AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. December 2006, Volume 8, Number 12: 818-825.

Medical Education

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The Educational Value of International Electives

A medical student, resident and long-time physician volunteer tell medical students how to make the most of international elective experiences.

Justin M. List, MAR, Rebecca Hope, MD, and by John L. Tarpley, MD, and Margaret Tarpley, MLS

In this three-part medical education article, a student, a resident and a clinician-educator share their experiences of voluntary global health service with Virtual Mentor readers.

Learning to Listen in a Resource-Poor International Setting: a Medical Student’s Encounter with the Power of Narrative in Kenya

by Justin M. List, MAR

After talking with a woman who was living with HIV and caring for an HIV-positive child in the resource-poor community of Kawangware in Nairobi and completing a public health needs assessment for her, one of my medical school colleagues posed the following question to our volunteer group as we were working at the clinic: “What do I say to her at the end of the needs assessment when she asks me if I have hope that she’ll live?” I remained silent. How can I as a healthy, educated, middle-class medical student from the United States answer a question so outside the context of my daily life? Given my position of relative global power as an American citizen and consumer, can I offer her more than words of solidarity or a prayer? What new moral claims do I feel placed upon me by these global neighbors as they let me into some of the most intimate parts of their lives? These questions were just the beginning of a larger personal reflection that grew from dozens of interviews with members of various resource-poor communities in Kenya and from discussions among seven of my fellow volunteers [1].

Most members of the group had just completed their first year of medical school only days before we arrived in Nairobi. As we laid the framework for our trip, we had decided that we wanted to experience an international service learning trip through the lens of public health by using a needs assessment to understand how social determinants of health impacted the lives of those we interviewed. We also designed health education modules covering hand sanitation and HIV transmission prevention. Compared to the modules, however, the needs assessments spoke volumes to us as illustrated by the eagerness to cooperate on the part of many of our participants.

For some of those interviewed, it was the first time they had ever felt listened to, as we found out from them or their translators. And hearing about the power of having a voice and feeling heard illustrated for me a learning point that I might have missed had I come to Kenya primarily to study the science of medicine. I could have easily done just that given the disproportionate infectious disease burden there. As a person who feels “heard” more often than not, I realized that these survey participants were teaching me more about the art of medicine than I might have expected at first glance. I quickly realized how valuable it was to ask comprehensive questions about their lives and experiences, the answers to which informed my understanding of how their health was shaped beyond the ailments of HIV or malaria they might have had at that moment.

I did learn some of the science of medicine, though, if not explicitly clinical. We used a needs assessment to acquire quantitative and qualitative data that—we hope—will serve the community through its analysis. But because we designed this trip from a public health perspective and left the stethoscope and Bates’ Guide to Physical Examination and History Taking behind, my education in the art of the medicine remained a key component of my experience in Kenya. Being invited for just a glimpse into some of the most unjust and difficult life stories imaginable demonstrated to me how powerful narrative (and the skill of listening) can be in the patient encounter.

I did not need to go to Kenya to understand this clinical pearl, but it was there that I most acutely did. I suspect other students also experience this abroad if not in resource-poor areas of the United States. Paul Farmer writes, “We need to listen to the sick and abused and to those most likely to have their rights violated. Whether they are nearby or far away, we know, often enough, who they are. The abused offer, to those willing to listen, critiques far sharper than our own” [2]. I experienced this “sharper critique” as stories of dying from tuberculosis and AIDS-related illness, stories of poverty and a lack of employment, of abuse and, yet, stories of hope, love and faith poured out from the mouths of Kenyan men and women and onto my feeble survey, a document I could bury myself in when the raw emotion of the situation hit me.

Medical students working abroad in resource-poor, low-income settings will encounter a host of experiences and confront a variety of feelings, perhaps including some I have described. Students bring a rich array of experiences and feelings with them that affect their ability to truly listen to the content of the patient’s words, and it is to our benefit to explore these feelings before, during and after our international immersion. Like me, students may find themselves seeking clarification about how to incorporate international health care into their future careers after short-term, life-changing work. And medical students traveling abroad for the first time in their burgeoning professional capacity should be prepared to expect the unexpected despite extensive planning and pre-trip education; to experience complementary or conflicting feelings of duty, ignorance, education, helplessness and purpose all in a matter of days or weeks; to anticipate an unfolding lifetime of further professional and vocational reflection and action.

Remaining truly present and attentive may be the most difficult aspect of learning the art of listening in medicine, especially where unfamiliar contexts, cross-cultural issues and language barriers coexist. As physicians-in-training, we have a potentially easy exit—turning our focus to the rigmarole of the chart, looking down at the survey with intent, deflecting a consideration of the often difficult-to-comprehend social determinants of health or concentrating on the biomedical components of the present illness. For me, listening to these difficult stories took more energy at times than I could have imagined listening could possibly require. And yet listening is a skill that we as medical students must continue to practice consciously as we discover our personal limits in relation to our pursuit of justice and caring for patients holistically.

Listening is an end unto itself, but it is also a means and a beginning to addressing aspects of patients’ lives that lie outside but impact the biomedical context. In seeking out patient narrative, especially in international resource-poor settings, we must ask questions (in a culturally sensitive manner) to which we may fear to know the answers, answers that expose injustice yet open a new world of possibility to the patient and physician.


  1. I want to acknowledge my partners and team members, Lisa Dunning, Kathy Hakanson, Mark Hakanson, Keen Harrison, PhD, Andrew Loehrer, Terri Parks and Jaime Sua. All of them opened themselves to the power of narrative through these needs assessment surveys and, through our shared stories from survey participant encounters, they provided me valuable insights.
  2. Farmer P. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press; 2005:239.

Justin M. List, MAR, a former fellow at the American Medical Association’s Institute for Ethics, is a second-year medical student at Loyola University Chicago Stritch School of Medicine. He received his master’s degree with a concentration in ethics from Yale University Divinity School and worked at Yale’s Interdisciplinary Center for Bioethics.

Doctor Without Borders or Doctor Without Qualifications? How to Be of Use and Stay Safe on International Student Placements

by Rebecca Hope, MD

It is likely that as a medical student you will learn more from an overseas placement in a low-income country than you feel able to offer. Faced with unfamiliar diseases and living in extreme poverty, patients seek medical care much later than you would imagine. Operating with limited resources tests your clinical skills when diagnostic investigations are rationed or unavailable. Immersion in a second language taxes your communication skills and ability to establish rapport. Working in a different culture will indeed foster understanding, tolerance and patience, and you may return with startlingly different ideas about the world and perhaps more questions than answers about what is happening on our planet.

In light of all this, how can medical students try to make their time overseas effective for their hosts and patients? An early venture to Nepal after my second year of medical training made me acutely aware of my limitations in the face of these challenges and inspired me to find out more before returning to international work. I offer some tips here to help you make the most of overseas placements.

Most of those who want to work in low-income countries do so in response to the humanist imperative: to help where there is need. As medics we are equipped with skills to benefit that most precious of possessions, human life. Where health workers are in short supply and the burden of disease weighs heavily, doctors can be of great help. But without careful planning, students may find themselves unsure of their role and uncertain about whether they help or hinder the work of their host organization.

Many students have found themselves out of their depth, asked to perform unfamiliar procedures with less supervision than they would have had at home. You may be, as I was, welcomed as the “overseas doctor” and, by virtue of foreign training, expected to have superior skills. As much as you feel ready to meet these challenges and gain practical experience, you are ethically—and perhaps legally—on shaky ground if you undertake the role of doctor without qualifications. Be aware of your limitations and discuss your level of experience and knowledge with your hosts beforehand. Do your best to familiarize yourself with local conditions, treatments and the social context before you arrive.

Be frank about what you hope to gain and agree to a suitable program or research project of mutual benefit. As students, you have much to offer; it may be that teaching English to health workers and students is the most useful thing you can do. Share expertise with local students and bring teaching aids or textbooks, and you’ll contribute to a long-term investment.

With the question of sustainability in mind, even experienced humanitarian workers return home asking, “Was my work of any use?” The fact that you have come and that you care, through work and through friendships, builds solidarity with overseas colleagues. It is worth thinking about how you can continue the support at home, through hospital or medical school partnerships and professional exchanges.

International rotations, if well-organized, are a valuable learning opportunity and introduction to international health work. Look forward to it and plan it well. There are some ills that medicine cannot cure, but an ability to see the bigger picture, the social, economic and public health issues surrounding each patient, will make you a better doctor…wherever you choose to work.

  • Hope R. The Elective Pack:A Medical Student's Guide to Essential International Health and Development. London, U.K.: International Health and Medical Education Centre; 2004. Available at: Accessed November 3, 2006.
  • Miranda J, Finer S. Rethinking your elective. Student BMJ. 2005;13:74-75. Available at: Accessed November 10, 2006.
  • Alma Mata. Available at: This is a free resource and network of about 500 health professionals and students interested in global health careers, training and research. It contains a database of humanitarian organizations, articles and interviews with doctors and students who have worked overseas.

Rebecca Hope, MD, is a junior doctor working in Cornwall, England. She became involved in international health through Europe's first bachelor of science program in International Health at University College London's International Health and Medical Education Centre. She has worked on projects with Save the Children, the Centre for International Child Health in London and Gudalur Adivasi Hospital, India, to study and improve community-based health insurance in low-income settings.

How Can Medical Students be Prepared for International Rotations?

by John L. Tarpley, MD, and Margaret Tarpley, MLS

Medical students seeking information about the feasibility of an international experience contact us regularly with questions about initiating the process. We encourage their interest because of the global perspective they will gain from interacting with diverse and often underserved populations. Added benefits include enhanced cultural sensitivity toward patients and professional coworkers in a field that is increasingly international. Many students also find they’ve broadened their career options as a result of global health service. The first meeting or correspondence with students, often before they have settled on a particular nation or continent, involves getting acquainted and asking several questions: Why do you want to go? What do you want to accomplish? How much time can you commit?

Students are motivated by a combination of the desire to serve, interest in academic research, curiosity about non-Western medical education and training and a wish for personal enrichment. Those who express humanitarian or faith-based ideals usually seek to be useful in whatever way an institution can employ a person with limited medical skills. Some hope to design a research project, while others desire to experience an exotic environment, with medical practice being only one aspect of the cultural enrichment they seek. The opportunity to interact with local medical students or residents might determine the choice. Any research project requires institutional review board approval or exemption from approval on the part of the home and the host institutions. The length of time a student can commit affects both the possibility of school credit for the rotation and the availability of funding sources. The specific requirements for credit and funding should be explored carefully. Longer stays may benefit the host because the student becomes more productive after learning the system. Settling on a mutually compatible time frame is often surprisingly complex, thus necessitating an early start when planning.

Advice for the Medical Student Seeking an International Rotation

Groundwork for an international experience must begin a minimum of 6 months before the proposed visit; a year ahead is not too early to begin gathering information: how much time the school will allow a student to be away from campus and how many weeks are required for an accredited rotation, for example. Networking begins by identifying individuals in the home institution with international experience and contacting several sending agencies and institutions about available openings. One source is International Health Opportunities, which can be found on the Web site of AMSA, the American Medical Student Association [1]. The Journal of the American Medical Association Volunteer Opportunities feature provides an alphabetical list with contact information for numerous agencies and institutions [2]. A third source is the American College of Surgeons’ Operation Giving Back Web site, which allows physicians to combine “location” choices and “specialty” in searching for global service opportunities. One eligible “practice category” in this online search system is “medical student” [3].

Considerations essential to each student’s decision include cost, language and culture, visas, skills, health and safety issues and the educational benefits. Airfare is usually the single greatest expense. Sources of support are rare, although some medical schools provide limited assistance. International institutions almost never offer funding but may assist with housing.

If English or another language in which the student is conversant is not the dominant language of the area, he or she must make certain that adequate translation services are available. Language difficulties compound adjustment frustrations and reduce a student’s usefulness. Likewise, students should examine their other skills and assets. In addition to the knowledge and skills acquired in the first years of medical school, some institutions may value computer expertise, English language teaching aptitude or a knack for simple repairs.

Suggestions for Students Overseas

Other suggestions for the student who has arranged an international rotation:

  • Acquire some knowledge of the history and culture of the area from books, articles or the Internet, bearing in mind the reality may be different than expected.
  • If a research project is anticipated, contact your home institutional review board as well as the institutional review board equivalent (e.g., ethics committee, board of directors) of the host institution to gather all the data required for project approval before you travel.
  • Ask about visa requirements, which vary widely. Travel agents can be helpful, but visa assistance may not be automatic.
  • Visit your local travel clinic if there is one. Get all recommended immunizations and follow prophylactic malaria medicine guidelines.
  • Road traffic events are likely to be the greatest injury risk, so employ sensible transportation strategies.
  • Once the arrangements have been established among you, your school and your international host, stick with your original travel plans.
  • Luggage allowances vary with stopovers, so if you are carrying supplies, additional charges might be levied.
  • Ask about appropriate clothing and suitability of items such as shorts or running attire. Slacks for women may be frowned on in some locales and acceptable in others. Comfortable shoes are always correct.

As you begin working, remember that you are a guest; be respectful and polite. Treat host physicians with the same respect shown to physicians in the U.S. Do not use first names with any hospital personnel unless they insist upon it. Titles such as doctor, mister, professor or madam are always correct. Offering gratuitous advice on how to improve procedures or infrastructure will be received politely but will be neither appreciated nor acted upon. “Now in Nashville, we do it this way,” is as annoying in an international setting as it would be in Dallas or Milwaukee. Water and electricity are often precious and intermittent, so practice economy in their use and have a good attitude towards conditions that are the norm for your hosts.

Culture Shock is Normal and Rarely Fatal

Cultural sensitivity—largely respect and humility—involves being cautious about what you say and do. Find a “consultant” early on and ask about the appropriateness of certain words or behaviors. In many cultures touching is not as commonplace as among Americans, especially touching between members of opposite sexes, and eye contact is not universally acceptable. Dress modestly; speak in a moderate tone. Be flexible regarding accommodations, food, communications and other arrangements. Most visitors are afforded the best available, so try to express gratitude even when accommodations appear less than optimum. Time, relationships and a positive outlook go far toward mitigating the effects of culture shock. Keep a journal and take photographs—but only after seeking permission from the subjects.

Appreciate the value of a “high touch, low tech” medical practice by observing that health professionals take careful histories and perform thorough physical exams when MRIs and sophisticated lab tests are unavailable. Emphasize the positive aspects of the experience. Honesty is in order, but focusing on problems may be viewed as culturally insensitive and hamper other students from obtaining an invitation from that medical center.

As the experience draws to a close, make certain you take away more than souvenirs. Perhaps you might learn a greeting (Africans often ask, “How is your family?” rather than “How are you?”) or adopt a procedure (Nigerian pediatricians have the mother hold the child during a routine well-baby check-up) or request a recipe. The international experience is a two-way street. What is acquired frequently outweighs what is given if a person is open and intent on gaining new insights and strategies.


  1. American Medical Student Association. International Health Opportunities. Available at: Accessed October 16, 2006.
  2. Journal of the American Medical Association. CareerNet Networking for Physicians: Volunteer Opportunities. Available at: Accessed October 16, 2006.
  3. American College of Surgeons. Operation Giving Back. Available at: Accessed October 16, 2006.

John L. Tarpley, MD, is professor of surgery, program director for general surgery and a master clinical teacher at the Vanderbilt University School of Medicine in Nashville, Tenn. International health, history of medicine and the role of spirituality in clinical medicine are areas of particular interest to him. In October 2006, he won the American College of Surgeons Volunteerism Award.

Margaret Tarpley, MLS, is an associate in surgery education at Vanderbilt University School of Medicine in Nashville, Tenn. She conducts bibliographical research and is a Web master for the Association of Program Directors in Surgery.

Do International Experiences Develop Cultural Sensitivity Among Medical Students and Residents? December 2006

The “Ethical Imperative” of Global Health Service, December 2006

A Caution Against Medical Student Tourism, December 2006

A Student Clinical Experience in Africa: Who Are We Helping? December 2006

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.