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Global Health Education for Tomorrow’s Doctors

20th October 2011

Austin Court, 80 Cambridge Street Birmingham Abstracts accepted as presentations

2 MBChB Global Health – Pioneering a new degree format at the Manchester Medical School

B Oremule

B Oremule, University of Manchester

Background Manchester Medical School is responding to its own ambitions, those of its medical students and the recommendations of the GMC to include and increase provision of global health education in the undergraduate medical curriculum. Global health education currently takes place in the form of the medical elective, international student selected components, Masters of Public Health programme and the Masters in Humanitarianism and Conflict Studies.

The university is looking to develop an ambitious, cross-departmental MBChB Global Health degree. This degree will guide students through quality-assured global health experiences with the aim for them to graduate with a list of defined global health competencies.

Methods This paper explored a working definition of global health and determined the current availability of global health education at the Manchester Medical School. A literature review was conducted to review the emerging principles, competencies and educational approaches to global health used in medical schools across the world. Twenty-five professionals in the fields of medical education, global health and public health were interviewed to provide professional opinion and guidance on the introduction of the new MBChB Global Health.

Results There are global health opportunities available at Manchester Medical School. Global health education is weakly integrated into the core curriculum. The additive components, including student-selected components and Masters programmes, are varied and robust. An MBChB Global Health degree would be new to the UK and could potentially be a comprehensive way of developing global health education to medical students. The interviews highlighted the challenges faced in other medical schools trying to introduce global health education and highlighted core principles to be kept in mind when introducing the new degree format.

Conclusion Manchester has a strong foundation on which to integrate global health into the core curriculum. The PBL structure of the course allows changes to be implemented quickly and easily for integrative change. The additive global health component can be expanded. Transformative change of the curriculum involving the creation of the MBChB Global Health should be based on the established MBChB European Option degree (in its tenth year). Robust research and evaluation of its introduction is essential, in order to ensure the quality and efficacy of the learning experience, and to facilitate the evolution of the course to keep up with rapidly changing global issues.

3 e-Learning Scenarios improve Global Health Learning for Students from North and South

M Ellis, S Achora, D Alder, A Baryashaba, J Cook, L Anderson

M Ellis, Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN

Introduction The GMC1 considers a ‘global perspective on the determinants of health and disease and variations in health care delivery and medical practice’ to be an essential requirement for doctors training in the UK. Government has called for stronger global health ‘LINK’ partnerships between NHS institutions and partners in less developed countries2. Healthcare students based in both high and low resource settings are increasingly demanding a global health education 3. Given the wide variance intrinsic to global health the challenge is to engage students with realistic shared scenarios to better understand the constraints and opportunities facing the global health community. Method We describe the development, use and evaluation of an electronic problem based learning 4 (ePBL) exercise designed to encourage students of diverse backgrounds to apply skills of critical evaluation and strategic thinking to solve problems arising from a health scenario in a low income setting. Three different roles may be taken in this exercise allowing students to explore the different perspectives of local frontline health staff, District Medical Officer and International NGO officials. Over year one we developed the resource with UK students. In year two we performed an integrative evaluation5 of its use. In year three we extended the exercise to students of a LINK partner institution in Uganda culminating in a live North-South student conference using open access learning software. Results ePBL using a scenario based case study is an effective tool to engage students with global health issues. The relationship between the decision-oriented scenario and background material is important – during development students requested enhanced oversight of the material to increase control of their learning. Learning sets form according to environmental factors including computer access issues. Mind mapping can provide a useful formative assessment tool for students to retrospectively review their route through decision tree based elearning material. North-South exchange using shared ‘whiteboard’ with live voice transmission is feasible in limited bandwidth environments and generates genuine insights for both student groups who overwhelmingly considered it to have added to their learning. Conclusion ePBL is a feasible method to enable diverse student groups to work through different roles in global health and development. Use of ePBL in the context of institutional North-South Links can add value for students whilst providing learning technology transfer opportunities for LINK partner organisations. As regional internet bandwidth broadens opportunities for virtual educational exchanges to enhance global health learning will grow.

References 1.GMC, Tomorrow’s Doctors. 2009, GMC: London 2.Chief Medical Adviser, Health is global: proposals for a UK Government-wide strategy. 2007, Department of Health: London. 3.Jessop, V. and O. Johnson, Tomorrow's Doctors: a global perspective. The Lancet, 2009. 373(9674): p. 1523. 4.Wood, D.F., Problem based learning. BMJ, 2003. 326: 328-30. 5.Draper SW, et al., Integrative evaluation: An emerging role for classroom studies of CAL. Comput Educ, 1996. 26: 17-32.

4 Will there be a place for Student Selected Components in Global Health if it is effectively incorporated into the curriculum?

H Haley

H Haley, 3rd year medical student, University of Leicester

Background The University of Leicester currently runs a 12 week course entitled Health and Development during the 2nd year of study; it is taken by approximately 10% of the cohort and focuses on many aspects of Global Health including sustainability, migrant healthcare workers and specific diseases such as Malaria and HIV. The course is assessed using presentations and an essay. The University of Leicester is currently working on integrating global health into the core curriculum so I ask; if this is done successfully will there still be a place for a student selected components with a focus on global health?

Method I have just completed the Health and Development Course and am currently on the committee working to integrate global health into the core curriculum, so I have a working knowledge of both aspects of the teaching of global health. Research indicates that there is an advantage to studying in smaller groups as it improves critical thinking (1) a key ability of a doctor. Every medical student is different and all will have different interests the advantage of the student selected aspects of the medical course is being able to look into the aspects of medicine whether it is; ethics, law, history of medicine, global health or something different. This variety allows for different interests to be addressed.

Results Global health is an important issue that every student requires a working knowledge of but evidence shows that people learn better when following their own interest, a student centred curriculum.(2)

The purpose of a student selected component is to allow personal development (3) therefore alongside a basic teaching in global health which is important for all students and required by the GMC it is still an advantage to provide a specific in depth small group teaching on global health.

Conclusion In conclusion the research along with my experiences of the course indicates that a small course with a key focus of global health is essential for allowing interested students to fulfil their potential. Though it is obviously beneficial for all students to receive grounding in global health issues access to a small course with equally interested people allows for an intense introduction from which students can go on to continue their interest in global health.(4)

References (1) Gokhale AA. Collaborative Learning Enhances Critical Thinking. Journal of Technology Education 1995 1995;7(1):22-23-30. (2) PRENSKY M. TEACHING DIGITAL NATIVES: Partnering for Real Learning. 1ST ed. LONDON: SAGE Ltd.; 2010. (3) MURDOCH-EATON D, ELLERSHAW J, GARDEN A, NEWBLE D, PERRY M, ROBINSON L, et al. Student-selected components in the undergraduate medical curriculum: a multi-institutional consensuson purpose. MED TEACH 2004 2004;26(1):33-34-38. (4) Edwards R, Rowson M, Piachaud J. Teaching international health issues to medical students. MEDICAL EDUCATION 2001 2001;35(8):807-808

5 Identifying Opportunities and Champions to take forward curriculum developments in Global Health

O M R Westwood, D James, A Pollock, M J Carrier, A N Warrens

O M R Westwood Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, Garrod Building, Turner Street, London E1 2AD

With the growing importance of globalization in healthcare and healthcare careers, the School has sought to evaluate the contribution of subjects currently embedded in the MBBS curriculum to our students’ understanding of this globalization. In addition we have looked for potential opportunities in key areas, e.g. health and pathology of migrant populations and how economic, climatic, and geopolitical factors affect health.

Located in one of the most diverse communities in the UK, our students already engage in clinical practice in MBBS Year 1, working with non-English-speaking patients and their families with the aid of translators and health advocates. There are also student-driven special interest groups in this area.

In this paper we discuss the highly developed understanding, learning and assessment within the MBBS programme as well as the current initiatives to widen our students’ experience of contemporary issues in Global Health [1] and draw comparisons with non-UK healthcare systems that has included collaborations with non-governmental organizations, e.g. Centro de Investigación de Enfermedades Tropicales (CIET), The Salvation Army.

To this end we consider how to enhance and sustain this thread of the curriculum, including approaches such as the identification of academic staff champions, the formal audit of the curriculum, as well as the workshops for enhancing awareness and inclusiveness via engagement with education and assessment leads (academic and clinical). The whole ethos for increasing exposure to opportunities that exist currently, and the support available to incorporate ‘Global Health’ into curricular activities are discussed.

References Brhlikova P, Pollock AM, Manners R. Global Burden of Disease estimates of depression--how reliable is the epidemiological evidence? J R Soc Med. 2011 Jan;104(1):25-34.

6 The benefits and barriers of student involvement in the introduction of Global Health Education into the core curriculum of Leicester Medical School

K Dolphin, T Drew

K Dolphin, Leicester Medical School

Global Health Education is a significant component of the work of Medsin-Leicester, a branch of the student-led network, Medsin-UK. Medsin-Leicester began a small working group with the aim of introducing Global Health teaching into the core curriculum at Leicester Medical School.

The working group designed learning objectives specific to global health and met with module leaders to discuss the integration of these learning objectives into pre-existing modules. The process is still ongoing, however so far it has been noted that the involvement of students in the introduction of the global health curriculum confers many advantages. These include students understanding of the demands of the existing curriculum and the ability of students to act as ambassadors for the changes.

The main barriers to the involvement of students in the process have been logistical issues such as conflicting timetables of staff and students and changes in student leaders. So far the concept of Medsin student involvement in the Global Health curriculum changes could be called a success.

This poster will further expand upon the process used to introduce Global Health Education at Leicester Medical School, before detailing the main benefits and barriers of student involvement.

7 Neglect of Advocacy teaching at UK medical schools

R Gulati, T Waterston

R Gulati, Paediatric Registrar, Leeds General Infirmary, Leeds, LS1 3EX

Introduction Advocacy is speaking out on behalf of those who are unable to do so themselves. Doctors need advocacy skills to ensure vulnerable patients are not discriminated against e.g. asylum seekers, those with mental health problems, children. Doctors are required to challenge blocks in the system (e.g. ‘whistle blowing’) and in doing so they can support the right of a vulnerable person’s right to health and health care. Within the context of global health, advocacy is an underpinning concept and it is therefore important that these skills are introduced early1.

Methods A literature review searching PubMed and ERIC was done to ascertain the extent to which advocacy is included within medical curricula. Clinical teachers and students at Leeds Medical School were approached, as were the Royal College of Paediatrics and Child Health (RCPCH), the General Medical Council and Medsin to gain opinion on whether advocacy was relevant to undergraduate teaching.

Results The Institute of Medical Ethics recently revised the consensus on ethics teaching at medical school; advocacy was only tentatively placed within a small number of learning objectives 2. Tomorrow’s Doctors 20093 has limited reference to advocacy, it is mentioned briefly in two separate sections of the document. The deficit of advocacy teaching was highlighted further by the Royal College of Physicians (RCP). The RCP encourages medical educators to ‘legitimise, encourage and harness the power of student advocacy’; They suggest a ‘two-pronged’ approach: academic courses and experiential training in public health issues including health inequalities4.

In Leeds Medical School there is no general consensus to whether advocacy should be integrated into the curriculum; this seems to be in keeping with other UK medical schools. Medsin at both national and local (Leeds) level were keen for advocacy to be incorporated into medical curricula.

Discussion Medical students need to be targeted; it is ‘entirely appropriate as they are often idealistic and will understand the point’1. At Leeds medical school we will be introducing teaching on advocacy into year 2. This will be integrated as a pilot in 2011/12 into the Innovation, Development, Enterprise, Leadership & Safety course. It will take the form of a group teaching session with discussion and case studies on advocacy in the context of global health. Student members of Medsin will help facilitate sessions It is the intention of the authors to introduce this idea to the conference in order to gain support from other medical schools within this extremely important area.

References 1. Waterston, T., Teaching and learning about advocacy. Arch Dis Child Educ Pract Ed, 2009. 94(1): p. 24-8. 2. Stirrat, G.M., et al., Medical ethics and law for doctors of tomorrow: the 1998 Consensus Statement updated. J Med Ethics, 2010. 36(1): p. 55-60. 3. Tomorrow's Doctors. 2009, GMC: London. 4. Royal College of Physicians. How doctors can close the gap. Tackling social determinants of health through culture change, advocacy and education. 2010, RCP: London.

8 Globally minded: student-led curriculum innovation at the University of Southampton

P Kiely, L McLenaghan, S Eckersley, A Cutts, K Maul

P Kiely, School of Medicine, University of Southampton, Southampton, Hampshire, SO17 1BJ

In 2009 the GMC updated ‘Tomorrow’s Doctors’, which set out the skills and knowledge that future doctors are required to have upon qualification. Article 10(d) states that students should be able to ‘explain sociological factors that contribute to illness, the course of the disease and the success of treatment − including issues relating to health inequalities, the links between occupation and health and the effects of poverty and affluence’.1 All of these topics come under the umbrella of ‘Global Health’. The GMC regulates both medical education and practice across the UK and so this recommendation ‘serves as a mandate for the incorporation of global health into the core curriculum’.2 The Global Health Education Project, GHEP, is a UK-wide student-led campaign that was launched in response to this document and promotes global health teaching at all levels of higher education.

A survey, modelled on an earlier version run at King’s College London, 3 was conducted of the BM4, BM5 and BM6 medical degree programmes at the University of Southampton, UoS, in order to assess both the demand for and satisfaction with global health teaching in the current curriculum. For the purposes of this survey students were asked to respond via e-mail over a three-week period and a total of 177 out of approximately 1300 were returned. The results raised two principal issues: firstly, that Southampton students are dissatisfied with the provision of global health teaching (43.5% expressed dissatisfaction versus 14.2% satisfaction), and secondly, that many students plan to spend part of their careers working overseas in resource- poor settings (56.3%). It is therefore the role of the institution as educator and the NHS as employer to prepare its graduates to be effective and safe practitioners worldwide.

Based on the results of this survey the GHEP committee successfully campaigned for the inclusion of a global health symposium to the academic timetable and has, in partnership with e- learning developers from the School of Medicine, created an online learning resource designed to prepare students for clinical electives. Higher education as a whole is currently re-evaluating its practice in line with cuts in public funding and tuition fee rises; whilst the UoS has already committed itself to delivering a ‘more flexible, personalised educational experience’.4 It is imperative that students make their voices heard throughout this process and it is hoped that, in presenting an overview of this work, a model may be provided for others.

References 1. GMC Tomorrow’s Doctors. http://www.gmc-uk.org/static/documents/content/TomorrowsDoctors_2009.pdf (accessed 31 Jul 2011) 2. A student take on curriculum change – RAISE. http://raise-network.ning.com/forum/topics/a-student-take-on-curriculum (accessed 31 Jul 2011) 3. Medsin Survey Report. https://docs.google.com/viewer? a=v&pid=explorer&chrome=true&srcid=0B3Q2tnwDrNI1NTYzZTRhMzctMzBjYy00ODUyLTk4YWQtMjAyOWIyMDJkNjJj&hl=en_GB (accessed 1 Aug 2011) 4. Changing the world. The University Strategy. http://www.soton.ac.uk/strategy/university_strategy.pdf (accessed 4 Aug 2011)

9 The perception of 5th year Imperial College medical students on global influences on health and global health education in undergraduate medicine

C T Cheong, Y J Chong, A Logeswaran, L A Chacko

C T Cheong, Flat 8, 100 Cornwall Gardens, London, SW7 4BQ

Introduction The emphasis of undergraduate medical school curriculum often focuses on training doctors to work in national situations. However, increasing globalisation means that health issues such as the global obesity epidemic, climate change, and migration is no longer confined to national borders. At Imperial College London, global health education is not specifically covered under the core curriculum, although it has been running an optional Global Health Short Course for medical students for the past four years. The aim of our research was to assess the views of medical students on global influences on health and global health education in undergraduate medicine.

Methods We provided questionnaires to 48 fifth year Imperial College medical students. All questionnaires were completed and returned to us immediately.

Results We had a response rate of 100%. 54% of students were unaware of the Global Health Short Course at Imperial College. 68% had some experience of developing countries, mainly through holidays and volunteering work. Only 50% of respondents have heard of Millennium Development Goals. Poor sanitation, poor access to clean water, and malnutrition were cited as the top 3 leading risk factors for mortality globally. When asked about the top 3 most important health issues that are affecting people globally, students most commonly cited starvation, infectious diseases, and poor sanitation. 52% thought that there shouldn’t be more teaching on global health issues in medical school. Of those that thought there should be more teaching, 68% would prefer this to be part of an optional study module. 60% are not aware of any student organizations related to global health. Of those who were aware, Medsin and MSF were the most commonly mentioned. 100% of respondents planned to go abroad for medical electives, with 56% doing it in a developing country.

Conclusion Our research highlights that many students are unaware of the actual global risks for mortality, which are chronic diseases such as high blood pressures, tobacco use and high glucose1. Many students were unaware of the Global Health Short Course that has been running at Imperial College for almost 4 years. General knowledge on global health was poor with many students not knowing about the Millennium Development Goals or student organizations related to global health. Surprisingly, the majority of students did not want additional global health teaching in medical school. We believe there is a need to introduce more global health teaching in the core undergraduate curriculum at Imperial College to highlight the importance of global health issues amongst medical students.

References (1) Mathers C, Stevens G, Mascarenhas M. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization, 2009:15.

10 Overseas faculty: potential problems with teaching on the global stage

J Kinnear, D Bould, A McCarthy, F Ismailova

J Kinnear, Anaesthetics Department, Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-sea, Essex, SS0 0RY

The University of Zambia Master of Medicine Anaesthesia training programme was developed as a Zambia-UK government initiative to assist in achieving the WHO’s Millennium Development Goals in Zambia. The education programme is supported and delivered by a ‘dispersed faculty’ of volunteer consultant anaesthetists from the UK and Canada. This is a relatively common model in developing regions where local educational expertise is lacking for a postgraduate teaching programme.1

Maintaining an effective faculty is essential to ensure sustainability of any teaching programme. A qualitative study is described whose aim is to elucidate factors that negatively impact the delivery of training by the dispersed faculty so that these may be addressed to improve effectiveness of teaching. Study methods include semi-structured interviews of faculty before and after their visit to Lusaka, as well as focus group discussions with visiting faculty and local anaesthetic staff at the University Teaching Hospital, Lusaka. Data will be analysed inductively for emergent themes.

Although data collection is in progress, emerging themes from initial analysis include;  Lack of cohesion: faculty members are consultant anaesthetists from the UK and Canada who have had little or no prior contact with one another. Communication is mainly by informal and ad hoc electronic methods, and this may result in the lack of a sense of common purpose and understanding between members.  Lack of continuity owing to the relatively short visiting trips (average of 2 weeks)  Negative environmental influences: delivery of education will occur in unfamiliar surroundings, in a hospital and country that most faculty members have never visited. Basic issues related to personal security, financial arrangements and adequate housing may negatively impact on teaching effectiveness. This includes the lack of such basic teaching resources as dedicated teaching facilities and educational media.  Clinical governance issues: postgraduate training occurs in a stressful clinical environment and will inevitably be adversely influenced by the poor governance structures that pertain in many resource-challenged environments.  Cultural influences: visiting faculty may have little appreciation of local conditions and expectations, and may come across as potentially disruptive to existing practices. Their ‘outsider’ status may render teaching ineffective since the postgraduate students will remain in the ‘zone of influence’ of the local practitioners who supervise them.

Educational effectiveness of a teaching programme that is supported from overseas may be affected by many poorly defined influences, and these need to be properly understood to ensure future success.

References 1. Twagirumugabe T, Carli F. Rwandan anesthesia residency program: a model of North-South educational partnership. Int Anesth Clins. 2010; 48(2): 71-78.

11 Defining core learning outcomes for participating in international health links

S Jewsbury, P O Neill, G Byrne

S Jewsbury, Chrolton, Manchester

Global health must go beyond the delivery of health aid and should encompass mutually beneficial sustainable development. In todays economic & political climate we need robust justification for spending resources in international development and must work beyond altruism.

There is enormous potential for learning through global health partnerships yet we lack a consensus of explicit professional and personal learning outcomes (LOs) from participation in international health links. It is likely that conflicting ideals exist within potential stakeholder perspectives, however, there is scope for greater understanding of the LOs experienced by staff and students and what the desired or LOs may be; we do not yet know if these are compatible. Without a solid understanding of these outcomes it is difficult to assess the educational impact of such participation and to compare quality across different links. Exploratory studies are needed to evaluate this further.

Research Questions  What are the core ‘desired’ and ‘actual’ LOs of volunteering in a developing health care setting?  Which LOs are most valuable to the individual and employing institution?

Methods We will take a grounded theory approach using mixed qualitative methods. The study population will form from NHS and Ugandan staff aligned with the ‘Uganda Maternal Health Partnership Hub’. This ’Hub’ involves 8 Obstetric Healthcare Partnerships between Ugandan and UK institutions. Each of the eight independently established links share the common aim of improving Ugandan maternal health, improving knowledge transfer and resources within Uganda.

Components 1. Thematic analysis of grey literature to explore assumed LOs of overseas volunteering and identification of stakeholders. 2. Delphi questionnaire technique of stakeholders to generate a ‘wish list’ of LOs 3. Interview NHS professionals who have volunteered for one of the ‘Hub’ links to elicit perceived learning outcomes. 4. Interview Ugandan health professionals working with volunteers to describe their observation of LOs after a period on the ground. 5. Observational studies of health care professional while volunteering in Uganda 6. Diaries and micro blogging of staff whilst volunteering.

Conclusions There is paucity in the literature around LOs of participation in international health partnerships. We hope to define a core set of learning outcomes that would span UG, PG and other health professions. If we can capture these outcomes we may be able to adopt qualitative and quantitative methods to assess them. Ultimately there is scope to incorporate them into the blueprint of future health partnership agendas.

12 Overseas Elective Placements in Resource-Poor Areas – A Student’s Perspectives

H E Fry

H E Fry, FY1 Doctor, University of Leicester Medical School, University Road, PO Box 138, Leicester, LE1 9HN

Introduction The medical elective placement can be one of the most valuable and memorable experiences in a medical student’s life. The chance to work alongside healthcare providers from around the world offers a rich opportunity for learning. Clinically they may see unusual cases not often seen at home and see practice that differs from what they are used to, but they also get to understand how the healthcare fits into the local culture and experience the challenges faced when providing health care in resource poor areas. However, an elective in a resource-poor area can be incredibly challenging and it is vital to the success of the placement to prepare students properly. I will present personal experiences from my elective placement to rural South India, and will consider what measures could be taken to improve it before, during and after the placement.

Preparation There is precious little space in the medical curriculum for global health teaching, so students going to resource-poor areas may have little understanding of what they see and why this is the case. It would be useful to have some teaching on global politics, corruption, cultural awareness and so on in order to place the experience in context. My elective took place at the Tribal Health Initiative in rural South India, serving the forgotten tribal population of Tamil Nadu. The lack of resources and funding was quite a shock, and when patient care is compromised due to lack of basic things that would be freely available in the UK it is difficult to cope with. Some ideas will be presented to help prepare medical students for their elective.

Whilst on Elective Placement Examples will be presented of learning opportunities from my elective placement in the areas of tropical health, infectious diseases and the interaction between health and the local society. These will illustrate the diverse range of experiences available to students taking electives in rural and resource-poor settings, as well as the need for adequate briefing to make sense of what they are seeing.

On Return to the UK It is important to debrief returning students to help understand the experiences that they have had and to help manage any culture shock. It would be helpful for students who have had interesting electives to do a short presentation.

Conclusion The medical elective is an extremely valuable tool for increasing students’ understanding of global health, but adequate support from the medical school is vital to ensure a positive experience.

13 Assessment of the Student Elective by Poster Presentation

J Philpott-Howard, A Tilzey, R Phillips, P Jones

J Philpott-Howard, King’s College London School of Medicine, King's College London, Strand, London, WC2R 2LS

At King's College London School of Medicine (KCLSM) our students have a 10 week Elective Period at the beginning of their final year during which they do 8 weeks of attachments. For the past 10 years the assessment of the Elective has taken the form of a poster presentation two months after the students' return. The poster contains the students' aims and objectives, an account of what they did, focussing on certain patients/experiences in more detail, a discussion on some of the broader e.g. public health issues, and their personal conclusions.

They have five minutes to present their poster to a minimum of two examiners who then have five minutes to ask questions, determining the depth of the student’s knowledge and understanding and the extent of their involvement. The examiners then have five minutes to complete a standardised marksheet, agree a mark and give feedback.

Between 400 and 450 students present their posters during morning and afternoon sessions, to up to 60 pairs of examiners in groups of six to eight students. The examiners are given written guidelines and attend a briefing session before the presentations. The following day a panel of senior examiners/moderators look at the marks, the mean mark and the mark distribution for each group, and in certain circumstances remark posters in some of the groups.

Poster prizes are awarded to the best posters. Very few students fail this SSC (usually fewer than five) and failure is often an indicator of problems such as poor motivation. Students who fail are referred to the person concerned with their pastoral care. We recommend a poster presentation as a form of assessment for the medical student elective since students find this a relatively enjoyable form of assessment, examiners enjoy examining and the posters, which are left on display for several days, are viewed by a wide audience including students who are planning their own electives.

Over the past ten years, relatively few changes have been made to the process, but this year we are planning to hold some of the poster presentations in other hospitals where our students spend their final year; this will involve doctors in these hospitals, and widen the audience.

14 Experience and evaluation of preparation, support and educational outcomes for elective attachments undertaken by medical students from King’s College London School of Medicine J Philpott-Howard, A Tilzey, O Evans, P Jones J Philpott-Howard, King’s College London School of Medicine (KCLSM), King's College London, Strand, London WC2R 2LS, UK For the past 10 years at KCLSM we have implemented initiatives for enhancing student planning and support for their elective placement. This is an eight-week attachment at the beginning of the final year. An Elective Committee was established in 2002 to bring together expertise in Microbiology, Virology and Occupational Health, and the Committee includes the Head of Year, an administrator and a student representative. In the two years before their elective, students are provided with advice on planning their attachments through an on-line handbook. A database of past elective experiences, compiled by students, is available on our Campus website. Students are required to prepare an assessed, written elective portfolio, with sections for reflection on the process of choosing and organising the elective, details of the attachment(s), career exploration, a global health issue, and health and safety. Clinical tutors assist students in their planning, and approve the elective plans. During the elective period, a priority e-mail enquiry system is provided by the KCLSM Academic Centre, and queries are referred to the relevant experts. In addition, six consultants are on call 24 hours a day for a week at a time, via their mobile telephones, for emergency advice on serious incidents such as illness or blood-borne virus (BBV) exposures. On their return, students must complete a detailed questionnaire about their experiences, the elective’s educational value, skills performed, and health or logistical problems. Finally, students prepare and are examined on an elective poster. In the most recent year (2010), 449 students undertook an elective period. 398 (88.6%) travelled outside the UK. The emergency elective e- mail and telephone system was used by 20/449 (4.5%). On their return, 241 (53.7%) reported moderate or severe illness while on elective, and of these 10 (2.2%) students reported exposure to blood-borne viruses. 433/449 (96.4%) students considered their elective to be a very (349, 77.7%) or moderately (84, 18.7%) valuable educational experience. These outcomes have been fairly consistent from year to year. Future developments include more detailed risk advice and risk assessment prior to the elective, and on the students’ return.

15 Global health education: the socially accountable medical school and the transformative curriculum

A Berlin

A Berlin, Faculty of Population Health & Medical School, UCL . Royal Free Campus, Rowland Hill Street, London NW3

The scope of global health is multidimensional and expanding presenting challenges for addressing the GMC’s learning outcomes1. The “globalised curriculum” plays out in the context of UK medical schools developing a range of entrepreneurial and educational interests to address their own institutional global agenda.

This presentation aims to stimulate debate by exploring how medical schools might frame their increasingly complex international relationships in a way that complements curriculum goals. I consider possible links through a discussion of the “socially accountable medical school” 2 and transformative learning.

Core elements of global health are supporting international health and addressing trans- national health challenges. International health focuses on activities that address ‘the health of countries other than one's own especially low and middle income countries'3 as might be experienced through an overseas elective. The broader elements incorporate issues that transcend national frontiers - “circumvent, undermine or are oblivious to the territorial boundaries … and are beyond the capacity of individual countries alone to address through domestic institutions'4: communicable diseases control; environmental threats; global movement of health professionals; and collaborative governance, monitoring and policy setting eg. Millennium Development Goals. Health professional education is a core part of this inter- dependent global picture5.

The “socially accountable medical school” is an aspirational notion elaborated in a global consensus statement of international standards representing over 20 countries2. It is a learning organisation highly aware of its local and global context and responsibilities. Transformative education builds on educational traditions6,7 which stress the active agency of the individual learner, their legitimate service and advocacy role, and the centrality of critical reflection for making judgements about taking appropriate action in socially diverse settings.

I consider how this transformative link between thinking and acting “outside the box” can address the limitations of a competency based approach for international health experience in the student elective as well the teaching of contentious trans-national global health topics. I will discuss claims regarding parallel links at an institutional level.

Key conclusions are that social accountability and transformative learning are complementary concepts worthy of further debate . It may be that well articulated , engaging global health education is helped by making clear links between the goals and activities of the institution and the individual learner in the globalised world reducing concerns regarding educational tourism and neo-colonialism while enhancing learning experience.

References (1) GMC (2009) Tomorrow’s Doctors, GMC (2) Anonymous. Global Consensus for Social Accountability of Medical Schools. Available at http://healthsocialaccountability.sites.olt.ubc.ca/files/2011/01/GCSA-Consensus-Document-English.pdf (Accessed 2011, March 6). (3) Fried L, Bentley MB, Buekens P, Burke DS, Frenk J et al. Lancet 2010; 375;537-8. 16 (4) Lee K, Collin J. Global eds. Global Change and Health. McGraw Hill, Open University Press. England 2005. (5) Frenk J, Chen L, Bhutta ZA et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58. (6) Illeris, K. (2007) How We Learn: An introduction to human learning in schools and beyond (London: Routledge). (7) Mezirow, J. (1991) Transformative Dimensions of Adult Learning (San Francisco: Jossey-Bass). Low Resource Settings Electives: Evolving, partnering, building on special study modules

P Waitt

P Waitt, Acute Medicine Registrar, Aintree University Hospitals NHS Foundation Trust

Introduction Medical education has rapidly evolved with teaching methods moving towards a student-centred approach. However, colleagues in low-resource countries suggested that overseas electives were often undertaken with poor planning, structure, and defined objectives. This observational study analysed the organization of overseas electives students during the four year period that I coordinated electives.

Study Site Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi

Methods Data on all overseas electives undertaken between 2007 and 2010. Retrospective analysis determined what information was provided to the host institution prior to arrival, including intended learning outcomes for the elective. Consideration was given to the variables which may have influenced the students’ quality of planning, organization and communication, such as the stage of training, country of origin and gender.

Results Data from 123 students originating from nine different countries were analyzed. 64.5% were female with an age range from 20-38 years (mean 23.5). Five were undertaking medicine as a second degree. Complete data sets were available from 57 students; 10 (17.5%) had provided objectives for their elective period. Seven of these had included their objectives in their initial application for an elective period in Blantyre. 82.5% of students overall did not inform the host institution of their learning outcomes, whereas 85% of students from Australia, the Netherlands and Belgium provided learning outcomes. The clearest objectives were provided by students undertaking the placement as a Special Study Module or an intercalated degree in International Health; a significant proportion of these subsequently published and presented their work internationally. Informal feedback from students suggested the experience had improved understanding of variations in global health, and factors impacting on health delivery, in addition to improving communications skills; this is comparable with other studies.1

Discussion This analysis highlights several aspects of organisation and planning which need improvement in order to effectively meet the competencies outlined by the GMC in 'Tomorrow's Doctors'. Considerable variation between sending countries was noted. In the best examples, institutions saw it as an opportunity for the medical schools to foster a two-way relationship between the sending and host institutions. With improved planning, students could maximise this important learning process.2

Conclusion Improved planning and communication of learning objectives with the host institution maximizes the two-way learning process of overseas student elective placements.

17 References 1 Thompson, M. J et al. Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review, Acad Med 2003; 78(3)342-7 2 Haq, C et al. New world views: preparing physicians in training for global health work. Fam Med 2000; 32(8)566-72

An introduction to: Medical Peace Work ‘not merely the absence of violence’

M Birch

M Birch, Medact

The role of physicians and other health workers in the preservation and promotion of peace is the most significant factor for the attainment of health for all. World Health Assembly, Resolution 34.38, 1981

Medical Peace Work is an emerging field of expertise related to the role of the health professionals in violence prevention and peace building. As part of this process nineteen European health groups have produced seven freely available, interactive online courses in medical peace work. The aim of these courses is to enable health professionals to expand their knowledge of the impact of war and other forms of violence on the health of individuals and populations, and to show how they can use their unique position to contribute to peace building, violence prevention and conflict transformation.

The issues covered range from suicide and interpersonal violence prevention to the abolition of nuclear weapons. All aspects of violence are considered, including structural violence, and the experiences of vulnerable groups such as refugees and migrants are covered in detail. This breadth of subjects is based on Prof John Galtung’s definition of peace, which echoes WHO’s definition of health: ‘Not merely the absence of violence, but a state of mutual beneficial relationships, fair structures, and a culture of peace. Peace is also a capacity to handle conflicts with empathy, creativity and by non-violent means.’

The negation of violence takes into account not only different types of violence, but also all the levels at which violence might occur, for example social or interpersonal levels; examples might include the abolition of slavery, divorcing an abusive partner, or understanding the risks of modern biotechnology. Medical peace work also involves the promotion of positive qualities that are associated with peace such as equality, justice, sustainable development, and fulfilment of basic human needs. Finally it also covers the ability to handle conflicts with empathy, creativity and non-violent means, as far as they fall under the influence of health professionals.

This means that the courses are not only designed for health professionals and students who wish to do humanitarian or development work or who want to work with human rights or medical peace organizations; they are relevant for all health workers, no matter where they work and live. Many doctors and other health professionals, including some who have worked in conflict zones, feel the need to help prevent war and promote peace, as well as to care for their patients. This workshop will be a chance for people to get an overview of the courses and what they involve, discuss the range of issues they cover and the core principles they represent, and sample some of their content.

The courses were developed by: Croatian Medical Journal , Finnish Psychologists for Social Responsibility , Global Doctors, Human Rights Foundation of Turkey, Institute of Public Health of the Republic of Slovenia, International Federation of Health and Human Rights Organisations, IPPNW Germany, Johannes Wier Foundation, Medact, Norwegian Centre for Telemedicine, Norwegian Medical Association, Nuremberg Clinic, NVMP Gezondheidszorg en Vredesvraagstukken, University of Bergen, University of Bradford, University College London, University Medical Center Hamburg-Eppendorf , University of Tromsø, County Governor in Troms

18 Abstracts accepted as posters

19 Educating Medical Students on the Need to Consider Sustainability and Carbon Emissions in Healthcare – Sheffield University's Experience

J Horsley

J Horsley, Sheffield University

Introduction Climate change is likely to have significant impacts on human health both within the UK and internationally. Medical students in the UK currently receive little information about the science or potential health impacts. Trying to introduce teaching on climate change and energy into the core curriculum is often difficult because of barriers both real and perceived.

Why teach climate change to medical students? Medical students will be tomorrows doctors, responsible for their patients health and for distribution of the considerable resources available to the NHS. Most actions to address climate change will promote health. Doctors as professionals are a credible and trusted source of information with experience in effecting behavioural change. Climate change provides a subject that is commonly addressed in popular media which also allows teachers to outline key concepts that are important in the teaching of public health. These include the role of wider determinants of health; concepts of international justice and inequalities; using evidence to determine if a relationship is causal and if it presents a remediable risk; delivering advocacy messages and promoting behaviour change; and a demonstration of key ideas such as the “inverse care law” and the “ecological fallacy”.

Sheffield’s Curriculum Sheffield University currently includes a one-hour lecture to first year students as part of the core curriculum. It also offers an optional module in fourth year which gives five two hour tutorial sessions allowing an in depth exploration of the science and health impacts, as well as broader concepts such as energy security and its links to human life expectancy and population numbers. This curriculum has been running for a year and was well received by students. A balanced group with some members who knew very little about the area and others who were well informed worked well.

Barriers Scientific consensus is increasingly in accord that climate change is real, man-made, and that it will have profound impacts on human health. The relevance of teaching sustainability and climate change to medical students is evident given the arguments above. There is a plethora of useful information and teaching resources available to lecturers. The biggest barrier is finding teaching time within a busy curriculum when competing with clinical matters.

20 Teaching sustainable healthcare to tomorrow’s doctors: a mixed method analysis of medical school innovations in England

C Tomes

C Tomes, NHS Cambridgeshire, Lockton house, Clarendon Road, Cambridge, CB2 8FH

Objective Climate change has been acknowledged as the public health challenge of the 21 st century. Sustainable healthcare teaching within medical schools contributes to climate change mitigation; yet less than 50% of English medical schools currently provide this. This paper aims to report on the extent that sustainable healthcare teaching initiatives have been successfully integrated into English medical schools, and furthermore to identify and explore change agents which have been important in enabling sustainable healthcare teaching.

Design A mixed-method research methodology was used to gain breadth and depth of the processes by which sustainable healthcare has been integrated into English medical schools. The research methods of this paper are two-fold; analysis of the ‘Teaching Sustainable Healthcare in UK Medical Schools Survey’ conducted in 2010; followed by Interviews with champions of the Sustainable Healthcare Education (SHE) agenda exploring change agents which have enabled sustainable healthcare teaching to occur in medical schools.

Results The survey results reported a lack of faculty support, uncertainty of where the topic fits into the medical curriculum and finding space as the most frequent challenges within English medical schools. This was consistent with interview data. Interview respondents differentiated between characteristics which were important in their experience to instigating SHE teaching (including organisational structure, cooperative climate, stable leadership, scope and complexity, and placement within the curriculum), separate from characteristics which were felt to be necessary in sustaining SHE initiatives (including evaluation, monitoring, student feedback and support, reliance upon champions, communication and politics). A theory - the ‘goldilocks analogy’ - was developed to explore the contradiction between the radical thinking and the conservative actions of SHE champions. The findings of this research project concur with the identified literature, and as such these results are able to strengthen the evidence base in this area.

Conclusions A number of variables are important in instigating sustainable healthcare education into medical schools. Different variables are important at different stages of development when conducting curriculum change. A number of future research avenues have been identified. Results from published literature and the research formed within this paper reinforce that tomorrow’s doctors will be important allies in responding to a climate changing world.

21 Innovative assessment: Visualising global health

B Brown

B Brown, UEA Medical School, University of East Anglia, Norwich, NR4 7TJ

At UEA Medical School Global Health is already included within the curriculum as in most other medical schools, however many medical students wish to increase their knowledge further, either as preparation for spending an elective internationally or for their future career. Students are able to select a topic to study in further depth, this year Global Health became an option for the first time.

As students specifically chose this subject motivation and enthusiasm were high among the group of 11 students which enabled the administrators of the group to introduce an innovative method of assessment.

Traditional assessment for this module has been in the form of an essay or test. The lecturers leading the group wished for the assessment to have neither the specificity of an essay or the narrowness of a test but to be able to draw on every area of study and to include not only knowledge but to give an option for students to show their opinions and own interests.

Therefore the method chosen for assessment was for the students to create a 3D model of a subject within Global Health of their choice. The model could be made from anything and created individually or in groups.

This allowed students to bring together all their learning in their own way, presenting their ideas and being able to interpret them in an individual way without constraint of language. It also promoted discussion within the group as the models were presented at the last session with the creator of the model presenting their model as they wished and answering questions from the rest of the group. Not only did this enable students to offer opinions and explore their interests it also cemented learning for the rest of the group in each area presented as each was discussed at length without prompting from the supervisors.

The models were widely varied in topic and breadth with some choosing broad topics such as ‘The Global Burden of Disease’ and some narrowing in on other topics such as ‘The Effect of Government Policies on Health: Comparison of the UK and Peru’.

Although when first presented with the idea of making a 3D model many students found the concept hard to understand, while making the models and presenting them students found it a worthwhile exercise, which really highlighted the connections between topics within global health that at first may be difficult to recognise.

22 Climate change in undergraduate medical education

“ Responding to climate change is not a distraction from the business of protecting health: it is part of the same agenda” – Margaret Chan, WHO Director General

E Cooke, H Gundersen , M Phull

E Cooke, Shaftesbury Road, Brighton

Climate change is a key global health issue, affecting the health of people in the UK and internationally. In 2009 it was named as the biggest global health threat of the 21st century by the Lancet.1 Temperature rises this century are predicted to exceed the internationally-agreed safe limit of 2°C above pre-industrial temperatures.2 This will result in altered spatial distribution of some infectious diseases, extreme weather events (such as heatwaves, floods and droughts), food and water insecurity, and environmental migration.

Heatwaves such as the one in Europe in 2003 which killed more than 20,000 people are expected to become more frequent and severe.3 Climate change is also a source of health inequality, as it is expected to affect poorer countries earlier and more severely 4 Climate change is therefore an important and growing determinant of global health.

Such diverse and significant effects of climate change on health in themselves make climate change a subject that is relevant to medical students and their education. However, medical students, as future healthcare professionals, should in addition recognise that strategies to reduce greenhouse gas emissions and mitigate climate change bring with them the opportunity to improve public health. Such co-benefits are demonstrated, for instance, in the championing of walking and cycling, promoting better physical and mental health whilst leading to a reduction in carbon emissions.

For medical students who already feel overloaded with material from other areas of the undergraduate curriculum, potential strategies for including climate change in the curriculum need to be well researched and thought out, whilst highlighting the importance of the subject matter. A suitable place in the core curriculum needs to be found to emphasise the importance of climate change as a global health issue. Meanwhile a positive focus on the health co-benefits of a adopting a low-carbon lifestyle could be a useful tool since it suggests a practical and feasible role for health professionals to play within a subject matter that can otherwise appear overwhelming.

References Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet. 2009 May 16;373(9676):1693-733. 1. The Accord: the outcome of Copenhagen. Directgov. Available from: http://www.direct.gov.uk/en/Nl1/Newsroom/DG_183445 (accessed 05.08.11). 2. The heatwave of 2003. Met Office Education. Available from: http://www.metoffice.gov.uk/education/teens/casestudy_heatwave.html (accessed 05.08.11). 3. Stern review: the economics of climate change. Summary of conclusions. Available from: http://webarchive.nationalarchives.gov.uk/ +/http://www.hm-treasury.gov.uk/independent_reviews/stern_review_economics_climate_change/sternreview_summary.cfm (accessed 05.08.11).

23 UK anaesthetic trainees’ preparedness for practice of global anaesthesia

J Kinnear, P Gill

J Kinnear, Anaesthetics Department, Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-sea, Essex, SS0 0RY

A primary objective of a curriculum for postgraduate medical training is to reflect the healthcare needs of the society within which the training programme is situated. However, with open borders and ease of travel, economic migration, and community displacement by unrest and natural disasters1, the global healthcare agenda has widened this remit to include delivery of healthcare in resource-poor and challenging environments. However, there appears to be minimal structured teaching in global anaesthesia to reflect this change. The result is that trainees who seek placements in underdeveloped countries may be ill prepared for the challenging circumstances and potentially add to the burden of the hosting country when they visit.2

A cross-sectional electronic survey of UK trainee anaesthetists was carried out to gauge their current experience and preparedness to practice ‘global anaesthesia’ in resource-poor settings. The study also looked at training opportunities for working in challenging environments. Four hundred and sixty-two trainees completed the survey, of which 131 (28.6%) had worked in resource-poor environments previously. Most respondents (311/68.2%) indicated that they would like to work in a resource-poor environment, but only 61(13.6%) felt adequately prepared to do so. Although 405 (89.5%) thought that working in a resource-poor setting would be beneficial to their training, 376 (82.3%) indicated that their current training programme did not offer relevant training opportunities. Of all the respondents, 114 (25.2%) had graduated from medical schools outside the UK.

Paradoxically, many trainees (248/54.4%) were opposed to global anaesthesia becoming a core training competency, because of the existing excessive curricular demands and the potential for further overload. Most agreed that it should be offered as an optional competency at a higher level of training. However, if a training programme was available in a resource-poor environment, then 180 (39.7%) stated that they would definitely participate, and only 13 (2.9%) were definitely opposed.

Despite the Royal College of Anaesthetists’ curriculum3 for postgraduate training in anaesthetics making a clear statement of support for trainees wishing to broaden their experience by working in resource-poor settings, and the Crisp Report2 urging educational bodies to value and facilitate such overseas training rather than discourage it, there is still reluctance to release trainees for out of programme placements, because it is disruptive to the efficient running of local programmes. UK postgraduate programmes in anaesthetics have yet to embrace the potential benefits of education in global anaesthesia.

References 1. Brewer T, Saba N, Clair V. From boutique to basic: a call for standardised medical education in global health. Med Educ 2009; 43: 930-933.

24 2. Crisp N. Anaesthesia in developing countries. Global Health Partnerships. The UK contribution to health in developing countries. ‘Crisp Report’ 2007. [homepage on the internet] c2007 [cited 2011 August 16] Available from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065374 3. Curriculum for a CCT in Anaesthetics. The Royal College of Anaesthetists. 2nd Edition. August 2010, Version 1.2, section 13.7.

Sustainability of an externally supported postgraduate anaesthesia programme

J Kinnear

J Kinnear, Anaesthetics Department, Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-sea, Essex, SS0 0RY

The University of Zambia Master of Medicine Anaesthesia training programme was developed as a Zambia-UK government initiative to assist in achieving the WHO’s Millennium Development Goals. The programme is supported and delivered by a ‘dispersed faculty’ of volunteer consultant anaesthetists from the UK and Canada, a common model in developing regions.1 However, there is evidence that these programmes frequently fail, which has been the case in Zambia where a programme supported by the American Society of Anaesthesiologists (ASA) in the 1990’s was discontinued after 3 years owing to ‘failure to establish indigenous leadership’.2

A qualitative, evaluative study is planned to reveal the factors which might impact sustainability of the MMed Anaesthesia project. Data will be collected by a combination of semi-structured interviews and focus groups involving visiting and local faculty. Inductive analysis will look for emergent themes, which are anticipated to include the following elements;

 Leadership: currently provided by a UK-based programme head who is supported by a local head of department. The eventual aim is to teach leadership to the postgraduate students in the belief that they will provide the eventual ‘indigenous’ leaders.  The curriculum has been driven by local needs and has been shaped by pragmatism rather than educational idealism. It will be allowed to evolve by regular annual review.  Scholarship has been consciously emphasised even though the relevance of academic teaching in a resource-poor environment is debated. It is an attempt to raise the low status of anaesthesia as a profession in Zambia so that it may become an attractive career choice.  Faculty is made up of visiting consultant anaesthetists, supported by a senior UK anaesthetic trainee acting as a teaching fellow. The MMed students will themselves be expected to teach the next cohort of students, and so become the future educational resource.  Educational governance and academic rigour is quality assured by the University of Zambia School of Medicine, but postgraduate training also requires a collegiate body of peers to assure its clinical governance, since teaching cannot thrive in the absence of good practice. There are current efforts to initiate a specialty college for the East African sub-region to perform this function.  Resource poverty is a challenge to any postgraduate teaching programme which requires ‘tools’ for the job.

The sustainability of an externally supported educational programme is a constant challenge, and its elements need to be consciously evaluated to ensure success.

Reference 25 2. Twagirumugabe T, Carli F. Rwandan anesthesia residency program: a model of North-South educational partnership. Int Anesth Clins. 2010; 48(2): 71-78. 3. Colip, M. 1996. Encouraging indigenous leadership abroad. American Society of Anesthesiologists Newsletter 60(11): 6-8.

Lessons from a workshop series on climate change and health advocacy for medical students

E Pool

E Pool, York Teaching Hospital NHS Foundation Trust, The York Hospital, Wigginton Road, York, YO31 8HE

Introduction Climate change will “put the lives and wellbeing of billions of people at increased risk”1. Hamel Green and colleagues see many roles for doctors in responding to climate change, from healthcare provision to research and advocacy3. Climate change is therefore highly relevant to medical students, particularly in light of the new requirement that they have a “global perspective”2 to their understanding of health. As this is a new topic in medical education, little is known about how best to teach it and overcome any obstacles in its delivery.

Background A workshop series, ‘Climate Change and Health Advocacy’, was delivered and evaluated to investigate how best to teach this subject. Thirty medical students attended from various countries, including Norway, Bangladesh and Australia. The series aimed to inform participants about the health effects of climate change and empower them to campaign on the issue. The structure of day one was education about health and climate change; a question and answer session about COP15; and group work on politics and health. Day two consisted of a presentation on climate change and health campaigns; group work on campaign planning and communicating campaign messages4.

Results The feedback forms show that 100% of participants who answered the question on satisfaction were either satisfied or very satisfied with the workshop. 77% found the workshops very relevant to work in their medical student organisations. In the free-text feedback participants particularly commented on the benefit of learning about politics and current climate change campaigns. However, only 69% of participants stated they were able to participate actively in the session. 18% stated that the workshops weren’t interactive enough and a language barrier provided an obstacle for some.

Discussion These results show that there is significant enthusiasm amongst international medical students to learn about climate change and health. It shows that they see the topic as relevant, as one participant wrote, “climate change is an important issue in my country”. The results also indicate that the structure of these workshops, with the combination of practical and theoretical elements, resulted in high satisfaction for participants. Increased interactivity and greater language awareness with mixed language groups could increase participation. These workshops could act as a model for others seeking to educate medical students about climate change and health, however further research is needed to establish how much information was retained and whether participants went on to campaign on the issue. 26 References 1. Costello, A. et al . (2009) Managing the health effects of climate change. The Lancet. 373: 1693 – 733 2. General Medical Council. (2009) Tomorrow’s Doctors. http://www.gmc-uk.org/education/ undergraduate/tomorrows_doctors_2009.asp (accessed 09/08/2011) 3. Hamel Green, E. I., Blashki, G., Berry, H. L., Harley, D., Horton, G. and Hall, G. (2009) Preparing Australian Medical Students for Climate Change. Australian Family Physician. 38 (9): 726-729. 4. Rose, C. (2008) How to win campaigns. Earthscan: London.

A survey of junior doctors to assess their attainment of and evidence for competencies outlined in the General Medical Council (GMC) ‘Tomorrow’s Doctors’ guidelines and implications for global health education

S Cetiner, S Zangana, J Earis

S Cetiner, Aintree University Hospitals, Liverpool, UK

Purpose In the UK, current medical training relies on doctors using electronic portfolios (ePortfolio) for assessments and provision of evidence for attainment of competencies. Moreover, final year medical students are expected to perform competencies outlined in the GMC ‘Tomorrow’s Doctors’ guidelines. Our study aimed to discover whether these competencies had been achieved by foundation doctors at Aintree University Hospital (AUH) and whether they had evidence to support this in their portfolios.

Methods 100 foundation doctors at AUH were asked to complete a survey of 42 questions (each representing a competency as outlined in the GMC ‘Tomorrow’s Doctors’ guidelines’) from June to July 2011 with a 62% response rate.

Results The results varied widely from 100% of the respondents feeling confident in performing competencies such as Venepuncture, to as low as 55% for more complex competencies such as skin suturing. However venepuncture was the only competency that 100% of the respondents could provide evidence for.

Discussion Our results show that foundation doctors are more likely to feel confident in and have evidence for the competencies outlined and linked to the NHS ePortfolio. However, for many of the competencies in ‘Tomorrow’s Doctors’, with 100% confidence ratings, such as blood pressure measurement, the trainees had almost no evidence to support this. Our findings suggest that the electronic based method of UK doctors’ assessments has been largely successful, efficient and user and environmentally friendly, making it clearer what is expected of them. However doctors face difficulty in providing evidence for attainment of competencies. This may be resolved in part by the development of a standardised, national student ePortfolio to complement the NHS ePortfolio for doctors, hence enabling students to accumulate evidence prior to qualifying as doctors.

On the global scale, especially in nations where health care is modeled on the British system, adopting some form of ePortfolio for their medical trainees will enable them to revolutionise their own training and development. However, the lessons learned from the introduction of the UK NHS ePortfolio system could be vital. Moreover, in nations with restricted internet access and financial constraints, it provides an even bigger challenge of closing the gap between them and the developed nations. This provides the NHS and the GMC with a unique opportunity to aid

27 such nations in this electronic challenge, thereby helping to modernise and standardise health care education globally.

References 1. General Medical Council. (2009) Tomorrow’s Doctors, Outcomes and standards for undergraduate medical education [online] Available at: http://www.gmc-uk.org/static/documents/content/TomorrowsDoctors_2009.pdf [Accessed 10/08/2011]. 2. NHS Education for Scotland (NES) ePortfolio. (2011) NHS ePortfolio [online] Available at: https://www.nhseportfolios.org/Anon/AboutUs.aspx [Accessed 10/08/2011].

Post-graduate training opportunities in global health, the trainee perspective: What and When? T Rittman, J Dorward, E Spry, F Martineau, C Brown (on behalf of the Almamata Working Group) T Rittman, 21 Perne Avenue, Cambridge, CB1 3RY Introduction There is increasing recognition of the role of UK doctors in contributing to global health but no clear training path leading to a global health career(1,2). Global health cross-cuts all specialities, but it is unclear whether different specialities require different approaches to delivering global health training. Trainees' views on type and timing of global health training have not previously been evaluated. In a selected group of trainees interested in global health we wished to assess:  popularity of different global health post-graduate training opportunities  if intended speciality influences type of training sought  length and timing of intended time spent overseas  perceived barriers to a global health career Methods An online structured questionnaire targeted junior doctors interested in global health and was advertised through mailing lists and word of mouth. Results 247 trainees from a broad range of specialities completed the survey. 79% of respondents were interested in long term development work and 84% of respondents wished to pursue a long- term career in the UK. Popularity of training opportunities The most popular training sought was spending time abroad, with PhDs least popular. Distance learning, MSc, diploma, residential training and joint CCT were approximately equally popular. Influence of intended speciality on popularity of training opportunities One way ANOVA demonstrated a significant effect of speciality on popularity of training opportunities (p<0.05). For individual training opportunities there was a significant (p<0.05) effect of speciality for more involved training: PhD, residential training and joint CCT. Our study was underpowered to identify for which specialities our findings were significant. Intended stage and length of time abroad There was a trend towards later, longer periods of time (1-3 years) spent abroad, during speciality training post-membership. Shorter periods (1-3 months) were more popular earlier in training during the foundation years. Perceived barriers to global health careers 79% of respondents felt there were inadequate global health training opportunities. Other obstacles identified were: difficulty obtaining career guidance, few mentors, little information available, and lack of deanery support. Conclusions In a selected group of junior doctors interested in global health: 28  A wide variety of global health opportunities were sought  For activities requiring a higher degree of commitment (PhD,residential training, joint CCT) intended speciality influenced popularity  Trainees wished to spend short periods of time abroad early in their training and longer periods later in their training  Perceived obstacles to global health training require addressing References 1. Crisp N. Global Health Partnerships: The UK contribution to health in developing countries. London: 2007. 2. Brown C, Martineau F, Spry E, Yudkin JS. Postgraduate training in global health :ensuring UK doctors can contribute to health in resource-poor countries (in press). Clinical Medicine. 1-5. Postgraduate Global Health Training: Out of Programme Experiences (OOPEs)

T Rittman, J Dorward, E Spry, F Martineau, C Brown (on behalf of the Almamata Working Group)

T Rittman, 21 Perne Avenue, Cambridge, CB1 3RY

Introduction Modernising Medical Careers (MMC) has brought a defined structure to UK postgraduate medical training. The more rigid structure of MMC has been criticised for its inflexibility regarding time out for junior doctors to work and train in Global Health 1. Trainees can take advantage of Out of Programme Experience (OOPE) placements to pursue global health interests.

In a selected group of trainees interested in global health we wanted to assess:  awareness of OOPE opportunities,  if they had applied for OOPE and reasons behind this decision  interest in a structured OOPE

Methods An online structured questionnaire targeted junior doctors interested in global health and was advertised through mailing lists and word of mouth.

Results Amongst 89 respondents, the majority (85%) were aware of OOPE opportunities, and 20% had applied for OOPE. 65% were 'extremely interested' in a structured, pre-planned OOPE defined as support in finding a mentor and appropriate placement abroad. Only 3.5% expressed no interest in this. One respondent suggested that they ‘Do not feel this should be at the disadvantage of self organised OOPE's’.

Of those who had not applied for OOPE, the majority did not feel prepared to take time out at this stage of their training, with an additional 31% preferring to use ‘natural breaks’ between training rotations. 20% had not applied because they felt their application would not be successful. One respondent commented that they had been ‘Told no immediately on asking [the] Deanery about [the] possibility’, while another stated that they ‘have heard anecdotal evidence from friends that getting time out of programme experience is heart-wrenchingly difficult. I left Core Medical Training for Public Health to pursue more flexibility in Global Health training’.

Conclusions OOPE placements are an important opportunity for specialist trainees to pursue global health interests, but may not be supported by all Deaneries. There is significant interest in structured OOPEs amongst trainees with an interest in global health.

References 29 1. Koplan JP, Bond TC, Merson MH, et al. Towards a common definition of global health, Lancet. 2009;373(9679):1193-5

An exploration of Swansea medical students’ experiences of active involvement in an international health student link

D Abankwa, L Anderson

D Abankwa, Consultant in Rehabilitation Medicine, Neath Port Talbot Hospital, Baglan Way, Port Talbot, SA12 7BX

Introduction The Swansea Gambia Student Link was established in 2006. The aim of the Link is to promote the sharing of learning between students from Swansea University School of Medicine and the University of The Gambia Medical School. In Swansea link activities are coordinated by a committee whose members get the opportunity to go on an exchange visit for up to two weeks to the Royal Victoria Teaching Hospital in Banjul, The Gambia where they engage in clinical and other educational activities with their Gambian colleagues.

Tomorrow’s Doctors (General Medical Council 2009) includes learning outcomes relating to global health, team-working, teaching and leadership The aim of this study was therefore to explore the experiences of the Swansea medical students in order to identify any educational benefits.

Methods Six medical students and junior doctors who have been actively involved in the Link were selected by purposive sampling. In depth interviews were conducted to explore their experiences of involvement in the Link. Transcripts of the interviews were analysed using an inductive approach by means of the conventional content analysis method (Hsieh and Shannon, 2005).

Results Interviewees reported educational benefits in five areas: improved clinical diagnostic skills, increased medical knowledge, experience of providing peer education, increased cultural awareness and some generic skills.

Discussion The exchange visit exposed students to a wide range of pathologies which they would not normally get to see in the UK. Their cultural sensitivity was increased by working alongside their Gambian colleagues in a different clinical context. They provided peer education to fellow students thereby extending their experience of teaching. Swansea Medical School stands to benefit from the additional opportunities provided to improve the quality of global health teaching available to its students. The main problem that students faced was that they had to take time out of core teaching to go on the exchange visit. In future exchange visits will take place when other students are on clinical placements to avoid this problem.

Conclusions and recommendations

30 Participating in an international health student link is a useful way for UK medical students to achieve several Tomorrow’s Doctors outcomes. Future research needs to look at the benefits to the Gambian students of involvement in the Link

References General Medical Council (2009): Tomorrow’s Doctors: Outcomes and Standards for Undergraduate Medical Education. Hsieh H-F, Shannon SE (2005): Three approaches to qualitative content analysis: Qualitative Health Research: 15: 1277-1288

Do high tuition fees affect the demographic of Medical and Dental Students worldwide?

F Mughal, Rl H Kassamali

F Mughal, Solihull Hospital, Acute Medicine, Lode lane, Solihull, West Midlands, B91 2JL

Background There is strong evidence that Medical Schools that charge lower tuition fees are more likely to attract students from lower socioeconomic backgrounds (1). This approach promotes greater diversity in the profession and in the long term, makes a positive and strategically very important contribution to Global health.

Objectives  To explore factors that influence student decisions when considering entry into higher education.  To assess potential impact of fees in Medical Schools on Global health.

Design Cross-sectional survey of 1st and 2nd year medical and dental students of the University of Birmingham. N=298.

Method A self-completed questionnaire designed to explore the financial background of the students, their views on how much tuition fee they would be willing to pay and whether they would continue their current course in 2012.

Results The response rate was 33.7%. Of these, just over 69% of students indicated that they would continue with their courses even if the tuition fees were raised to 2012 entry levels whilst 28.5% declared that they would terminate their studies. Over 53% of this group said they would have chosen a different course. The results also highlight a significant correlation between family income and students’ decisions on higher education. Furthermore, the feedback indicates that female students were more likely to quit their courses, than their male counterparts. There does not however, appear to be any significant difference between the views of medical and dental students on this issue.

Discussion n the United Kingdom where the disparity between the rich and poor is becoming increasingly more evident, the rise in tuition fees will only serve to widen the gap; it does not help to bridge it. Developed countries such as Canada, New Zealand and Singapore have also identified this trend and the issue is fast becoming a matter of international concern (1-3). Studies reveal that reduced diversity in medical schools can have an adverse effect on the medical care of underserved populations (4-6). There is an overwhelming argument for universal access to higher education and healthcare; the two are intimately linked together.

Conclusion

31 The introduction of higher tuition fees will have a disincentive effect on those students applying for medicine and dentistry from lower and middle income groups. This is observed globally, as well as on a local scale; as shown by our work conducted at the University of Birmingham Medical School. References (1) Merani et al. Increasing tuition fees in a country with two different models of medical education. Medical Education 2010;44:577-586 (2) Heath et al. Parental backgrounds of Otago medical students. The New Zealand Medical Journal 2002;115:1165. (3) Ng et al. Cost of medical education, financial assistance and medical school demographics in Singapore. Singapore Medical Journal. 2009;50(5):462 (4) Bergen SS Jr. Underrepresented minorities in medicine. JAMA 2000;284:1138-9 (5) Gordan TL. Study of U.S. medical school applicants. Journal of Medical Education 1979; 54:677-702 (6) Kassebaum DG. On rising medical school debt: in for a penny, in for a pound. Academic Medicine 1996;71:1124-34 Intercalated Bachelor of Science Degree In Global Health at Imperial College London

Y J Chong, L A Chacko

Y J Chong, 18, Octavia House, 213 Townmead Road, Fulham, London, SW6 2FH

Introduction Traditionally, courses related to Global Health are offered as degrees in International Health such as the International Health BSc at University College London and Birmingham University. The Imperial College London intercalated Bachelor of Science degree in Global Health was the first of its kind in the UK when it was officially launched in September 2010. The first intake of 28 students had students from a varied international background such as Sudan, Singapore, Malaysia, Iran, South Korea, Hong Kong and Italy. This course also attracted considerable interest from other medical schools, with 27 applicants and 5 acceptances.

Materials and methods This one-year degree for intercalating medical students is a relatively new concept that reflects the increasing interconnectedness of health and its determinants. Health issues such as the global epidemic of obesity, climate change, and the rapid spread of new infectious diseases are no longer confined to national borders. Socioeconomic, environmental and technological changes often compound existing inequalities in health within and between countries. Such challenges necessitate the call for global leadership and commitment to achieve equity in health for people worldwide. The course was comprised of three compulsory modules, each lasting 5 weeks. Students were then required to undertake a 10 weeks research project.

The first module provided an introduction to old and new infectious diseases. Core concepts that were taught included global burden and surveillance of infectious disease, neglected tropical diseases, mathematical modelling of the spread of diseases, vaccination and antibiotic resistance.

The second module looked at the challenges of new epidemics such as obesity, diabetes, tobacco and environmental hazards. Students were also introduced to the concept of climate change, its effect on health and novel adaptation strategies.

The final module touched on global health leadership. Global health institutions and health systems were discussed with an emphasis on organization, governance and financing. Other topics that were taught included ethical issues in research in resource-poor countries, and the role of science, technology and the pharmaceutical industry in shaping global health interventions. Most student projects were undertaken in the UK largely due to financial restrictions. However, there were two students who undertook BCG vaccine research in Uganda with grants from the Medical Research Council.

Conclusion

32 In 2009, the GMC stated that doctors should be able to discuss the determinants of health and diseases from a global perspective1. With global health issues becoming more important, we are likely to see more medical schools in the UK offering specialist Global Health degrees.

References (1) General Medical Council 2009. Tomorrow’s Doctors (UK, General Medical Council)

Using an e-Portfolio to Make Global Health Learning Transparent

C Murray, J Mason, D Murdoch-Eaton, T Owens

C Murray, University of Leeds, School of Medicine, Room 7.09 Worsely Building, Clarendon Way, LS2 9NL

This poster presentation will outline a new approach to global health education being introduced at the University of Leeds in September 2011. This new approach will utilise an on-line competency mapping function within students’ personal e-portfolio spaces which will be linked to global health learning within the core curriculum.

Last year a student selected component project was undertaken to highlight areas in the curriculum where learning about global health was taking place, identify if students and tutors were aware of this learning and investigate ways of make this explicit to both. A main outcome of the project was the mapping of learning and teaching activities within the curriculum against the Medsin global health learning outcomes and competencies.1

It was discovered that students at Leeds are exposed to global health education across all years of the MBCHB and in virtually every core unit of the course. Not all of this learning, however, is identified by the students or tutors as falling under the ‘banner’ of global health. The internationalisation of the curriculum may be taking place but there is a need to make this education and learning transparent to enable students to identify, contextualise and define the issues related to global health as well as enable them to articulate and evidence their skills as a global citizen and as a medical professional working in a global context.

Several approaches to making this learning transparent were explored and the MBChB e- portfolio, used by all students to support assessments, personal tutorials and personal development planning, was identified as an appropriate delivery mechanism. The use of a mapping functionality would enable the Medsin framework to be imported into the e-portfolio, facilitating evidence collection from the core curriculum learning activities identified from the mapping exercise.

This poster will outline how the task was approached, the criteria used to identify global health learning and teaching activities and how this learning is to be made explicit through the use of technology. Evaluation approaches will be outlined and discussed.

References 1. Medsin. Global Health Learning Outcomes-Draft for Consultation. http://www.medsin.org/coreglobalhealth (Accessed 10th August 2011)

33 Medsin Exchanges as a means of promoting global health education

P Reidy, C Peal

P Reidy, 1 City Bank, Cathedral Yard, Exeter, EX1 1AE

Medsin, the well-known UK student Global Health advocacy group, is part of the lesser-known International Federation of Medical Students Associations (IFMSA). 1,2. In operation since 1951, the IFMSA brings together medical students from over 100 countries and operates a very successful international exchange programme that handles over 8000 medical student exchanges annually. 3. Within the UK this exchange programme is operated under the title of ‘Medsin Exchanges’ and handles over 60 bilateral exchanges a year, involving 120 students across 6 medical schools. 4. As an exchange programme one of the primary aims of the IFMSA is to improve intercultural learning. However, under an initiative spearheaded by Medsin, the IFMSA has recently been driving for the inclusion of tangible global health education within the exchange programme. This initiative has been promoted in two distinct manners. Firstly global health questions designed to spur thinking on health systems, disease burden and ethical considerations of international placements have been included within the programme through the use of compulsory student logbooks. The second tool is the hosting of ‘global health evenings’ by each medical school that participates in the exchange programme. At these events the students who come to the UK on exchange are asked to give a short 15 minute presentation on how the health system of their country functions, a description of the main diseases they encounter and an example of how a specific condition, for example a myocardial infarction, would be managed. These presentations are enhanced by moderated discussion on the issues that are raised, with direction given to relevant global health resources to encourage further learning.

These two initiatives have just begun to be trialled across several medical schools in four European countries. We hope to compile the results of these evaluations by the end of September and make recommendations for wider adoption across the IFMSA network.

The Medsin exchange programme offers an excellent and reputable method of increasing a university’s global health education offering while at the same time encouraging direct student participation in and consideration of global health ideas & activities. It brings together the international and intercultural aspects of the current elective scheme but with in built reciprocity, and is therefore arguably a more equitable and sustainable solution to medical school electives than what currently exists. For these reasons, Medsin exchanges provide an ideal vehicle through which to deliver global health education to tomorrow’s doctors.

References 1. www.medsin.org 2. www.ifmsa.org 3. www.medsin.org/projects/exchanges 4. www.ifmsa.org/index.php?option=com_content&view=category&layout=blog&id=74&Itemid=123

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