Going Global

Since 2009, the Office of International Activities (OIA) has provided critical support to medical students in pursuit of international electives in global health. With burgeoning interest in global health among students and residents in recent years, the OIA has never been busier.

by Zach Read - zread@unch.unc.edu

In the past decade, interest in global health has grown exponentially among medical students in the U.S. and Canada. Today, approximately one-third of students participate in an international health elective during medical school.

Four years ago, in response to the increase, the UNC Institute for Global Health & Infectious Diseases and the UNC School of Medicine Office of Medical Education collaborated to create the Office of International Activities (OIA), which provides comprehensive pre- and post-rotation support and education to medical students and resident physicians.

An infographic showing some of the facts and figures about the OIA.“We work hard to take the interest and ideas from medical students and residents and form them into educational, research, and mentoring objectives and ways of learning,” says OIA director Martha Carlough, MD, MPH, associate professor of family medicine. “Our goal is to make sure that the medical learner’s interest in global health is educationally appropriate and as safe and sustainable as possible.”

OIA assistance includes site identification or screening, faculty advising, safety and travel policies, ethics and cross-cultural training, post-trip debriefing, and evacuation insurance, among other critical areas of support. In four years, the OIA has provided support for a wide range of experiences. Students have gathered reproductive health data at UNC Project-Malawi in Lilongwe; worked in a small clinic in Tanzania shadowing local doctors and assisting with lab procedures in minor surgery; and traveled and worked in northern India with a team of medical students and faculty from across the U.S. through the Himalayan Health Exchange.

As medical student and resident physician interest in global health has grown at UNC, so has the OIA’s level of support. To date, the OIA has helped 300 medical students travel to 43 different countries, and along with the Medical Foundation and Student Affairs, it now awards more than $50,000 annually in international health fellowships for individual students and student groups – a more than four-fold increase from the $12,000 provided during the 2009-2010 launch year. Since April 2012, the OIA has helped 40 residents travel to 15 countries.

“We knew the demand was there, but the success of this office in such a short time period is even more than we could have hoped for," says Myron Cohen, director of the Institute for Global Health & Infectious Diseases. "This should be a model for how other schools incorporate global medical education."

The OIA’s flexible offerings make it possible for students with varied interest levels to have global health experiences. Students without career-level interest in international health may learn in larger groups overseas and complete an educationally appropriate experience. Other opportunities, especially those for students interested in careers in global health, may require one-on-one learning or extended opportunities such as year-long research projects or fellowships. The staff of the OIA gets to know each student and helps them find the appropriate fit.

“We have to figure out which students and residents are really invested at that deeper level, those who, for example, are going to be a Doris Duke scholar or are going to spend half their career overseas – those who really need that further investment and close mentoring to help them achieve their goals,” says Dr. Carlough, who has more than 15 years of experience in global health and development work, including nine years in residence in Nepal.

Although a large percentage of students travel overseas during their time in medical school – in the case of UNC, slightly more than the one-third average found at medical schools nationwide – the OIA understands that most students will wind up returning to the U.S. for the remainder of their training and careers.

“Of all the students that make global health part of their training, only a small number make it a significant part of their career work,” says Dr. Carlough. “But the positive educational impacts of those opportunities are deeply felt by all. Students who have done global health work overseas are more likely to care for the underserved, accept patients without insurance, provide more culturally humble and appropriate care, and become better diagnostic clinicians. So every investment matters.”

Medical students returning from overseas

The OIA has begun measuring the impact of global health experiences with medical students who have returned from overseas electives. The Office is tracking past participants and will eventually have results that will reveal whether global health experiences have affected student decision-making about their career paths and whether students are satisfied with the opportunities they’ve had.

What the OIA knows so far is that overseas experiences help students apply the knowledge they’ve gained from working and treating different cultural groups in low-resource settings to the care they provide when they return.

“Nationally, we know that if you do international health electives in medical school, you are moderately more likely to practice in Health Professional Shortage Areas (geographic areas where there are inadequate practicing physicians in the U.S.) than if you haven’t,” says Dr. Carlough. “We don’t know if that’s true for UNC students yet, but hopefully within the next decade we will have some of those answers.”

Suzanne Barakat
Click to view a slide show of Suzanne Barakat's time in Turkey.
Some recent students have already reported on the impacts of their overseas experiences. In June, fourth-year medical student Suzanne Barakat did an emergency medicine rotation in two Turkish towns along the border with Syria. In the town of Kilis, temporary home to 20,000 Syrian refugees, Barakat was given a room at a makeshift clinic that saw 500 patients a day. Aided by her fluent Arabic, Barakat worked with Turkish physicians and treated 80 patients a day, seeing them for four to five minutes at a time.

“All of a sudden you’re thrust into a low-resource setting with nothing more than your clinical judgment, your stethoscope, and a blood pressure cuff, and you have to triage, diagnose, medicate, treat, and refer patients to the hospital, if need be,” says Barakat. “It was definitely challenging.” 

After her experience, Barakat, who began her medical education with an interest in OB-GYN and emergency medicine, is leaning toward family medicine.

“I’m really grateful for the opportunity to go overseas and for the encouragement and support of the OIA,” says Barakat. “It solidified my interest in global health, working in low-resource settings, and serving the underserved. I found that family medicine is the best avenue for me to continue that.”

Barakat recommends that students interested in global health and overseas opportunities contact the OIA.

“That’s the only way to do it,” she says. “They have tremendous resources, and everyone is incredibly helpful.”

Fourth-year medical student Claudia Castillo had a similar experience to Barakat. Castillo has had opportunities to learn and work in Peru, Gabon, and Haiti, providing her a varied set of experiences that has shaped her perspective on the practice of medicine and the delivery of care.

“Looking at it broadly, seeing the health care systems in different countries and the organization of some of the entities was very eye-opening for me,” says Castillo. “I know our system is far from perfect – clearly we have some major problems – but it was interesting to see that in a lot of these places you have to buy your own medications before you can even have a surgery, even if it’s emergency surgery. It made me appreciate what we have here.”

Castillo’s experiences have already influenced her career choice. Born in Peru but raised in the U.S. from the time she was 15, Castillo was struck when she learned from her Peruvian mentor that most of those who leave Peru to receive medical training never return. In her case, she plans to work in global health throughout her career.

Beginning with an interest in pediatrics, followed by a shift to OB-GYN, Castillo, like Barakat, has found that family medicine allows her to use her skills more broadly. Her experiences have confirmed her desire to work with the underserved in the U.S., while perhaps simultaneously helping facilitate the development of family medicine training programs abroad. Now that she has been overseas, she believes her experiences will bring her closer to immigrant populations she hopes to treat in the U.S., whether from Haiti, the Caribbean, Africa, or Latin America.

“I’m very much appreciative of different cultures, and I want to serve in communities that are underserved,” she says.

Like Barakat, Castillo recommends the OIA to other medical students.

Claudia Castillo
Click to view a slide show of Claudia Castillo's time in Haiti.

“I think it’s especially important to work through the OIA, because they are always an email away,” she says. “They knew where I was and they were a great resource to have. Whether you plan to work overseas or not, if nothing else, the experience helps shape who you are as a physician and makes you more appreciative of what you have here.”          

The future

As the curriculum at the School of Medicine changes, third- and fourth-year students will have longer periods of time to spend overseas in global health electives.

“Two years from now, fourth-years will be able to have four months overseas,” says Dr. Carlough. “We are preparing for how to serve that need now.”    

Under the leadership of Dr. Carlough and associate directors Sylvia Becker-Dreps, MD, MPH, assistant professor of family medicine, and Ian B. K. Martin, MD, assistant professor of emergency medicine and internal medicine, as well as program manager Sam Hawes, MPH, the OIA will continue to work on improving the experiences of medical students and resident physicians in global health settings. They have begun medical student debriefings of international rotations, which Dr. Carlough says are tremendously effective.

“We help them learn to adjust to the experience overseas before they go and then readjust to the American medical system when they return,” says Dr. Carlough.

The OIA looks forward to incorporating measures for residents returning from training as well.

“That’s an area in need of development because residents go for a month and it’s extremely intense, and then they return and they’re thrown back into their UNC system,” she says. “I think it would be very easy to bury that experience and not integrate it. Integration of the skills you’ve learned overseas and the experience you’ve had is key in processing and using what you learned in the future.”

As a resident, Bari Byrd in OB-GYN has elective time to go abroad or do research during her third year. Thanks to scholarships she learned about through the OIA, she was able to go to a remote area of Zambia, where she did OB-GYN work, honing her operating skills, learning about OB-GYN practice in low-resource settings, and building experiences she plans to integrate into her future work. Byrd is grateful for the OIA’s assistance to residents.

“It’s hard to apply for a grant to get funding to go abroad when you’re in residency and working as much as we do,” Byrd says. “The OIA is an easy way for residents to learn about available funding and opportunities. It saved me time and money.”

As UNC becomes increasingly global, the OIA will continue to send medical students and residents into the world for further training and experience.

“The OIA is completely committed to experiences in global health for medical students and residents,” says Dr. Carlough. “It is a place of service and support for them to have the best experiences possible and to figure out what of their experiences they want to integrate into becoming a very good doctor.”

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