clinical experience in a developing country ( mcur607 ) is a pass  fail sophomore elective course implemented at cms in 2006 . the course provides a curricular framework for medical students wishing to gain exposure to the clinical and cultural practices of a developing country during the summer after their first year . sophomore electives offer in - depth training in specific or applied areas of the basic medical sciences to medical students in good academic standing who have completed first - year requirements . eligible students choose from a number of didactic , interdisciplinary , research , or service - oriented classes . mcur607 fulfills two out of the three pass  fail sophomore elective units required for medical student graduation . nv and mc designed the course with a vision for participants to develop into well - rounded course objectives describing valuable skills and knowledge attainable through a study - abroad experience early in students ' medical careers related directly to the university 's existing core competencies ( table 1 ) . with the support of ihig 's faculty advisor ( cl ) , jointly serving as course director , the course proposal was presented to the educational affairs committee and accepted as a new sophomore elective . mcur607 course objectives two months prior to traveling abroad , first - year medical students submitted a clinic approval form to course faculty , describing the clinic or clinical program , expected volunteering activities , contact information of physician mentor , and any additional program or language requirements , as well as planned dates of travel , specific costs , and living arrangements . course teaching assistants ( hp and ah ) , two student officers elected through ihig , screened submissions for completeness and adherence to course objectives , requested missing program details , and advised students having difficulty with the process . most students traveled to clinics chosen from an established list created by ihig based on the experiences of previous students and faculty . these students completed a new clinic approval form , which required additional details on how they discovered the program , the type of clinic or hospital , the patient population served , and any affiliations with a medical school . in either case , faculty oversight encouraged students to plan early for a successful trip and ensured that students programs met the course mission and requirements . along with the clinic approval form , students also submitted a waiver and release form prior to travel . developed in collaboration with the university general counsel , the waiver released the university from liability for a student 's health or injury and required students to obtain adequate health insurance covering medical evacuation and repatriation . students were encouraged to go to the state department and center for disease control and prevention ( cdc ) websites to monitor any political unrest or infectious outbreaks in their planned country of travel . students were required to volunteer at a clinic in a developing nation for at least 60 h and a minimum of three weeks under the direction of a physician mentor . currently , at cms , sophomore elective credits require 30 h of involvement to obtain one credit . hence , this elective required students to complete 60 h of work . after completing the experience , the mentor signed a physician verification form to confirm the hours worked and provide feedback on the student 's behavior . some students incorporated language study into their clinical experience . in this case , students also kept a patient log with patient age , gender , chief complaint , diagnosis , and treatment . while not specifically required , students were encouraged to keep a journal for self - reflection , interact and communicate with indigenous people , travel within the country , and appreciate alternative perspectives . specifically , the essay addressed ( a ) the program , country , and daily activities ; ( b ) two country - specific determinants of individual health or quality of life ( i.e. , sanitation , endemic diseases , governmental or public policy ) ; ( c ) a patient who made a strong impression on the student ; ( d ) how the experience may impact the student 's future career in medicine ; and ( e ) any unexpected obstacles or challenges faced during the stay . students also created a 10-min powerpoint presentation with a photo journal illustrating their experience and its impact , both cultural and academic . students who traveled with peers in the same program could opt to create one powerpoint and present as a group . the essay , powerpoint , as well as patient log and physician verification form , were submitted to course faculty by the second week of the sophomore year , either in person or through an online drop box as part of the university 's online course management system . within one month of submission , all students who completed the course attended a mandatory meeting and shared their presentations with each other . presentations were also given throughout the year at university - wide meetings sponsored by ihig . the group selected presentations representing a variety of regions and cultures , often in conjunction with a cultural organization on campus , in order to recognize past participants and inspire new ones . presentations also shared the achievements and challenges of student experiences , led discussions on country - specific , medico - cultural issues , and raised awareness of global health issues around campus . nv and mc independently screened the reflection essays for common themes ; only those themes recognized by both screeners were used to define learning outcomes . themes were chosen based on the repetition of keywords and the patterns of ideas noted while reading the essays . these quotations were then counted to calculate the frequency of each learning outcome and a portion selected for publication ( see table 4 ) . two months prior to traveling abroad , first - year medical students submitted a clinic approval form to course faculty , describing the clinic or clinical program , expected volunteering activities , contact information of physician mentor , and any additional program or language requirements , as well as planned dates of travel , specific costs , and living arrangements . course teaching assistants ( hp and ah ) , two student officers elected through ihig , screened submissions for completeness and adherence to course objectives , requested missing program details , and advised students having difficulty with the process . most students traveled to clinics chosen from an established list created by ihig based on the experiences of previous students and faculty . these students completed a new clinic approval form , which required additional details on how they discovered the program , the type of clinic or hospital , the patient population served , and any affiliations with a medical school . in either case , faculty oversight encouraged students to plan early for a successful trip and ensured that students programs met the course mission and requirements . along with the clinic approval form , students also submitted a waiver and release form prior to travel . developed in collaboration with the university general counsel , the waiver released the university from liability for a student 's health or injury and required students to obtain adequate health insurance covering medical evacuation and repatriation . students were encouraged to go to the state department and center for disease control and prevention ( cdc ) websites to monitor any political unrest or infectious outbreaks in their planned country of travel . students were required to volunteer at a clinic in a developing nation for at least 60 h and a minimum of three weeks under the direction of a physician mentor . currently , at cms , sophomore elective credits require 30 h of involvement to obtain one credit . hence , this elective required students to complete 60 h of work . after completing the experience , the mentor signed a physician verification form to confirm the hours worked and provide feedback on the student 's behavior . some students incorporated language study into their clinical experience . in this case , students also kept a patient log with patient age , gender , chief complaint , diagnosis , and treatment . while not specifically required , students were encouraged to keep a journal for self - reflection , interact and communicate with indigenous people , travel within the country , and appreciate alternative perspectives . specifically , the essay addressed ( a ) the program , country , and daily activities ; ( b ) two country - specific determinants of individual health or quality of life ( i.e. , sanitation , endemic diseases , governmental or public policy ) ; ( c ) a patient who made a strong impression on the student ; ( d ) how the experience may impact the student 's future career in medicine ; and ( e ) any unexpected obstacles or challenges faced during the stay . students also created a 10-min powerpoint presentation with a photo journal illustrating their experience and its impact , both cultural and academic . students who traveled with peers in the same program could opt to create one powerpoint and present as a group . the essay , powerpoint , as well as patient log and physician verification form , were submitted to course faculty by the second week of the sophomore year , either in person or through an online drop box as part of the university 's online course management system . within one month of submission , all students who completed the course attended a mandatory meeting and shared their presentations with each other . presentations were also given throughout the year at university - wide meetings sponsored by ihig . the group selected presentations representing a variety of regions and cultures , often in conjunction with a cultural organization on campus , in order to recognize past participants and inspire new ones . presentations also shared the achievements and challenges of student experiences , led discussions on country - specific , medico - cultural issues , and raised awareness of global health issues around campus . nv and mc independently screened the reflection essays for common themes ; only those themes recognized by both screeners were used to define learning outcomes . themes were chosen based on the repetition of keywords and the patterns of ideas noted while reading the essays . these quotations were then counted to calculate the frequency of each learning outcome and a portion selected for publication ( see table 4 ) . in 2007 , 30 second - year cms students ( n=30 , 15 males , 15 females ) participated in and successfully completed the mcur607 elective with a combined total of 3,276 h spent abroad . students completed an average of 109.2 h each , with a range of 40300 h. students traveled across four major continents : asia ( south , east , and southeast ) , africa , central america , and europe . thirty - four percent of students traveled to china , 23% to india , 14% to ecuador , 7% to ghana , 7% to south korea , 3% to armenia , 3% to the czech republic , 3% to the philippines , 3% to costa rica , and 3% to vietnam . table 2 describes the programs offered at the various international health sites at which students participated . international health sites ninety - three percent of students observed surgical procedures , 70% conducted physical examinations , 46% assisted in surgery , 43% of students performed history taking , 17% administered medications ( rx ) , 17% conducted social counseling , and 10% stated  other.. the skills listed under the heading of  other included inserting intra - venous ( iv ) lines , inserting foley catheters , inserting naso - gastric tubes , and assisting with cardiac stress tests . one hundred percent of students interacted with physicians , 87% with nurses , 23% with physiotherapists , 13% with religious chaplains , 7% with social workers , and 7% with others . another student witnessed the integration of chinese acupuncture with allopathic medicine . within one week of the mandatory student presentations , 100% of students completed a  post - experience survey composed of various statements pertaining to international health ( table 3 ) . prior to survey distribution , institutional review board ( irb ) approval was granted and students provided informed written consent . this survey used a 5-point likert scale ( strongly disagree , disagree , somewhat agree , agree , strongly agree ) , with each response receiving a numerical value from one to five . we compiled and analyzed data from the survey based on whether the response was one or two ( negative ) or three to five ( positive ) . one hundred percent of students were exposed to a new culture , 100% would recommend mcur607 to colleagues , 100% would like to make future contributions to international health in developing nations , 97% reported exposure to a new language , 93% felt more culturally sensitive , 90% thought the cms curriculum prepared for this international experience , 87% learned novel skills that they would not normally have learned in north america at this stage of their education , 83% improved their knowledge on international health initiatives , and 70% believed this international experience altered their career choice . post - experience survey comments table 4 correlates student essay - derived learning outcomes and cms core competencies . the most common themes reference cultural influences on medical care , government involvement , and socioeconomic issues . the remaining themes , from most to least frequently mentioned , include references to learning compassionate medicine , challenge of language barriers , future student involvement with underserved populations , preclinical student motivation , sanitation and sterility concerns , self - awareness and recognition of personal limitations , cultural sensitivity , lack of preventative medicine , strengthening non - verbal communication , and comparisons with american health care . post - experience essay themes and quotes number of student essays with reference to theme . in 2007 , 30 second - year cms students ( n=30 , 15 males , 15 females ) participated in and successfully completed the mcur607 elective with a combined total of 3,276 h spent abroad . students traveled across four major continents : asia ( south , east , and southeast ) , africa , central america , and europe . thirty - four percent of students traveled to china , 23% to india , 14% to ecuador , 7% to ghana , 7% to south korea , 3% to armenia , 3% to the czech republic , 3% to the philippines , 3% to costa rica , and 3% to vietnam . table 2 describes the programs offered at the various international health sites at which students participated . international health sites ninety - three percent of students observed surgical procedures , 70% conducted physical examinations , 46% assisted in surgery , 43% of students performed history taking , 17% administered medications ( rx ) , 17% conducted social counseling , and 10% stated  other.. the skills listed under the heading of  other included inserting intra - venous ( iv ) lines , inserting foley catheters , inserting naso - gastric tubes , and assisting with cardiac stress tests . one hundred percent of students interacted with physicians , 87% with nurses , 23% with physiotherapists , 13% with religious chaplains , 7% with social workers , and 7% with others . post - experience survey composed of various statements pertaining to international health ( table 3 ) . prior to survey distribution , institutional review board ( irb ) approval was granted and students provided informed written consent . this survey used a 5-point likert scale ( strongly disagree , disagree , somewhat agree , agree , strongly agree ) , with each response receiving a numerical value from one to five . we compiled and analyzed data from the survey based on whether the response was one or two ( negative ) or three to five ( positive ) . one hundred percent of students were exposed to a new culture , 100% would recommend mcur607 to colleagues , 100% would like to make future contributions to international health in developing nations , 97% reported exposure to a new language , 93% felt more culturally sensitive , 90% thought the cms curriculum prepared for this international experience , 87% learned novel skills that they would not normally have learned in north america at this stage of their education , 83% improved their knowledge on international health initiatives , and 70% believed this international experience altered their career choice . post - experience survey comments table 4 correlates student essay - derived learning outcomes and cms core competencies . selected student quotes reflect common themes witnessed during their international experiences . the most common themes reference cultural influences on medical care , government involvement , and socioeconomic issues . the remaining themes , from most to least frequently mentioned , include references to learning compassionate medicine , challenge of language barriers , future student involvement with underserved populations , preclinical student motivation , sanitation and sterility concerns , self - awareness and recognition of personal limitations , cultural sensitivity , lack of preventative medicine , strengthening non - verbal communication , and comparisons with american health care . post - experience essay themes and quotes number of student essays with reference to theme . as world cultures integrate , students and physicians across the usa have increased their concern for cultural sensitivity and competence . in order to better understand the interactions of these cultures with the health care system , many medical students elect to volunteer in clinics and hospitals abroad or join a global multiculturalism track ( 4 , 10 ) . medical students have driven much of the growth in global health education ( 2 ) . this paper describes the global health curriculum initiated , designed , and executed by medical students with faculty assistance and support , as well as its successful impact on the development of its participants as well - rounded physicians . the structured curriculum of mcur607 led to a paradigm shift of the extracurricular ihig from a mere travel club to an academic experience of cultural immersion and reflection on health care determinants . despite students pretravel exposure to international health through peer and physician - led ihig lectures , mcur607 students remained surprised by their firsthand experience with cultural and societal - specific practices integrated into the hospital environments . one student was astonished by the rarity of prenatal care in a large , urban center of vietnam . she attributed this to providers lack of emphasis on prevention education and limited demand secondary to the existence of traditional home remedies . a student who observed decreasing health care quality for poor patients in india learned how government corruption blocks the flow of finances allocated for system improvement . another student did not expect emergent surgical care in china to require advanced payment , and his colleague concluded that  health care is a business worldwide. rather than make simple observations , students used critical thinking to analyze the practice differences as a socio - behavioral science . as seen through their essays ( table 4 ) , students primarily emphasized the impact of social class and economic disparities on health care access , as well as the role of culture on influencing a nation 's practice of medicine . these cross - cultural interactions help to promote the recognition of diverse practices , beliefs , and value systems , which is imperative for the practice of medicine as global interdependence strengthens . for example , many students who traveled to east asia found that physicians defer to a patient 's family rather than the patient when disclosing terminal prognoses . in the future , students who encounter a family wishing to withhold a terminal prognosis from a patient can address the situation in an empathic , culturally sensitive manner . several other students in india , china , and ecuador observed the integration of indigenous healing modalities with western medicine and found them extremely compatible . they are more likely to question patients about any complementary or alternative medicine the patient may have used in order to provide more comprehensive care . such medico - cultural experiences have the potential to influence the way students practice medicine in the future due to their new perspectives . patient relationship , thus contributing to improved health status of immigrants arriving in the usa and the diverse cultures that make up this country . the positive impact of the global health experience on the practice of medicine extends beyond treating members of different cultures . in addition to exposure to various languages , students felt as though they had strengthened their non - verbal communication skills and the ability to provide comfort to patients with whom they could not speak . students renewed their confidence while surviving and adapting in settings with fewer resources , language barriers , and cultural differences . many redefined their understanding of privilege and , from this self - awareness , realized their desire to incorporate treating underserved populations into their careers . a reward of global health education not previously described in the literature ( 2 , 4 ) is the short - term impact to motivate preclinical students . as summarized in tables 1 and 4 , the vast benefits from a clinical experience in a developing country that students have described meet each of the mcur607 objectives and fulfill all six cms core competencies . despite the successful outcomes of the course , there exist several logistical hurdles of cost , language , and planning for students participating in mcur607 . students must fund the trip themselves , and it is acknowledged that there are students who can not participate in the course due to financial constraints . there are no scholarship funds available from cms , but students are given information from ihig about outside scholarships for which they can apply . some programs , like that in zhejiang province of china and dervin village of india , may subsidize housing or food costs , thereby attracting considerably more students . for universities without affiliated global health funding or departments like cms , financial challenges remain an obstacle for students who wish to participate in clinical experiences abroad . a large amount of time and resources must be devoted to finding a suitable placement for the student to fulfill their course obligations . if the experience does not materialize as planned , students must also problem - solve in real time . two mcur607 students traveling to costa rica discovered that their program , while fulfilling the language teaching as promised , did not have adequate site placements for the clinical portion of the experience . one student took the initiative to find her own clinical site and the other decided to use the time to travel rather than completing the course requirements . these students managed to communicate via email with the course faculty who attempted to assist with a new placement , but the ultimate responsibility fell on the students . while students strengthened their non - verbal communication skills , several students wished they could speak the language of their patients to benefit the site . even students who had experience in a language often felt local dialects or slang prevented them from fully participating in patient care . the language barrier drove many students to participate in surgical procedures that are not subject to the same language constraints of the history and physical examination in the clinic setting . despite these obstacles , students enjoyed the course and all agreed they would recommend it to their peers . because no data were collected from students who traveled abroad prior to the creation of mcur607 , we can only infer the advantage of this model aside from the additional course credit students receive . the course founders , mc and nv , did travel in the year prior to course creation and agree with the benefits of the structured curriculum from an empirical standpoint . in addition , no control data were collected from peers of mcur607 participants who did not travel , so we can not know if students are developing similar skills through non - international experiences . the authors recognize the subjective nature of the data and the difficulty in preventing observer bias by the two authors , mc and nv , who coded the essays for themes . for this reason , we included the exact quotations from student papers in table 4 ; however , we do not include the full text of 30 essays for logistical reasons . finally , we faced challenges in monitoring the quality of student experiences . while we attempted to validate the clinic sites in advance through submission of detailed approval forms , all assessment was at the discretion of the course faculty . the physician verification form and patient log can be reviewed if there is question of experience quality , and the reflection essays offer students an opportunity to disclose their own analysis of any limitations in the experience . because of the subjective nature of the course , there is , ultimately , an implicit trust in students who organize their experience , to research quality and report any irregularities . while considering the challenges of the course and limitations of this paper , we do feel that other schools interested in developing an international health elective may follow our model . the foundation of the course involves a student organization that focuses on international health to serve as a focal point for information and publicity . the organization provides a means to engage dedicated students who wish to serve as course teaching assistants and the faculty advisor can double as course director . this is particularly useful in ensuring the course 's sustainability when there is no dedicated global health department at the university . in order to travel for a substantial period , students must also have a block of time during their preclinical years to complete the international elective . we have successfully established a student - initiated preclinical elective in international health and documented significant learning outcomes for students . in its pilot year , mcur607 course organizers have obtained information from essays , patient logs , presentations , and post - experience surveys completed by traveling students . such submissions , student comments , and the medical education literature provide a continuous source of feedback from which organizers can actively improve the course . a recent study ( 14 ) posed several valid ethical questions regarding the benefit afforded to a host country , as well as the possibility of maleficence when students participate in short - term clinical experiences abroad . though physician - mentors provide clinical supervision , students themselves should reflect on possible ethical violations and negligence in their essays . while not a requirement , a small percentage of motivated students do bring medical supplies ( e.g. , gloves ) to their sites or organize fundraisers upon their return based on witnessed needs during their clinical experience . in addition to encouraging such activities , we can actively seek subjective information about the benefits for the host country from host physician - mentors . we have also shown that mcur607 students wish to incorporate global health into their career , which may impact host countries in the long term . interestingly , the literature also states that many students are more enthusiastic about primary care after returning from international heath efforts ( 2 , 4 , 15 ) . early global experiences afforded by mcur607 may impact student decision making during a formative stage . future studies should attempt to collect and analyze data regarding student specialty choice and host country benefit with the aim of answering these questions . the authors have not received any funding or benefits from industry to conduct this study .
introductionglobal health education is becoming more important for developing well - rounded physicians and may encourage students toward a career in primary care . 
 many medical schools , however , lack adequate and structured opportunities for students beginning the curriculum.methodssecond-year medical students initiated , designed , and facilitated a pass  fail international health elective , providing a curricular framework for preclinical medical students wishing to gain exposure to the clinical and cultural practices of a developing country.resultsall course participants ( n=30 ) completed a post - travel questionnaire within one week of sharing their experiences . 
 screening reflection essays for common themes that fulfill university core competencies yielded specific global health learning outcomes , including analysis of health care determinants.conclusionmedical students successfully implemented a sustainable global health curriculum for preclinical student peers . 
 financial constraints , language , and organizational burdens limit student participation . in future 
 , long - term studies should analyze career impact and benefits to the host country .