New certificate honors students’ efforts in global health

During two clinical rotations at the Xiangya hospital system in Changsha, China, medical student Adam Sang came to appreciate the comparative luxury of the 15-minute patient encounter in the United States. In Changsha, Sang said, a physician would interview a patient in a room where 20 other patients might be waiting for a turn with the doctor, clamoring for attention within earshot of the ongoing interview. Privacy was nonexistent.

In Tugela Ferry, South Africa, Michael Peluso learned the value of using story-telling to encourage adherence to a drug regimen. Health workers at the Church of Scotland Hospital there told HIV-positive patients that the virus was like a snake. The snake would emerge from a hole in the ground to attack them, but the medicine could keep the snake at bay. During another rotation at Mulago Hospital in Uganda, Peluso learned how to practice medicine with very limited resources. “I felt that the most valuable tools that I had were my stethoscope and my reflex hammer,” said Peluso, who will begin an internal medicine residency at Brigham & Women’s Hospital in Boston.

In Ghana on a Downs International Health Student Travel Fellowship, Stacey Kallem looked into how children and adolescents learned about their HIV status. Many, she found, believed their medications were for malaria, TB, or an unnamed “blood sickness.”

“The vast majority of patients who were at the HIV clinic … had no idea what their diagnosis was,” said Kallem, who also completed electives in Peru and China. “No one had told them because they were so afraid of stigma.” She presented her findings to colleagues in Ghana, who used her research to obtain an NIH grant for a five-year trial of disclosure methods, including hiring a counselor to facilitate conversations among caregivers and family members.

The three students, along with three others, graduated this year with more than a medical degree. They are the first medical students at Yale to receive a Certificate in Global Medicine that recognizes their interest and efforts in global health. To receive the certificate, which was approved by the Yale Corporation last year, students must complete course work, do research in global health, demonstrate linguistic or cultural competency, show leadership in global health activities, and complete international electives at sites in Africa, Asia, the Pacific, or Latin America.

“We felt that we had enough elements to have a robust program that could be recognized by a certificate,” said Robert M. Rohrbaugh, M.D. ’82, professor of psychiatry, and director of the Office of International Medical Student Education (OIMSE). “For students who are interested in global health, it’s very clear that the world is getting smaller. It’s important for students to have awareness of other cultures, and the best way to achieve awareness is to be ‘the other’, not knowing the customs, feeling a little bit out of place. At a very basic level, it’s good for us all to keep in mind that we need to have some cultural humility in our work, especially with folks who aren’t familiar with our system.”

The OIMSE was established in 2006, and a year later the office organized the first international elective for medical students—three students traveled to Uganda. Now between 30 and 35 medical students complete clinical electives at more than 10 sites around the world each year. Each site provides its own lessons. At the Alam Sehat Lestari clinic in Borneo, founded by a Yale alumna, the focus is on primary care. In Uganda, students see cases of AIDS that are more advanced than those they might see at home. In Cordoba, Argentina, students can focus on nephrology or cardiology. In Ayacucho, Peru, students spend time at a psychiatric clinic. At the Church of Scotland Hospital in South Africa students participate in the management of patients with multi-drug resistant tuberculosis. Each international site is mentored by a Yale faculty member with deep knowledge of and a strong relationship with the site, said Rohrbaugh. “It’s been a very important piece to me to have a colleague who knows the site, travels to that site, understands the issues at that site, and knows people at high levels there.”

The program starts in the classroom during the first year of medical school—all first-year students may take the Global Health Seminar, an interprofessional course that focuses on public health and clinical issues in global health. In the second year, students can take seminars on tropical medicine, global mental health, and pediatric global health issues. They must produce original research that contributes to the field of global health and show leadership through participation in student interest groups or activities related to global health, such as the Global Health Working Group or the HAVEN Free Clinic. The students write reflective essays about their experiences to demonstrate their cultural competence and place them in a broader context. International immersion occurs via clinical electives (for fourth- and fifth-year students) and through the Downs Fellowship program, established in 1965 to send medical, nursing, public health, and physician assistant students to resource-poor countries to conduct intensive scientific research.

“The certificate is very flexible, which I think is consistent with the Yale system,” said Peluso, who developed the curriculum with Rohrbaugh, Janet Hafler, Ed.D., assistant dean for educational scholarship, Richard Belitsky, M.D., deputy dean for education, and Michael Schwartz, Ph.D., associate dean for education. “There are multiple ways of fulfilling each of the requirements. That is unique to the philosophy of this institution and one of its strengths.”

The certificate may take on added importance as interest in global health continues to grow among health professional students and young physicians. The students who received certificates this year plan to make global health an integral part of their medical careers.

“Before I came to medical school I had a more narrow view of global health as primarily going abroad and treating people,” said Kallem, who is starting a residency in pediatrics at Children’s Hospital of Philadelphia. “Through seeing different models of how people incorporate global health here at Yale I realize there are so many different avenues. You can do medical education collaborations, you can have a research partnership, or you can do capacity building in a country.”

Sang, who is pursuing a surgery residency at Stanford, also plans to continue international work. “I think that outside my passion for surgery itself, this profession will give me opportunities to go abroad and work in resource-limited settings in a variety of ways,” he said.