Introduction

Globalisation provides opportunities and challenges to medical education. There is an increasing interest in overseas service trips and global health education where medical students engage in Overseas Community Involvement Project (OCIP). These trips involve medical students, usually from high income regions, travelling to a lower resource setting. The trips, ranging from 1 week to 3 weeks in duration, are student-led, supervised by a physician mentor who may not necessarily accompany them. Such trips were more common prior to the COVID-19 pandemic related travel restrictions. Currently, it is picking up pace once again as the world is steadily recovering from the pandemic.

As this overseas service activity begins to resume, it is time to re-think how it can be approached. These trips raise ethical issues such as sustainability of student involvement or a lack of follow-up of patients after a diagnosis of a chronic illness during the trip [1,2,3,4]. In addition, when students volunteer, significant resources are dedicated to this activity including time, money and even utilisation of the receiving countries’ scarce resources. Safety of all involved is also an issue as there are no regulations about personal protective equipment or operating protocols should the students encounter an infectious disease outbreak. Hence, it is now more important than ever to be clear on the risks and benefits of such trips.

If the risks and benefits are well taken into consideration when planning an OCIP, these trips may have the potential to benefit the community in low-income settings through collaborative partnerships [5, 6]. For the students, the OCIP may serve as an educational tool or pedagogy in medical education. The experience can be very rich and may stimulate learning of important but often neglected topics within medical education which are also challenging to teach such as health systems and socioeconomic and cultural determinants of health [7,8,9]. The OCIP also provides students with early exposure to community health [10] and may potentially be a valuable source of experiential learning.

While a few studies [11,12,13] described the benefits and issues around volunteerisms in global health, very little medical education research has been conducted to demonstrate the possible learning outcomes of an OCIP. Specifically, there is a gap in understanding how the OCIP experience relates to medical education competencies. Furthermore, the literature on the experience of Asian medical students volunteering in overseas community projects is sparse. As global health issues are increasingly incorporated into medical education with growing interest in OCIP, it is important to understand what Asian medical students learn and how this complements their medical education back home. This in turn can help the medical educators structure the OCIP to optimise its learning value. Therefore, the aim of this study is to gain an in-depth understanding of the experiences and learning outcomes of the medical students who participated in the OCIP.

Methods

Study design

A qualitative study design was chosen as the study requires an in-depth understanding of students’ experiences.

Setting and participants

This study was based in one medical school in Singapore, a metropolitan city state. Each of the three medical schools in Singapore have multiple OCIPs which are student-led with physician oversight. Such OCIPs have been in existence in each of these schools since their setup and is voluntary. It is currently not part of the medical curriculum but is available for anyone to join in medical school. The term OCIP is used rather than short term experiences in global health (STEGH) because the objective of such trips is to provide service to an underserved community rather than a ‘global health experience’. The OCIP group usually revisits the same location to ensure continuity of care. The OCIP activities typically include screening camps, health education or training to equip the community with a certain set of skills. Project Aasha is an annual OCIP where participants spend two weeks in the rural, mountainous region of Nepal. Landlocked between India and China in Asia, Nepal has a population of about 30 million, spread across the valley of Kathmandu (its capital) and unique terrains comprising of the world’s highest mountains and terai (lowland region). Though healthcare is heavily subsidised for the poor, the challenging terrains affects accessibility, and the poor health literacy and volatile politics makes implementation of policies difficult. Hence, universal health coverage and equitable health provision is still a struggle. The trip was based in Bung village in the Himalaya mountains in North-eastern Nepal at an elevation of 1800 m and Biratnagar city, a terai in Eastern Nepal. The health service consisted of first aid training and women’s health education for school students, health screening and cataract surgery for the villagers. This trip rooted from the local community leaders approaching the physician mentor of Project Aasha. They were concerned of the general poor state of health of the villagers- where many of them do not continue with follow up care for their chronic conditions, there was poor health literacy and there was a major concern about injuries and the lack of first aid knowledge as the nearest hospital was a day’s walk away. Following contact with the community leader, and prior to this trip, Project Aasha members did a separate trip for a needs analysis (by performing a door-to-door survey) and also proceeded to apply for permits to allow the team to practice in the village of Bung.

The OCIP team consisted of a physiotherapy group (four students and a mentor) an ultrasonographer, five doctors (from specialties of Ophthalmology, Emergency Medicine, Orthopaedics and Surgery), fourteen medical students and two Nepalese student translators. Pre-trip, the students were involved in researching about the community they would be visiting in Nepal, preparing the logistics for the team’s stay, trip itinerary, medical equipment, medications and training materials for the community. There was also a sharing session in which the teams that had previously went to Nepal shared their experiences. Once in Nepal, the team reached their destination by jeep on partially built gravel roads and trekking through the mountainous terrain. The team took the same route that the villagers would take to reach secondary and tertiary healthcare facilities. This gave them the opportunity to meet the various stakeholders in the clinics and hospitals, with the aim of understanding the local health system. The mentors accompanying the students utilised reflections [14] to consolidate students’ daily experiences. Reflective learning, where a deliberate attempt is made to share and reflect on one’s experiences from the day [15] is key to Project Aasha as it helps shape the experiences into learning moments. Participants for this study were 14 medical students who took part in the trip.

Data collection

At the start, the students were asked to share verbally within the group and in a reflective log on their motivations to participate in the OCIP. On each of the four service days, they were also asked to fill a personal daily reflective log. The end of each service day consisted of a daily debrief, where operational issues of the day will be discussed followed by a group reflective session, where the supervising seniors (doctors and physiotherapists in this trip) also shared their reflections. The reflective log asked all the students to pen down their experience and learning points for the day while the group reflective session asked some of them to share their experiences from the day. This was recorded and transcribed verbatim. At the end of the trip, two focus group discussions (FGD) were conducted on-site where the students were asked to share their overall experience from the trip and what they have learnt. They were audio-recorded and transcribed verbatim. Hence, the data collection comprised three different sources- reflective journals, overall group reflections and the two FGDs.

Data analysis

The transcribed data and written materials were thematically analysed by two coders (GN, MN). GN and MN are both medical doctors with public health training. Disagreements were resolved by a third coder (SY) who is an academic faculty member with expertise in global health and health services research through iterative meetings. Following the initial thematic analysis, compiled themes and sub-themes were subsequently mapped onto the ‘Accreditation Council for Graduate Medical (ACGME) core competencies for medical professionals’ since it is a commonly used framework to measure the competencies of the medical doctors in Singapore. Themes and sub-themes that did not fall within the ACGME categories but emerged from data were also compiled. Therefore, our analysis involved both inductive and deductive approaches. To bolster the strength of our qualitative analysis, we employed data triangulation by incorporating multiple data sources including on-site reflective journals, recorded group reflections and focus groups. These sources allowed us to capture comprehensive exploration of students’ experiences. The analysis involved two independent coders, each responsible for examining the three sources of data. By comparing interpretations of the coding, we assessed the extent of convergence across various data and between coders while also identifying any divergences. This approach ensured a rigorous examination of the experiences and learning outcomes. Through analysis, a conceptual diagram for the learning outcomes from OCIP was generated.

Ethics

The study was declared to have exempt status and ethical waiver by the SingHealth Centralised Institutional Review Board (Ref no. 2018/3226).

Results

Table 1 shows the characteristics of participants and their motivations to join the trip. There was a balanced number of male and female participants from both year one and two of the same medical school, with an average age of 20 years old. Approximately three quarters (75%) did not have a prior OCIP experience. The majority of students (50%) stated that the experience of healthcare in a low resource setting was the main motivation to join the trip, followed by the experience of healthcare within a different culture, learning how to plan for medical mission trips, wanting to join a sustainable OCIP project and an interest in serving an underserved population.

Table 1 Participant characteristics
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Learning points during the preparation phase of the trip

Table 2 shows what participants learnt during the pre-trip preparation phase. Three themes were identified – organisational skills, teaching skills and the ability to take into context the culture of the recipient community when developing health education materials. As this is a student-led trip, the students organised all aspects of the trip for the team as well as for the Nepalese community. Consequently, many reflected on acquisition of organisational skills during the preparation phase.

Table 2 Learning points during the preparation phase of the trip
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The students also prepared teaching materials for first aid, hand hygiene and women’s health under the physician’s guidance. The initial teaching materials were adopted from the internet, which lacked localisation and thus appeared to be unsuitable for the villagers. For example, for menstrual hygiene, the menstrual cup was seen to be too invasive and culturally inappropriate, and the sanitary napkins were viewed as environmentally unfriendly as compared to using a cloth. Through feedback from the physicians as well as sharing from their predecessors who had visited the village the year before, they learnt to tailor the teaching materials accordingly to the local culture, beliefs and practices.

OCIP experience and learning outcomes according to ACGME framework

Participants’ experiences and reflections engendered various themes under the six domains of the ACGME framework. These quotes for the themes are summarised in Table 3.

Table 3 OCIP experience and learning outcomes mapped onto ACGME framework
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Patient care (PC)

Their reflections depicted the experience of humanism. Besides attending to the patients, the students observed how the doctors, translators and physiotherapists interacted with the patients. This allowed them to appreciate different facets of patient care such as understanding patients’ unique concerns besides the medical complaints and seeing them as an individual rather than a collection of symptoms and signs. Socioeconomic and cultural determinants of health were another two emerging themes of this domain. As one student reflected, “an elderly couple with social issues that greatly outweighed their medical ones, leading me to rethink how to we treat patients”. Seeing them in-situ within their villages and communities allowed the students to appreciate how their lifestyle, habitat and beliefs could influence their presenting medical complaints and health behaviors. For example, students noticed that despite medical advances and awareness, villagers preferred to follow the practice of being isolated during the menstrual cycle or deliver at home instead of using a birthing center due to their own cultural beliefs.

Medical knowledge (MK)

Besides clerking for the patients, the students took on the roles of a pharmacist and a triage nurse which helped them improve the understanding of the patient’s healthcare journey and narratives. Students also worked closely with the doctors who would supervise all the cases they saw. This opportunity allowed them to “use medical knowledge to correlate the clinical presentation with the disease” and apply their medical knowledge in a safe, protected environment.

Practice based learning and improvement (PBLI)

Interactions with the stakeholders especially enabled the students to appreciate the role of PBLI in striving for quality care for the villagers. As this OCIP doesn’t involve any NGOs, the students had the chance to directly interact with the village leaders and clinic leads to understand the healthcare issues in the village and brainstorm on solutions. Through conversations with these stakeholders, they were able to “understand the situation better and design programmes that will benefit the communities the most.” In this process, they learnt how best to investigate and evaluate the needs of the population and the importance of regular feedback to improve the system.

Interpersonal and communication skills

During the OCIP, the patients mainly spoke the Nepali language which indeed created a challenging language barrier. When the students had to work around this barrier, it allowed them to appreciate the importance of non-verbal communication as well as accuracy in understanding the patients’ narrative when taking a history from them. As one student described, students learned “how to make patients feel engaged and connected to you even though I was speaking through a translator.” During the daily reflections sharing, the physicians shared their communication challenges back in multiracial Singapore where knowing English alone is insufficient as each of the elderly patients speak their ethnic dialect. This reflection allowed the students to relate the experience to the situation In Singapore and reflect on how they would communicate across language barriers.

Systems based practice (SBP)

This OCIP was designed in a way that the team has to trek through the mountains from the nearest town to reach the villages for medical service provision and training. This follows the villagers’ journey should they need to travel to a tertiary hospital as the roads are not conducive for vehicular travel. The experience made the students realize how such a system can especially impact the speed of treatment in times of emergencies. During reflections, the physicians also shared that although Singapore is a developed country, for an elderly or disabled patient, their frequents trips to the hospital for multiple medical appointments is comparable. Hence, an ideal situation may be to have a strong primary healthcare facility near their homes, staffed by health professionals who have built a good rapport with the villagers and can manage common chronic conditions. It was commonly reflected that such experiences and sharing enabled them to understand healthcare delivery in low resource settings and relate it back to practice at home. Many reflected on health inequity as they saw how those living in the mountains were disadvantaged due to inaccessibility by virtue of the terrain or when they were unable to afford transport via helicopter to reach a tertiary hospital when time critical care is needed. In addition, the health post at these mountainous villages were often left unattended unlike those along more popular trekking routes like the Everest Base Camp trek or in the city. This created an unreliable system and affected the confidence the villagers have on the healthcare providers. Birthing centres were also present, but they were located on the top of a hill which was challenging for pregnant ladies to travel to. Hence people defaulted antenatal follow-ups and delivered at home. Such experiences brought about reflections on healthcare systems, accessibility and delivery. Specifically, students highlighted the importance of “understanding the bigger picture of the healthcare system in the management of patients.”

Professionalism

Many themes emerged under the domain of professionalism, such as the ethics around such short-term mission trips as well as role modelling when the students saw how the local doctors worked hard for the underprivileged population. Students reflected that healthcare is all “about heart” and they should “always reach out to those in need of greater help.” Experiencing healthcare in a low-income setting also brought about a sense of gratitude. Concurrently, organizing and conducting the trip together with different healthcare professionals provided the platform for the development of teamwork, leadership and interprofessional skills. Lastly, through their experience and reflections, the students reflected on their self-resilience as well as the resilience of the Nepalese people in managing with the minimum. Students observed that witnessing how Nepalese people navigate challenges despite limitations in healthcare infrastructure provided them with “a better insight into what it means to be resilient and how to cope with difficult situations.”

The ACGME framework is broad enough to encompass the various themes from the students’ reflections. Interestingly, these themes refer to the soft or non-technical skills (NTS) in the medical curriculum. These themes also fall within the domains of global health education (socioeconomic and cultural determinants of health, PBLI, SBP), personal (teamwork & leadership skills, resilience) and professional (humanism, MK, ICS, interprofessional skills) development. Teaching the NTS is challenging and may sometimes be perceived as less important by the students. Hence, we propose an alternative conceptual model (Fig. 1) to highlight learning outcomes from OCIPs. It aims to help the facilitator and learner in reflecting on their experiences, converting them into learning moments and effectively consolidating learning outcomes in an OCIP. Our framework takes the form of a pyramid, with “Personal Development” forming its base, “Professional Development” building upon that foundation and ultimately capped with “Global Health Awareness”. It is structured as such because it is imperative for the learner to develop personal competencies and attributes to be in a comfortable zone, to glean the higher-order professional and global health skills offered by an OCIP experience. For example, without addressing personal competencies such as teamwork or adaptability to the challenging environment, students may struggle to progress to the next stage of learning professional competencies. Only by adequately addressing these two foundational skills, can students develop a deeper appreciation for global health principles, such as social determinants of health. Understanding the students’ motivations pre-trip can set the learners’ agendas and shape the experiential learning outcomes. Lastly, reflections during the trip and a healthcare journey approach can meaningfully contribute to reaching these outcomes.

Fig. 1
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Framework for OCIP learning outcomes

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Discussion

This study sought to understand Singaporean medical students experience and learning outcomes of the OCIP. While findings from this study echo the benefits of global health experience published elsewhere [8, 10, 16], this is the first study to show how the OCIP experience could translate to various facets of ACGME domains. Our results demonstrate that OCIP is relevant to undergraduate medical education and could be a pedagogical tool for acquiring ACGME competencies as well as skills relevant to their personal, professional development and global health understanding.

The OCIP provides the opportunity to utilize both experiential learning [17, 18] and reflections, which are powerful pedagogical tools in medical education and part of the Kolb’s learning cycle. It provides the space to experience medicine in a more relaxed setting. The dedicated sharing time allows them to reflect and conceptualise the experience and eventually test out what they have learnt the following day [17]. The experience, reflection, abstract conceptualisation and experimentation are all part of the Kolb’s cycle.

The OCIP also contributes to the transformative learning process [19]. The students had certain assumptions at the start of the OCIP, which were challenged during the trip. Some of the self and group reflections evoked deep discussions which brought about a change in their perspectives. This is similar to studies which show that critical reflection of experiences serve as a pedagogical approach to learn complex concepts [20, 21]. For example, a successful physician is seen as one who can diagnose a patient’s problem and prescribe the appropriate management. However, in the low-resource setting, there was the realization that such skill would not suffice in the optimal long-term management, due to the scarcity of treatment or the inability of villagers to travel regularly to tertiary hospital for continued treatment. Thus, a “health systems” thinking process would be required to address the patient’s problems. Upstream problems (e.g., sanitation, diet) need to be addressed and active effort needs to be made for effective health education and preventative health. Allied healthcare may need to be stationed at the village health posts. The physician should be able to effectively communicate a diagnosis to the villagers and help them understand the impact of illness and treatment noncompliance on their lives such that they follow up on their treatment. And most importantly there should be a system to ensure continuity of care after the departure of overseas physicians. From this experience, it became evident that a successful physician should possess strong leadership skills and ability to bring all of these together.

Such an experience showed the students that a successful physician also needs to have NTS. The Lancet Commissions have proposed a new approach in medical education that focuses on teaching NTS to address health inequity [22]. These topics are also important to develop a future generation of doctors who are community and socially responsible [20, 23]. However, these are challenging topics to teach. The OCIP experience generated the importance of NTS - such as PC, ICS, SBP and professionalism. A well designed OCIP can facilitate the learning of these challenging concepts [24].

Findings from this study can pave the way for adoption of more relevant competencies to measure the impact of an OCIP. For example, cultural competence or humility has been one of the commonly used learning outcomes. However, the limitations of using this term as a learning outcome are being recognised, as it has not succeeded in reducing health disparities. In response, some have proposed a transnational [23, 24] approach to medical education and a global health curriculum to complement OCIPs. The transnational approach comprises both of medical and social competencies that allow the physician to manage patients in various settings. Some of the learning themes identified in this study fall within the transnational framework [24] and hence, these outcomes (e.g., health systems understanding) may be used to measure the educational effectiveness of an OCIP. Adopting a transnational approach may potentially result in incorporating new competencies into medical education to cultivate socially responsible physicians.

Our findings underscore the need to develop a curriculum for physicians leading OCIPs on how to facilitate the experiential learning through reflections [20]. A curriculum covering topics relevant to the practical and medical education aspects of an OCIP is much needed [4]. Although there are existing guidelines on global health ethics [2], infectious diseases, tropical and travel medicine, currently, there is no guideline on how to facilitate the experiential learning process of medical students during an OCIP. Our findings serve to act as an impetus to develop a more structured approach to OCIPs to ensure that its educational benefits are appropriately assessed.

This study has a few limitations. The study was based on a single OCIP group in Singapore which may limit the transferability of the findings. The physician leads of the OCIP group utilized reflections to facilitate learnings from the OCIP experience and hence there is uncertainty if similar learning outcomes will be achieved if an OCIP didn’t consist of reflective practice. This study explored the OCIP’s benefits solely from the perspectives of the medical student volunteers, leaving the viewpoints of local translators or local population unaccounted for. Further research work is warranted to include the perspectives of the community receiving help [25] to understand the OCIP’s experiential learning in a more holistic manner.

Conclusion

The rich experience of an OCIP can provide valuable lessons that classroom or bedside teaching may not achieve. In today’s globalized world, as patient care becomes more complex, it is essential to be an all-rounded physician. The experiential learning from OCIPs can facilitate this development. Future steps should focus on how to make such trips more impactful and relevant for the community it serves and to develop a pre-trip checklist of competencies that encompasses the essential NTS required for such trips.

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