Capturing Medical Students’ Idealism

Janice K. Smith; Donna B. Weaver

doi:10.1370/afm.543

Published eLetters

If you would like to comment on this article, click on Submit a Response to This article, below. We welcome your input.

Submit a Response to This Article

Compose eLetter

Title *

Author Information

Contributors
First Name and Middle Initial * First or given name, e.g. 'Peter'. Last Name * Your last, or family, name, e.g. 'MacMoody'. Email Address * Your email address, e.g. higgs-boson@gmail.com Occupation * Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Affiliation * Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

What code is in the image? *

Enter the characters shown in the image.

Vertical Tabs

Jump to comment:

Is enduring idealism engendered by international experience?
Ronald E Pust

Published on: 09 October 2006
Reinforcing Students' Idealism
Cynthia Haq

Published on: 01 October 2006
Comments on Case Study: "Capturing Medical Students' Idealism"
Joseph Hobbs, MD

Published on: 29 September 2006
Comments on Smith and Weaver, "Capturing Medical Students� Idealism"
John J. Frey III, MD

Published on: 26 September 2006

Published on: (9 October 2006)
Page navigation anchor for Is enduring idealism engendered by international experience?
Is enduring idealism engendered by international experience?
Ronald E Pust, Tucson AZ, USA
If one waits a few days (as in the case of this article by Drs. Smith and Weaver) for the wise songs of colleagues, one can shout “Amen” to the choir, while not pronouncing a benediction.
So I want to affirm the account of her childhood idealism by Dr. Haq(1), the focus on the US health workforce by Dr. Hobbs(2), and Dr. Frey’s(3) studied skepticism about the evidence on enduring outcomes of our mutual endeavors...
Show More

If one waits a few days (as in the case of this article by Drs. Smith and Weaver) for the wise songs of colleagues, one can shout “Amen” to the choir, while not pronouncing a benediction.
So I want to affirm the account of her childhood idealism by Dr. Haq(1), the focus on the US health workforce by Dr. Hobbs(2), and Dr. Frey’s(3) studied skepticism about the evidence on enduring outcomes of our mutual endeavors in educating for global health. All three – and the original article(4) – rightly ask whether the interposition of salt water between medical students and their U.S. medical school home leads to long term, career-determining commitments. Drs. Smith and Weaver are preaching to a loyal, yet questioning, choir.
While an overland route could also be explored between Galveston, Texas, and Mulukuku, Nicaragua, likely few have ever made this grinding and gradual journey at ground level. Is it not more formative to encounter commitment to underserved people first at home, where charity proverbially begins, rather than through educational experiences made all the more exotic by the sudden and stark contrasts, inherent in international air travel? My point is this: We all know individual students who at some point after their return from an international experience worked in US cross-cultural and underserved settings. But why should we assume, among the myriad of influences in any person’s life, that the international experience was uniquely formative? Is it not more likely that the cumulative values and experience of medical students prior to or entirely apart from their education – whether that be in Texas or Tokyo, Wisconsin or Wales – are at least as predictive and productive of careers of service? Clearly Drs. Smith and Weaver would agree, along with most of us who have done observational studies that, similar to theirs, preclude control groups. Yet, in abstracts of our published studies, these limitations are often deleted (though surviving in this abstract(4)), implying that we have adduced “evidence.”
Despite the invariably optimistic conclusion of our studies on engendering or reinforcing medical student idealism, we are now recruiting foreign medical graduates in accelerating numbers for America’s underserved areas(5), and, as Dr. Frey(3) notes, our family practice residencies. Our expanding and economically effective demand is transforming the physician “brain drain” – the effluence toward affluence – from a trickle to a torrent.
If the 40 years since the genesis of family practice in the USA are any guide, incontrovertible evidence that our educational efforts are fulfilling in family medicine’s societal service goals may never be possible(6). Nonetheless, as citizen-educators we must dedicate our careers to what we know is right and equitable. We must keep both of our eyes – the passionate and skeptical – “on the prize”. Reinforcing idealism in medicine is a lifelong quest whether those clinicians are our students – or us. In both domestic(6) and international service(7), many of us(3) have debated the relative influence of experiences before medical school, in the preclinical years(4) vs. the clinical(7), and during residency and beyond. Wherever we find ourselves serving in this endurance race, we may gain renewed collective strength from seeing ourselves as a relay team – a team that must repeatedly reinforce idealism in the face of encroaching “reality.” On this long road, our best advice may be borrowed from the bumper sticker admonishing us to “Question Reality.”
At the end of the journey, it may not be the quantity, or even the quantifiability(8), of our educational outcomes in international health that are the most enduringly valuable. Those long term values inhere in our learners in three successively smaller cadres. The first are the many whose North American careers are indelibly enriched and more perceptively effective because they have learned, with G.K. Chesterton, “The whole object of travel is not to set foot on foreign land; it is at last to set foot on one’s own country as a foreign land.”(9) Next are those fewer whose career carries and keeps them quietly learning and serving at the farthest outposts, whether in this country or in distant continents. Finally are those rare doctors who remain at those outposts, yet enrich us all by distilling the lessons learned(10) in looking at “one’s own county as a foreign land.”
References:
1. Haq C. Reinforcing students’ idealism. (1 October 2006)
2. Hobbs J. Comments on case study: “Capturing medical students’ idealism” (29 September 2006)
3. Frey JJ. Comments on Smith and Weaver, “Capturing medical students’ idealism (26 September 2006)
4. Smith JK, Weaver DB. Capturing medical students’ idealism. Ann Fam Med 2006;4:S32-37S. References 1-4 available at URL: http://www.annfammed.org/cgi/eletters/4/suppl_1/S32
5. Mullan F. The metrics of the physician brain drain. N Engl J Med 2005;353:1810-8.
6. Campos-Outcalt D, Chang S, Pust R, Johnson L. Commitment to the underserved: evaluating the effect of an extracurricular medical student program on career choice. Teaching and Learning in Medicine 1997;9:276-81.
7. Pust R, Moher S. A core curriculum for international health: evaluating ten years’ experience at the University of Arizona. Academic Medicine 1992;67:90-94.
8. Potts M, Prata N, Walsh J, Grossman A. Parachute approach to evidence based medicine. BMJ 2006;333:701-3.
9. Chesterton GK. Aphorisms by GK Chesterton. Available at: http://www3.baylor.edu/~Ralph_Wood/chesterton/ChestertonAphorisms.pdf
10. Downing R. Suffering and Healing in America: an American Doctor’s View from the Outside. Radcliffe Publishing; 2006.
Competing interests: None declared
Show Less

Competing Interests: None declared.
Published on: (1 October 2006)
Page navigation anchor for Reinforcing Students' Idealism
Reinforcing Students' Idealism
Cynthia Haq, Madison, Wisconsin USA
Reinforcing Medical Students’ Idealism
When I was seven years old my family and I lived in Lahore, Pakistan. Images of poor children who surrounded us and begged for food as we shopped remain etched vividly in my memory. When I asked my mother, “Why are these children poor? Why don’t they have enough food?” She simply responded, “There but for the grace of God goes you.”
Reflecting back more than...
Show More

Reinforcing Medical Students’ Idealism
When I was seven years old my family and I lived in Lahore, Pakistan. Images of poor children who surrounded us and begged for food as we shopped remain etched vividly in my memory. When I asked my mother, “Why are these children poor? Why don’t they have enough food?” She simply responded, “There but for the grace of God goes you.”
Reflecting back more than four decades later, I appreciate that these experiences and my mother’s wise comments indelibly shaped my character and subsequent life choices. As a child I tried to imagine what it would be like to be hungry with no prospect of food, or to be ill without the means to buy medicine or assistance. I was confused and embarrassed by the vast gaps between the abundance I enjoyed and the unmet needs of many children like me. These experiences left me troubled, set the stage for my commitment to a career in medicine, and continue to influence my work to improve access to primary health care for medically underserved populations in the US and abroad.
Drs. Smith and Weaver have described a unique program at the UTMB to provide first year medical students with opportunities to provide health care in medically underserved community settings in Nicaragua (1). This study demonstrates that a brief international experience can greatly influence medical students’ attitudes, awareness and skills. Students’ self- assessments included increased idealism, greater commitment to serve the medically underserved, enhanced awareness of the complex determinants of health, and enhanced history, physical examination and cross-cultural communication skills. These findings reinforce prior studies regarding the impact of international experience on physicians in training (2, 3, 4).
International health electives, and/or experiences providing health care to the poor and medically underserved within the US, have the potential to dramatically alter the lives of students who have not experienced poverty or witnessed severe deprivation. The lessons learned from wading through sewage, watching children sorting through piles of rotting garbage for bits of food, and gazing into the eyes of a person who is suffering cannot be adequately conveyed in a class, through a book, or on a screen. The experience of being with the poor and suffering offers a close-up view that provides opportunities for understanding and the potential to engender compassion and action.
Drs. Smith and Weaver have also demonstrated that an educational program of tremendous value can be developed and sustained for modest costs. Careful student preparation, clear educational objectives, guidance by experienced faculty, and collaboration with local health providers shaped and enhanced the value of this experience for US students and for the individuals and communities served in Nicaragua.
The percentage of US students studying abroad has grown steadily over recent years reflecting students’ growing desires to learn from and to serve medically underserved populations (5). As Dr. Frey notes above, similar needs are present and such experiences can be developed within our own borders. And as Dr. Eckhart notes, these experiences not only affect career choices, but also the values of professionalism and humanism that physicians carry throughout their careers (6). My experiences in Pakistan and later work as a doctor in Uganda shaped my life choices just as medical students’ experiences shape their futures.
Ultimately more than idealism will be required to achieve the goal of equitable health care within the US and abroad. Yet idealism and humanitarian values can inspire action and further development of just health systems that provide economic incentives and non-economic rewards to prepare, attract and retain health professionals in areas of need.
1. Smith JK, Weaver DB. Capturing medical students’ idealism. Ann Fam Med. 2006;4(1 Supp):S32-S37.
2. Haq C, Rothenberg D, Gjerde C, et al. New world views: preparing physicians in training for global health work. Fam Med. 2000; 32:566-572.
3. Godkin M, Savageau J. The effect of medical students’ international experiences on attitudes toward serving underserved multicultural populations. Fam Med. 2003;35:273-278.
4. Ramsey AH, Haq C, Gjerde CL, Rothenberg D. Career influence of an international health experience during medical school. Fam Med. 2004; 36:412-416.
5. O’Neil E. Awakening Hippocrates: a Primer on Health, Poverty and Global Service. American Medical Association. 2006.
6. Eckhert NL. Getting the most out of medical students’ global health experiences. Ann Fam Med. 2006;4(1 Supp):S38-S39. Available at: http:// www.annfammed.org/cgi/content/full/4/suppl_1/S38
Competing interests: None declared
Show Less

Competing Interests: None declared.
Published on: (29 September 2006)
Page navigation anchor for Comments on Case Study: "Capturing Medical Students' Idealism"
Comments on Case Study: "Capturing Medical Students' Idealism"
Joseph Hobbs, MD, Augusta, USA
In this issue of the Annals of Family Medicine, there is a brief commentary by Eckhert and a case study by Smith and Weaver addressing the potential impact of educationally-structured global health experiences on the skills and attitudes of medical students. Beyond the unique experiences and skills obtained in these international settings is the potential impact on students’ understanding of not only a broader view of healt...
Show More

In this issue of the Annals of Family Medicine, there is a brief commentary by Eckhert and a case study by Smith and Weaver addressing the potential impact of educationally-structured global health experiences on the skills and attitudes of medical students. Beyond the unique experiences and skills obtained in these international settings is the potential impact on students’ understanding of not only a broader view of health but their attitudes as well. Both articles speculated that these types of experiences could result in a renewed interest in community involvement, especially as it relates to the underserved. They also embraced concepts of a goal-directed curriculum with objectives, evaluations and appropriate mentorship to move these from mere experiences abroad to ones that create a global health perspective and impact students’ idealism and interest in serving the underserved.1,2,3
The adequacy of the physician workforce to meet the needs of all citizens, especially those in underserved communities, continues as a national and international problem. The potential that community-based educational experiences at home or abroad could impact students’ attitudes towards serving underserved populations is a concept worth pursuing further. The case study, “Capturing Medical Students Idealism”, illustrates a medical school program where international health experiences had positive effects on preclinical medical students’ attitudes. This small case study which is limited by factors appropriately noted by the authors such as generalizability, student self selection biases, lack of validated instruments to measure student attitudes, and its retrospective observational design merely suggests the need for more robust educational research concerning the impact of community-based clinical educational experiences.2
Although the attitudes discussed are not unique to primary care or Family Medicine, it would be helpful if future well-designed educational research could determine the types of community-based educational experiences, whether at home or abroad, that could sustain or increase primary care and Family Medicine specialty selection. If the assumptions of these authors are correct concerning the impact on student attitudes, it would appear that more targeted research could provide the evidence necessary to advocate for broad-based changes in medical school curriculum to increase medical education in appropriately prepared community settings. These changes, coupled with the admissions of students likely to pursue primary care careers, could result in students with more knowledge of the full spectrum of the national and world health care needs and cultivate interest and participation in activities serving the health care needs of the underserved populations.1,2,3,4,5
References:
1. Smith JK, Weaver DB. Capturing medical students’ idealism. Ann Fam Med. 2006;4(1 Supp):S32-S37.
2. Eckhert NL. Getting the most out of medical students’ global health experiences. Ann Fam Med. 2006;4(1 Supp):S38-S39. Available at: http://www.annfammed.org/cgi/content/full/4/suppl_1/S38
3. Godkin M, Savageau J. The effect of medical students’ international experiences on attitudes toward serving underserved multicultural populations. Fam Med. 2003;35:273-278.
4. Ramsey AH, Haq C, Gjerde CL, Rothenberg D. Career influence of an international health experience during medical school. Fam Med. 2004;36:412-416.
5. Rabinowitz HK, Diamond JJ, Veloski JJ, Gayle JA. The impact of multiple predictors on generalist physicians’ care of underserved populations. Am J Public Health. 2000;90(8):1225-1228.
Competing interests: None declared
Show Less

Competing Interests: None declared.
Published on: (26 September 2006)
Page navigation anchor for Comments on Smith and Weaver, "Capturing Medical Students� Idealism"
Comments on Smith and Weaver, "Capturing Medical Students� Idealism"
John J. Frey III, MD, Madison, WI, USA
In the summer of 1969, one of my closest friends from medical school and I came to a parting of the ways. We both wanted to spend elective time in our senior year in Latin America. He found a program where he would spend two and a half months in the highlands of Guatemala and, instead of Mexico, I spent the same amount of time in the Rio Grande Valley of South Texas. We both returned with improved Spanish, although mine...
Show More

In the summer of 1969, one of my closest friends from medical school and I came to a parting of the ways. We both wanted to spend elective time in our senior year in Latin America. He found a program where he would spend two and a half months in the highlands of Guatemala and, instead of Mexico, I spent the same amount of time in the Rio Grande Valley of South Texas. We both returned with improved Spanish, although mine had a distinctly "Spanglish" quality to it and his had Mayan words inserted here and there. We both had learned much about ourselves and of the arrogance of privilege and we struggled with ways to be useful in a place where we knew we were temporary visitors. We came back to the "reality" of Chicago altered forever by what we had seen and, by turns, hopeful and discouraged about the forces that kept people in poverty with little hope and hard lives to lead.
My friend and I have, however, engaged in debate about the value of working in international health vs. work in one’s own country that for us, after 27 years, remains unresolved. We have reached a sort of truce. He is a perinatologist for the Alaskan native people and I practice in a community where half of my patients are Mexican immigrants or Mexican Americans. But the article by Smith and Weaver in this issue of the Annals has stirred some ashes of that old debate for me. I am not sure if the findings from their study has put my personal concerns about "here vs. there" to rest.
One of the challenges for educational research, noted by the authors, is assessing the long term effects of short term experiences. Any attempt to attribute career outcomes to specific curriculum requires followup beyond residency education and on into practice. Unfortunately, alumni offices follow graduates better and with more persistence than medical educators do. Until we know what the long term effects of international experiences are on physician behavior, the jury is out on what differences such experiences actually make.
Idealism and service orientation are admirable qualities in any group of professionals and, studies have shown, have an effect on career choice of students who enter medical school with those attitudes.(1) However, the correction of social ignorance - tempering idealism with humility - is an essential lesson for students who want to make a difference in a practical rather than theoretical fashion and be effective in improving the health of a community on the community’s terms.(2)
The large number of students who enter medical school with an interest in international health has, thus far, not translated into a large number of students who choose careers caring for patients in the health underserved communities in this country.(3) While Smith and Weaver show that interest is high for students, interest does not equal commitment. An irony of the past 10 years is that the chief reason for the fill rate for family medicine residency programs nationally is the growth of International Medical Graduates (IMG) who move here for training.(4) After graduation, IMGs are also entering urban practice and are treating a higher percentage of medicaid and medicare patients than their US graduate colleagues.(5) Whatever the reasons, IMG’s are helping meet the workforce needs of our country better than US graduates. If any measures of idealism or organized international experiences would change that trend, it would be a good thing. If not, we can all feel better while communities - both here and abroad - do worse.
1. Madison DL. Medical school admission and generalist physicians: a study of the class of 1985. Acad Med. 1994 Oct;69(10):825-31.
2. Hart JT, Relation of primary care to undergraduate education. Lancet. 1973 Oct 6;2(7832):778-80.
3. Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. JAMA. 2006 Mar 1;295(9):1042-9.
4. Klein LS, Ruddy GR, Phillips RL, McCann J L, Dodoo MS, Green LA. Who filled first-year family medicine residency positions from 1991 to 2004? Am Fam Physician. 2005 Aug 1;72(3):392.
5. Morris AL, Phillips RL, Fryer GE Jr, Green LA, Mullan F. International medical graduates in family medicine in the United States of America: an exploration of professional characteristics and attitudes. Hum Resour Health. 2006 Jul 18;4:17.
Competing interests: None declared
Show Less

Competing Interests: None declared.

Main menu

User menu

Search

Capturing Medical Students’ Idealism

Published eLetters

Plain text

Vertical Tabs

Jump to comment:

In this issue

Citation Manager Formats

Related Articles

Cited By...

More in this TOC Section

Similar Articles

Subjects

Content

Info for

Engage

About

Main menu

User menu

Search

Capturing Medical Students’ Idealism

Published eLetters

Plain text

Vertical Tabs

Jump to comment:

In this issue

Citation Manager Formats

Jump to section

Related Articles

Cited By...

More in this TOC Section

Similar Articles

Subjects

Content

Info for

Engage

About