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Before You Go

Organizing a Rotation - The Basics

There are numerous people who can assist medical students in getting an international experience off the ground. A great place to start is the medical school advising office. Often there are administrators who are specifically tasked with handling international rotations. They will work with the medical student to obtain elective credit, and may have a list of organizations or foreign schools that students have successfully rotated at in the past. Mentors within one’s intended specialty can often offer contacts for international rotations specific to your professional field. They can also provide valuable information on timing the rotation to best augment the students ERAS application, (i.e. not conflict with sub-internships or interviews).
As another resource, students are encouraged to reach out to previous PIs or current research colleagues for any information on projects happening internationally. There may also be international conferences, presentations or seminars that mentors may be aware of which can be great starting points for finding international contacts. Students who have previously successfully completed an international rotation are great resources who can provide contact information for in-country organizers, and tips on the application process. These students can also give site-specific information that is invaluable.

Program Type

Often the simplest path to an international clinical elective is through a pre-arranged program that is approved by or affiliated with your home institution. Your medical school has likely developed a relationship with international universities or hospitals and has sent students to these locations in the past, so the application process is often less burdensome. Additionally, many home institutions have a database of reviews and advice from past rotators that may help you to choose a program that fits with your goals. However, a drawback to these pre-arranged international rotations is that the options for locations and types of programs may be limited at some medical schools.
Alternatively, you can design your own elective in the location of your choice. This requires more dedication and time, as you must make all arrangements with both the home and host institution. For these self-created electives, most home institutions require faculty recommendations or sponsors from the home institution and/or a faculty supervisor at the
host institution. You should also be aware that some institutions reserve the right to deny academic credit, supervision, direction, or economic support for any international electives in regions deemed to be high-risk (for example, in areas with travel restrictions placed by the U.S. State Department). It is always smart to check early in your search process to see if your school has any restrictions in place.

Non-clinical Electives

You should also consider the type of international experience you are seeking. The vast majority of international rotations are clinically focused, but there are also opportunities for non-clinical electives as well, such as research, language immersion, or service-based electives. As with clinical international electives, the policies vary by home institution, but in general no credit is given for language immersion or non-clinical community service electives. However, some institutions may offer partial credit for combined clinical and language immersion programs. Research electives are usually easier to receive credit for but generally must be arranged individually by the student, although some home institutions do have international research affiliations. Usually, you must demonstrate that you have spent a minimum amount of hours directly participating in research during your elective and/or produce a research product, such as a data set or manuscript, by the end of your rotation. As with clinical rotations, be sure to verify your institution’s policies early in your planning process to ensure that credit is granted.

Requirements

Each institution has a specific checklist with all the documents and requirements to apply for a GH elective. Most applications include a personal statement, letters of recommendation, projected schedules, waivers, immunization records, travel itineraries, copies of passports and airfare, and possibly financial information. Additionally, verify that you have completed all prerequisites for the international rotation – some schools require completion of all core clerkships prior to international rotations.
Be sure of what will be expected of you when traveling abroad. Find out the exact dates of your elective, your responsibilities as a member of the team, the language requirements (students must be conversant with the language of the host country unless there is a provision for translators) and finally be familiar with the goals and learning objectives of the elective.
Your school very likely will require a Letter of Acceptance from your elective site, in particular when it is an independently arranged elective. Contact your local administrator to determine if your school requires a specific format.
Finally, most schools will have GH orientation courses, lectures, simulations or workshops designed to offer an immersion on most aspects
related to global health and international rotations including culture specific and ethical considerations. They are aimed to facilitate your experience and explain in more detail the whole process.

Organizing a Rotation - When to Go?

Perhaps the most useful advice as a medical student is to start planning early. It is generally advised to plan at least one year in advance of an anticipated program start date. Several institutions require applications six to nine months in advance, and assembling the necessary documentation and health clearance can take a significant amount of time.
There are two popular times for scheduling an international experience during medical school. The first, and by far most common, is during the latter part of fourth year. At this point the student has enough clinical rotations completed to qualify for most international experiences, and has the scheduling flexibility of a second semester fourth year. The second time is the summer after first year. Many schools have one to two months of vacation or research scheduled during this period and students may choose to embark on an international experience. When students do not qualify for clinical rotations, there are language, research and health care oriented options available (See table 6.1).

Organizing a Rotation - Where to Go?

When deciding where to go, you should keep in mind the goals of your international experience. Medical students are still rounding out their medical education and options for international medical experiences are broader than those for say a resident or attending. Is the goal to gain clinical experience in an international setting with an away rotation? Or is to add to your international medical resume and study relevant topics such as infectious disease, public health or a foreign language abroad? Although specific programs are constantly changing dates and availability, see Table 19.1 for a framework of broad categories that medical students should consider when searching for an international program.


Opportunities in International Medicine Available to Medical Students

Experience Type
Description
Pros
Cons
Resources

International Away Rotations

Hosted by international medical schools, these rotations offer the medical student the opportunity to work directly with the healthcare education and delivery systems abroad.

Get hands on experiences in international medicine. Learn to work in more austere and resource-limited settings. Truly test your medical knowledge without relying on the lab or imaging results you do at home. Most clinically-oriented experience.
Many require significant advance planning, applications, visas, travel permits (apply early!). Programs are fluid and often changing, websites may not be updated. Find a contact at the sponsoring institution you are interested in.
IFMSA - Oldest centralized database for international away rotations, listed by country in their explore section http://ifmsa.org/exchange/scope/explore/exchange-conditions
GHLO – AAMC’s website for medical schools hosting international student rotations. https://www.aamc.org/services/ghlo/
AMSA – Medical student hub for international rotations in a variety of specialties. http://www.amsa.org/members/career/international-exchanges/

Specific global EM resources:
ACEP’s International Division: has a list of rotations on their website http://apps.acep.org/InternationalRotations/default.aspx
SAEM/GEMA: has lots of information in their website www.globalem.net



Lamar Souter Library International Healthcare Opportunities Clearinghouse (HOC)
Links and contacts to almost 70 organizations
NGO, non-NGO, for-profit, and religious institutions listed

Website: http://library/umassmed.edu/ihoc

Contact emails:
Lisa.Palmar@umassmed.edu
Robert.Vanderhart@umassmed.edu

International Aid Organizations
These multinational organizations often have opportunities for volunteers from any type of graduate school. Experiences are always changing but can range from being an intern at their headquarters, to doing field research at international sites.
Learn international medicine-politics, fundraising, resource allocation etc. Learn important non-clinical determinants of health: overcrowding, poor sanitation, communicable disease, displaced populations, food and water access. These are widely respected organizations in both the medical and wider humanitarian communities.
These experiences usually require a significant time commitment (6 weeks-1 year). Thus it may require you to use some of your elective and vacation time fourth year. They are highly competitive programs. They may not be medically focused in the day-to-day-to-day experience.
No aggregated website. Check out the NGO websites:
World Health Organization (WHO)-Internships are available in a wide variety of areas related to the technical and administrative work of WHO. 6-12 weeks.
Center for Disease Control (CDC)-Programs have included international research with CDC faculty. Additional programs in epidemiology. 6 weeks-1 year.
Médécins Sans Frontières (MSF). Also known as Doctors Without Borders-Intern position-while most U.S. internships are at the headquarters in New York, NY, there have been multiple positions that have required international fieldwork. 2 months-1 year.

Language immersion programs
Going to work with a unique population in residency or in your practice? Fourth year can be a great time to do a cultural immersion experience, and learn the language your patients will speak. There are a variety of private, university, and exchange language programs available to graduate students.


There will likely not be much time to devote to studying a foreign language after fourth year. International medical missions often prefer multilingual providers. Great addition to one’s skill set as a future provider. Cultural competency with future patients!
Medical schools often don’t award elective credit for these experiences, thus you may need to use vacation time. Not medically focused. Can be expensive.

There are numerous language immersion programs set in countries with native speakers. If there is interest in a particular region or language, explore the websites of local universities for foreign student language courses, search for private companies offering language instruction, and ask the advisors at a home institution in that languages department about opportunities abroad.

Public Health Schools
Take a course in statistics, public health, disaster management, or infectious disease. Many universities offer “short courses” of study that can be completed in 2 weeks to 2 months. See the resources section for example.
Round out education with topics that are highly valuable as an international physician, but may not have been covered in medical school. A great way to see a region of interest, as any location with a university is likely offering a short course.
Courses can be expensive. Travel and airfare are often not included in tuition. Dates are fixed; some institutions offer relatively few courses.
Look for short courses or summer courses offered by universities in your region of interest. Examples in the past have included:
London school of Hygiene and Tropical Medicine offers short courses in a variety of public health topics.
Schools in regions of endemic diseases can offer short courses in their management: For example The University of Ghana School of Public Health offers an annual short course in malaria monitoring and evaluation.
Statistics courses at international universities are universally applicable to future international research and widely available



Can I afford it?

Funding an international experience is a significant concern for most medical students. Fortunately there are a number of funding opportunities available. The first place to start at your home institution. You should ask advisors, a PI, and even other relevant degree programs (i.e. public or global health programs) what funding opportunities are available. Next, it is useful to research local scholarships, including regional, religious and other community funding options that are available. Additionally, there are several national and international scholarships specifically for medical students to complete international rotations. It is helpful to invest some time into scouring the internet for international medical scholarships, as there are major international grants, research programs, and NPO/NGOs that offer medical student funding. Finally, if funding is not secured but there is an opportunity to participate in a great international experience consider this: you are likely already accruing major debt by being a doctor in the United States. Is the difference between $200,000 and $202,000 enough to prevent you from going on a formative international experience? It’s a personal decision but something to consider.


After you Return

Immediately after you return from your international rotation, be sure to complete any reports/evaluations/dissertations required by your home institution. Consider promoting your experience on campus or at conferences to other medical students who were once in your shoes trying to establish an international rotation. Not only will this potentially aid your site by encouraging other students to go, but you can also improve your public speaking, and network with other students who are interested in international health. Additionally, it may be possible to aid the clinic or organization you worked with by fundraising or donating needed supplies. Try to identify a need of your site, and find creative ways to meet that once you are home. Try to keep in touch with your international colleagues. It is always great to have an in-country contact, and it promotes the cross cultural exchange that is essential to global medicine.
There are multiple organizations that aim to keep people interested in global health informed and connected. Consider joining these organizations: ACEP, SAEM, AMSA (to work with IFMSA). You may also contribute directly, or benefit from, the emerging mentorship programs in global health. Keep an eye out for opportunities related to mentoring within the field.

IFMSA

The International Federation of Medical Student Associations is a multinational organization of medical students from over 100 countries.
Founded in 1951, the IFMSA aims to unite medical students across the globe, provide a forum to address educational and humanitarian issues, and promote cultural competency through exchange programs. Each participating nation is represented by its own national member organization (NMO). Medical students in the United States are represented to the IFMSA by the American Medical Students Association (AMSA).
The IFMSA benefits U.S. medical students in two ways. One, there are multiple international conferences, seminars, and leadership training events held for interested medical students. For example, AMSA members can apply to represent the U.S. at IFMSA’s two General Assemblies. Held biannually, medical students from around the world meet to discuss emerging issues in medical education and international medicine. The second way medical students can utilize IFMSA’s resources is by securing an international away rotation through their Explore Program http://ifmsa.org/exchange/scope/explore/exchange-conditions. This program aims to facilitate the cultural exchange of international medical students by streamlining the international away rotation process. They have created a centralized database on their website that lists host institutions and contact information for participating international medical schools.
A word of caution: while this is one of the best and most comprehensive databases available, contact information can sometimes be out of date. However, their list of host institutions is a great place to start searching for rotations. The IFMSA is a highly recommended resource for medical students interested in learning more about international medicine. Getting involved in both the community of international medicine and contributing to the leadership of this field can never be started too early. The IFMSA provides students the opportunities for both.


Other General Resources for Medical Students

Medical school attracts students from diverse backgrounds who share, at least in part, a common interest in serving their communities. More medical students are seeking experiences in global health. Between 1978 and 2004, the number of medical students who participated in a clinical experience abroad increased from 5.9% to 22.3%.2 Some medical schools have responded to this growing interest by creating electives in international medicine or even establishing global health tracks within their programs. There is a recognition that the first step towards a career in global health begins with education. Medical students can best serve the global community by learning fundamental issues affecting global health today. Regardless of availability of formal electives or global health tracks, you can achieve global health education through extracurricular programs, student interest groups, policy and advocacy, and clinical experiences.

Extracurricular programs

Extracurricular programs in global health can fill educational gaps or complement existing coursework in medical schools. They generally fall into two categories: concurrent and parallel programs.

Concurrent programs: Concurrent programs offer training modules or formal curricula that may be undertaken within the four years of medical school. They do not require taking time off or additional years of training after graduation, and educational material can be seamlessly integrated into any institutional program. One model of concurrent programming employed by the World Health Organization and the Consortium of Universities for Global Health utilizes online training modules that serve as primers to fundamental topics including the global burden of disease, traveler’s medicine, and immigrant health. This model benefits students who wish to study the material at their own pace or who are interested in specific issues. A second model of concurrent programming provides more structured, formal education utilizing live online lectures and remote conferencing for students to participate in journal article reviews, peer discussion and mentorship. The American Medical Student Association (AMSA) Global Health Scholars Program http://www.amsa.org/members/career/scholars-programs/global-health/ is one of the most popular examples of this model.

Parallel Programs: Parallel programs in contrast require students to commit to time off from medical school, which can range anywhere from two months to up to two years. These programs offer in-depth, career-oriented training for students with a serious commitment to the promotion of global health. Examples include the Fogarty International Clinical Research Scholars Program http://www.fic.nih.gov/programs/pages/scholars-fellows.aspx and the Centers for Disease Control-Hubert Global Health Fellowship http://www.cdc.gov/hubertfellowship/. Whereas concurrent programs may be pursued at any time during medical school, parallel programs are often competitive and require an early commitment. Students should begin researching parallel programs and discuss their interest with academic advisors within the first year.

Policy Advocacy

Policy advocacy is another avenue for exploring pertinent issues related to global health. Students can participate at the grassroots level or through top-down, systems-based approaches. AMSA has organized action committees that encourage student participation including workshops on global health ethics and lobbying activities to advance components of the 2010 Global Health Act and Global Health Initiative. Special interest policies related to specific disease burdens or geographic locations can also be studied through student-run advocacy groups. Through these multiple channels students can gain an understanding on how global health policies are designed and implemented.

Getting your foot in the door!

For medical students simply seeking to gain elementary exposure to global health, student interest groups and international clinical experiences provide a good start. Student interest groups fulfill multipurpose roles, arranging for visiting lecturers, organizing participation in global health conferences, and matching experienced faculty mentors with interested students. Most importantly, student interest groups can allocate funding for these pursuits from their institutions, AMSA, and other organizations. International clinical experiences represent the more glamorous aspect of global health, in which students can work on faculty research projects, volunteer with aid organizations, participate in mission projects affiliated with various institutions, and learn languages through immersion programs. Each area alone is insufficient in gaining a comprehensive understanding of global health, but in combination they create a solid foundation on which to build a future in international health.