Brandon Hidaka

Learning Objectives

Understand the value of an international medical experience for students
Articulate how cultural daily habits, infrastructure, and social structure interact to influence the international distribution of disease burden
Envision how my international rotation will impact my career as a physician and health scientist

I was inspired to participate in an international medical experience as a first-year medical student. An invited speaker from the Wichita campus spoke about how his month in Africa as a fourth-year medical student altered the course of his career; now as a mid-career physician, he spends one-to-three months serving abroad annually. He spoke of (a) seeing conditions he would never have otherwise, (b) gaining unique hands-onexperiences, (c) learning how to care for people in a resource-poor environment, and (d) a fresh perspective on humanity and one’s own culture. He also encouraged one to participate as a medical student, because opportunities as a resident and practicing physician lack the same infrastructure and support of a sponsoring school. Since that formative noon lecture, I had always planned on going abroad during my final year of medical school. Only later did I learn of the ample research demonstrating the benefits of international clinical rotations.

Following a clinical rotation in a developing country, medical students report (a) enhanced clinical prowess, (b) greater appreciation for costs and resources, (c) improved cultural competency and sensitivity, and (d) a lower need for advanced imaging and laboratory tools (reviewed in (1)). Additionally, as the world becomes increasingly crowded and modernized, physicians will need more knowledge about tropical diseases and emerging infections; international medical rotations offer first-hand experiences with conditions that one may otherwise never encounter in the United States. Lastly, students (almost) unanimously value their international experience, stating that they would recommend it to peers (1). The reasons listed above likely underlie the growing participation in international clinical experiences among medical students in the United States (1). It is estimated that about one in three U.S. and Canadian medical students participate in an international experience during medical school (2).

In addition to improving clinical and intercultural skills, international experiences in medical school have been linked to different career paths. For example, these well-traveled students are more likely to enter a primary care specialty and earn a secondary graduate degree in public health (1). After working abroad clinically, individuals are also more likely to work with underserved populations (in the United States) as a physician(1). One cannot help but be changed by witnessing the clinical needs of other types of people and seeing how their needs are met (or not) with less.

International medical experiences broaden one’s perspective. There are increasing efforts to implement global health curricula into medical schools (2). “Global health is the study and practice of improving health and health equity for all people worldwide through international and interdisciplinary collaboration” (2). This includes understanding disease distribution and health inequities between countries, serving diverse patient populations, and training to practice travel/immigrant medicine (2). Fair and equitable medical care is a human rights issue that depends on clinician’s cultural competency. I gained a glimpse into a refugee/immigrant’s experience when I was trying to navigate a country in a foreign language. I cannot imagine needing to navigate a medical system in matters of life and death.

The leading contributors of human disease varies among countries according to an economic gradient. In the poorest countries, like those in sub-Saharan Africa, childhood underweight and household air pollution (from indoor fires for cooking and heating) are the main causes of health loss, as measured by a disability and early mortality (3). Meanwhile, in the rest of world, elevated blood pressure, is the chief modifiable risk factor for disease (3). The causes of elevated blood pressure, which is a metabolic disorder, relates to the following characteristics of modern-industrialized societies: aging populations, high energy and low micronutrient dietary patterns, tobacco use, and decreased physical activity with greater urbanization and mechanization of labor (3). In short, infectious diseases exacerbated by undernutrition undermine the health more in poor countries, while metabolic conditions from over-nutrition pluslow physical activity harm people the most in affluent countries. How much could health improve globally if food were more appropriately distributed?

The healthcare systems of developing countries suffer from the same types of problems that plague ineffective healthcare systems in economically advanced countries. In Latin American countries, for example, segmented healthcare systems that have been built piecemeal result in large regional variations in quality of care, as well as lower overall quality and access for those of lowest socioeconomic status (4).It is essentially another issue of maldistribution of resources. Inadequate funding, coupled with inefficient/corrupt governments also undermine the healthcare systems of our southern neighbors. Latin American countries spend 5-11% of their GDP on healthcare with only half coming from the government, compared with a global average of 63% (4). Witnessing the underfunding of healthcare firsthand was in stark contrast to the waste and excessive expense of our medical system. Going forward, I will be much more mindful of the cost of the medical care that I provide.

As a conscientious health researcher, I am disturbed by the fact that more research money is invested into treating chronic conditions that affect affluent societies (and often the richest people therein), while many more common diseases in poorer parts of the world are under-studied. There is an increasing need and interest in growingresearch collaborationsbetween developing countries and more modern ones. I would like to measure the health effects of societal transition to a more modern economy. I am passionate about identifying and implementing the most cost-effective ways to treat and prevent lifestyle-related diseases. After my international experience, I am considering a focus on disease prevention (I have the most experience with breast cancer) in immigrant populations.

I travelled to Mexico with the main goal of learning Spanish, because it is the most common language in the US that I do not speak. It has long been recognized that language is a major barrier to medicine (5). Poor communication between the patient and healer impedes information gathering for an appropriate diagnosis, as well as the healing process via poor understanding of the recommended plan on the part of the patient or a lack of cultural sensitivity by the physician. Additionally, poor use of language also raises the ethical issue of informed consent. I am frustrated that, even after my Spanish improves with practice, liability will remain a major barrier for me to openly serve Spanish-speaking-only patients. However, making the effort to learn the language will, I hope, be viewed as a sign of respect.

My international experience affirms the research touting the benefits for medical students. I have gained an enhanced understanding of the distribution of disease as it relates to lifestyle. I am inspired to continue to learn Spanish and serve immigrant patients as a physician and public health scientist. It was a formative experience, for which I will be forever grateful.

References

1. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health in medical education: a call for more training and opportunities. Academic Medicine. 2007;82:226-230.

2. Battat R, Seidman G, Chadi N, Chanda MY, Nehme J, Hulme J, Li A, Faridi N, Brewer TF. Global health competencies and approaches in medical education: a literature review. BMC Medical Education. 2010;10:94.

3. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, AlMazroa MA, Amann M, Anderson HR, Andrews KG. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2013;380:2224-2260.

4. Goss PE, Lee BL, Badovinac-Crnjevic T, Strasser-Weippl K, Chavarri-Guerra Y, St Louis J, Villarreal-Garza C, Unger-Saldaña K, Ferreyra M, Debiasi M. Planning cancer control in Latin America and the Caribbean. The Lancet Oncology. 2013;14:391-436.

5. Woloshin S, Bickell NA, Schwartz LM, Gany F, Welch HG. Language barriers in medicine in the United States. Jama. 1995;273:724-728.