery. The participants also represented diverse training backgrounds including in the US and internationally, differences in professional experience spanning decades, and included attending physicians who had and had not worked with international students. Table 1 contains further participant characteristics.

Table 1 Characteristics of Study Participants (n = 22)
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Themes emerging from the FGs, together with representative quotes, are in Table 2. The first main theme is administrative requirements for successful visiting international student externships. Participants described hosting international students as a significant endeavor requiring careful planning and coordination akin to that for their own trainees, and that such a commitment is daunting amidst demanding faculty responsibilities. Discussion paid attention to the experiences of the people directly involved in the clinical setting, leadership, communication, and personnel, physical, institutional, and financial resources. The other main theme is the impact of individual student qualities; intertwined with a differing educational foundation and linguistic and cultural distances, interpretation of visitor behaviors and other qualities may be magnified. While discussing the elements of a visiting clinical externship, FG participants described their heightened importance when working with international students due to increased student variability overall, inconsistent language and cultural fluency, and the consequent recognition of the student as an ambassador for their home institution and country.

Table 2 Focus Group Themes: Components of Visiting International Student Externships
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DISCUSSION

To our knowledge, this study is the first to explore visiting international medical student clinical externships in the US from the perspective of clinician-educator physicians who interact with this trainee population. The primary themes — administrative requirements for success and the impact of student qualities — do not naturally follow the FG questions which explored the externship’s value, purpose, and relationship to the institution. Matching their roles for their own institution and trainees, participants embraced the hosting of international trainees and commonly demonstrated a corresponding problem-solving mindset. For example, regarding the purpose of visiting international student externships, participant input included reframing of the topic: “The purpose must be defined, to make it more valuable to the students coming and to the students here.” In this way, the challenges and components to effective visiting international student externships together with relevant qualities of the visitor population emerged as FG themes.

In the globalization of medical education, visiting medical student externships are complemented by cross-border curriculum partnerships (CCPs). The perspective piece on CCPs by Waterval and colleagues identified many of the same thoughts for program success as those in our study. Administratively, there should be a masterplan with faculty development and monitoring of quality that includes easy communication among all involved.7 A key underlying theme in CCPs and visiting student externships is the importance of investment in faculty buy-in, support, and recognition of their contribution. Our participants’ concerns about the burden of yet another request — in this case, hosting a visiting student during their clinical work — are reflective of the current burnout of physicians across specializations and clinical experience8. Adding to faculty (and hosting trainee) demands without this investment risks negatively impacting their individual performance and the learning climate.

Our study had some limitations. It was conducted at two institutions, which may not be representative of all US medical schools. The FGs had small sample sizes but were typical for the methodology and did achieve saturation.

Based on the study results, at the University of Pittsburgh, we revised our processes regarding hosting international medical students. We vet applicants at the School of Medicine level based on student characteristics, our relationships with their home universities, and how the students will add to our academic diversity. We prioritize students who are high achievers and fluent in English, and can articulate specific motivations to come to our campuses. We favor students from schools with which we have ongoing relationships, yet we consider students from countries not usually represented here. We have established formal onboarding programs for students. In our communication with faculty members, we explain program details and negotiate expectations based on their interest and availability. Recognition for participation has included financial remuneration, letters to department chairs, and inclusion on trips abroad to visit other schools. The effects of these revisions are being assessed through faculty member satisfaction questionnaires and discussions.