How to Develop an International Clinical Rotation

Thinking about creating an international clinical rotation for your students? Check out these lessons learned from other PA educators.

1. Do Your Research

“First and foremost, don’t rush into it at the cost of not doing it right,” said Nick Hudak, MSEd, MPA, PA-C, chair of PAEA’s International Clinical Rotations Subcommittee and a faculty member at Duke University. “International rotations involve unique challenges, but they can be managed with adequate preparation.”

The most recent data, from 2009, indicates that about 47% of PA programs offer international clinical rotations, which means there’s a wealth of knowledge out there for you to draw upon. The International Clinical Rotations Subcommittee provides a slew of resources to help get you started, and several of its members will be presenting on the topic Thursday afternoon at this year’s Forum.

2. Partner Up

Whether it’s an organization, a clinical site, or a national government, the need for effective partnerships is essential.

When undertaking the development of an international rotation, many PA programs opt to work with an organization specializing in those types of experiences. “Don’t try to reinvent the wheel,” said Wilton Kennedy DHS, PA-C, from the Jefferson College of Health Sciences. “Partner with somebody who knows what they’re doing and who has a philosophy of not medical tourism, but actually increasing capacity in a local community.”

It can also help to think outside the box. “In El Salvador, I worked closely with Peace Corp volunteers who were amazing,” said Zehra Ahmed, MBBS, PA-C, from the New York Institute of Technology.

When a rotation has trouble generating participants, collaborating with other institutions that also have interested students can help the program move forward. University of Utah has partnered with both U.S. and Canadian PA programs, and Nadia Cobb, MS, PA-C, from the University of Utah, said the students then learn from each, an additional benefit.

3. Choose Clinical Sites Carefully

When choosing which countries to visit there are many factors — safety, accommodations, and travel logistics among them — to consider. Finding appropriate clinical sites within that country is the next challenge.

For students to receive course credit, international sites must meet ARC-PA criteria. “These experiences are part of the course, with learning objectives, and should meet the requirements of supervised clinical experience versus service learning,” Hudak said. He also recommends having students evaluate the site just as they would a domestic clinical rotation.

4. Prepare Students

For rotations in rural areas of third-world countries, the challenges go far beyond just those associated with practicing medicine. Students are eating different food, dealing with undeveloped infrastructure, experiencing an unfamiliar culture, and often communicating through translators.

“Students go through this very repeatable pattern of living it, struggling with it, coming to terms with it, and then loving it,” said Cobb.

Ahmed notes that it’s critical to discuss with students how to behave appropriately prior to arrival. In Haiti, she met doctors who’d had a negative experience with U.S. health care students, saying they were disrespectful to the local people and seemed only concerned with completing their survey.

“The problem is when this kind of thing happens, it reflects poorly on everybody,” explained Ahmed. “Situations like that can do a lot of damage.”

To combat experiences like this, her university requires students to complete a didactic course covering cultural differences. Then once they’re abroad, students need to remember their own limitations.

“Many [students] expect to travel to developing countries and do whatever they want clinically,” Ahmed said.

Local preceptors, too, can overestimate American students’ capabilities. “That is something you have to be careful about,” Ahmed noted.

5. Prepare Faculty

Hudak advises that a program designate a specific faculty member to manage international rotations and then provide that person a sufficient amount of time and support to fulfill the responsibility.

Cobb created a rotation that sent students to Ghana nine different times — she admits the first trip was rough.

“Our first year I had not met all the preceptors and didn’t know what needed to be emphasized,” she said. “It was extraordinarily challenging because I couldn’t help prepare the students emotionally.

Now she works reflection time into the itinerary, which allows students to process and discuss their experience.

a group of health care students stand in front of seated elementary school students

PA and DO students from the New York Institute of Technology teach elementary school students about nutrition during a rotation in El Salvador. (Photo courtesy NYIT)

6. Know That It’s Not for Everyone 

Cost is, unfortunately, a hindrance for many students interested in international rotations, but there are several other reasons they may choose not to participate.

“The rotations are rewarding, but it’s not a tourism rotation,” Kennedy said, noting that Jefferson’s Belize trip includes sanitation projects, like building latrines. “A lot of people think they want to go, and then we start talking about what they’ll be doing and the conditions, and people start backing out.”

For others, giving up another elective for the international experience is too big a sacrifice.

“Going to Ghana means you don’t get to do one of your electives, and students think, ‘Oh my gosh, I really struggle with cardiology,’” Cobb said.

Students who already had a strong interest in global health are often the ones to take advantage of the opportunity. “These students already have a fire, and I think these trips increase the temperature of that fire,” Cobb said.

7. Have a True Impact

While PA students gain immeasurably from the experience of practicing medicine abroad, the arrangement also needs to have tangible benefits for the clinical site — a community needs assessment can help with that.

In eastern Uganda, Jefferson College PA students help increase capacity by working with lay midwives who have no formal training. Jefferson is tracking outcomes related to the infant and maternal death and complication rates in the community. “We fully expect to see gains in this area,” Kennedy said.

Ahmed advised thinking twice before bringing medical equipment into a country, even if it’s permitted. “So often you go to clinics and see machines — such as EKGs or relatively simple infant incubators — but they’re not being used because they don’t have a [replacement] part.”

Depending on the country, getting medications through customs can be a challenge, but even if it’s not, you should confirm the same medications are available locally. “Otherwise, what’s the point?” said Ahmed. “The NGO I worked with [for an El Salvador rotation] decided to use the money we had to actually go down there and buy the medications locally and give it to the doctors.”

motorcycle with extension on side to transport patients

An ambulance in Uganda used to reach patients in rural areas.                                                                                                                        (Photo courtesy Jefferson College of Health Sciences)

8. Be Prepared for Cost

This is true not just for PA students, but faculty, too, who often have to pay their own way, at least in the initial years. For many, it’s a labor of love.

William Childers, EdD, MS, PA-C, has previously traveled abroad with PA students and aims to develop international rotations as the program director at West Liberty University. “It takes students out of their comfort zone,” he said, “and I think that teaches them to reflect a little bit more deeply on why they’re doing what they’re doing.

Cobb sees the potential for a new financial resource in the future. “I’m hoping as alumni remember how changing the experience was for them, they will come forth and help support current students,” she said.

9. Enjoy the Rewards

Hudak said international rotations give students the opportunity to learn deeply about cultural determinants of health, different health care systems, and the quality of health care that can be provided in settings with various types of resources. The influence of these experiences often cannot be overstated.

“These kind of immersion rotations are incredibly powerful,” said Cobb. “I think the impact is life-changing in personal as well as professional ways.”