Examining the Role of International Service-Learning in American Medical Education: A National Exploratory Study

Abstract

There is a recent rise in demand for international rotations in medical school, during which U.S. schools send medical students to another country for an immersive educational experience, but there is little research surrounding the characteristics, ethics, and institutional support for these types of rotations. This study examines the types of international rotations that exist in medical education in the United States and its territories as key avenues for international service-learning (ISL) by investigating the key characteristics of international rotations and the structural and programmatic features necessary to support such rotations; the barriers and facilitators to the advancement of ISL from the perspectives of stakeholders within medical education who design and implement international rotations (i.e., faculty, staff, administrators); broader contextual factors that might influence a medical school’s decision to include ISL in its medical program; and whether relationships exist between components within a medical school or institutional environment and the inclusion of international service-learning components performed during international rotations. This study utilizes a mixed methods design with an exploratory approach. Quantitative data were collected through a survey that was sent to all 185 MD- and DO-granting medical schools in the United States and its territories that had full accreditation status as of July 2018, which had a response rate of 31%. Qualitative data were then collected through 15 interviews with international rotation coordinators that had also responded to the survey. Inductive and interpretive methods were used to analyze data. Key findings from this study provide highly contextualized guidance to scholars and practitioners interested in the transformative potential of service-learning, or any other reform effort in medical education, and the organizational components necessary to sustain such efforts. Results in this study demonstrate the variety of ways in which international rotations are designed and implemented across medical schools. Design aspects of international rotations depend greatly on safety considerations, components required for academic credit, student considerations such as level of experience, and the agency or motivation of the international rotation coordinator to include certain components as part of international rotations, such as pre-departure orientation or post-travel debrief and reflection. Formal structures and processes are shown to help support international rotations, integrate international rotations more formally into medical school curricula, and strengthen partnerships with community host sites. Issues of funding and timing a student could perform an international rotation during the four-year program were most influential to student participation as well as to design decisions regarding planning and implementation of international rotations. Barriers to planning and implementing international rotations include cost and safety challenges as well as challenges to meet student expectations during the design of international rotations. Other barriers included challenges to integrating international rotations into broader medical school curricula, such as finding faculty or school leaders to support international rotations. Elements that helped facilitate international rotations included high student interest, convenient opportunities to develop community partnerships, and international rotation coordinators’ personal experiences and motivation, such as passion or personal mission to inspire students or promote health equity. Broader contextual and environmental aspects that could drive or deter a medical school’s participation in international rotations included the various perceived benefits and disadvantages associated with international rotations and additional contextual factors within and surrounding medical schools held great influence in a medical school’s decision to engage in international rotations. Factors that drove medical schools to participate in international rotations included student demand, addressing changing workforce demands, and broader environmental drivers, while factors that deterred a medical school’s participation were related to a lack of structures or processes in place or the length of time a medical school had been open. Aspects within a medical program were found to influence the inclusion of international service-learning components in international rotations, such as a medical school’s mission, length of time international rotations had been offered at a medical program, presence of sites in lower-income countries, and whether international rotation coordinators held joint appointments or affiliations with other offices.