Local liaisons

Because of the connection via the anatomy departments, each school had one dedicated international anatomy faculty member serving as a contact. Although the program was initiated by Columbia University, all schools and faculty members were considered equal to one another. Regular faculty meetings online and email communication with all partners ensured a constant flow of communication and transparency.

Every year, each school selected up to two volunteer national student leaders (NSL) who led the student cohort from their respective schools and represented their school and country at the videoconferences (see program details below). The NSL formed their own sub-leadership groups and worked closely with the coordinating entities at Columbia, thus representing a second level of communication in this multi-member collaborative partnership.

Small group work

The purpose of the small group work was to give students a framework to practice international teamwork, develop an understanding of others’ customs, and to familiarize themselves with differences in culture and work ethics.

Small groups typically consisted of three to five students from three countries (at least one each from North America, Europe, and Asia/Australia). Beginning in the fall, students met online for one semester to work in small groups during several structured sessions. Session topics covered the differences in the anatomy courses, body donation policies, healthcare education and delivery systems, health law and ethics, and public health.

The program content goal deliberately went beyond anatomy and its related topics. Only one of the small group sessions was dedicated to discussions related to anatomy and the practice of body donation. The purpose of this first session/exercise was to serve as an “ice-breaker” and to reflect on subjects that were familiar to all participants (i.e., anatomy, body donation, working with the deceased). In this first session, the students were asked to compare the format of their anatomy courses, followed by reflection on the topic of body donation in self-reflection and as an international group. Body donation processes can vary between countries, even between schools in one country (e.g., some schools accept direct donations from families while others have a centralized system; some schools pay the donors). Because body donation is handled so differently, it serves as a tool to raise awareness about cultural differences. A list of suggested discussion topics for the remaining sessions was initially developed by faculty and further expanded upon over the years per students’ requests (Table 2).

Toward the end of the small group sessions, the students worked with their peers on a short collaborative small group paper covering one topic from the aforementioned list, creating a video and slide presentation together. The reasons for producing the paper and presentation were to strengthen their collaborative efforts, to communicate efficiently, to work across different time zones, to exercise professionalism and tolerance of others in an international setting, and to practice international public speaking at the videoconferences.

International student conferences

At the end of the semester the students presented their collaborative small group work to the entire cohort at two large international virtual conferences, with all students and faculty participating (Figure 1).

The groups of students from each country met in their respective lecture halls, libraries, or AV rooms, and connected via an online videoconferencing program (Zoom)©. NSL from each country served as moderators for the conferences, with minimal faculty involvement – although faculty was present with their groups online.

The conferences were divided into three blocks. Block 1 included a cultural presentation by the respective NSL. The presentation covered various characteristics (e.g., history, geography, art, architecture, customs, stereotypes, food, etc.) of each country and region. The purpose of the cultural exchange was to introduce different cultures and customs to these junior students and to inspire them to learn about a different country beyond the perspective of healthcare.

Block 2 included selected international group presentations on the topics the students had previously chosen for their collaborative papers. This exercise was practice for international public speaking and listening, developing an appreciation of non-English speaking students, and for non-native speakers to practice their fluency in English.

Block 3 included an introduction of the students that had expressed an interest in international exchange. Students introduced each other and paired up as “buddies”. This portion was meant for virtual international networking and was the only time when all students met together online.

The two international online conferences ended in early spring, completing the semester of virtual exchanges.

Student mobility

Subsequently, in the summer following the conferences the students travelled to the partner countries in order to perform short-term research in basic science laboratories (from 1–2 months up to 12 months). In addition, they socialized with their peers in the host country. This portion of the program was introduced to deepen collegial friendships, help students to immerse themselves in an academic life in another country, and for them to acquire research skills in the basic sciences.

Research laboratories were selected based on the students’ preferences for an area of research (e.g., immunology) and institution, subject to availability in the host laboratories of the partner countries (Table 3).

The anatomy faculty in each country assisted with laboratory placement, and supported grant applications. Funding sources varied (i.e., departmental, school, or university scholarships and stipends, governmental, GH program), and students also self-funded their trips. Peers helped each other with travel logistics, accommodations, leisure activities, and facilitated immersion into academic life in the host countries.

Student visits were divided (by countries) into several travel groups, to ensure that not all students travelled at the same time and that participating students were available for hosting the incoming students in each country. Incoming students experienced a rich social program hosted by peers and faculty (e.g., cultural activities, walking tours, picnics, private parties, etc.). This allowed for mingling with their peers during their stay abroad, outside of their time involved in a research project. A constant flow of new incoming international short-term students internationalized the host campuses.

Evaluation

Program evaluation can be separated into short-term and long-term results. Short-term evaluations had two purposes – evaluate the program itself (i.e., via feedback about what students liked and how the program could be improved), and assess student learning (i.e., to measure what they felt that they had learned). In this program, qualitative data included students’ perceptions of what they had learned.

Questionnaires (Qualtrics)© were sent to the students, after both the virtual and the travel portions of the program, to evaluate the success of the endeavor. Questions included closed and open questions and Likert scales. Success was measured using students’ perceptions of their satisfaction with the above experiences, their knowledge about covered topics and basic sciences research, and their fundamental understanding about other cultures and healthcare systems. Questionnaires in Qualtrics were developed in collaboration with the Center for Education Research and Evaluation (CERE) at Columbia University and were approved by the IRB at Columbia University (#AAA0003715) and at McGill University (#A07-E54-17B).

Long-term evaluation to measure what effect the program had on the students’ careers and lives, and subsequently on global healthcare, could not be evaluated at this stage.

Software and computer programs

Questionnaires were collected using Qualtrics. Analysis of data was performed using NVivo12© and Excel©. Online software used for the small group discussions included Facetime and Skype. The large group conferences were conducted via a university-licensed Zoom account.

Since the students only worked with peers from two other countries, they connected and socialized with the larger group via closed social media sites (i.e., Facebook©, Instagram©, and Twitter©).

Stepwise introduction

Very few published programs build on a trajectory of international experiences and involve both industrialized and LMIC countries [31]. Unlike others, this program involved a stepwise and sequential introduction of international experiences.

International experiences, particularly in the US, frequently aim to support the social justice notion of IoME, and historically often involved humanitarian work in the LMIC as part of GH programs [12, 23]. The authors suggest that these goals need to be revisited at a time of espoused global social equality and accountability and should be more inclusive of all aspects of IoME. In contrast, European and Asian schools and their exchange programs tend to have a broader scope, with student mobility including industrialized countries, most often the Anglo-Saxon countries [14] – to support competitiveness and collaboration.

Often, there is little introduction to acquaint young students with international differences, although pre-departure training is considered important and offered in recent years [21, 32]. The students in this program felt that they were well prepared in many areas for travel, such as culture, emotional wellness/culture shock, knowledge, and safety [32].

Early internationalization

Reports on early internationalization efforts for junior medical students are limited [3, 6, 33, 34]. In this program, the majority of the participating students were still in the formative phase of their lives. The authors assert that early international connections have a higher chance for long-term sustainability of the newly formed collegial friendships. To date, the program has not been in existence long enough to have longitudinal results. It was encouraging to learn that the majority of students planned to remain in contact with each other, which indicates potential long-term sustainability. Personal communications with past participants indicate that active interaction on social media and private visits are still ongoing with involvement dating back to the initial travel participants of the program. Long-term follow-up will provide data on this subject.

International peer-to-peer teamwork

Limited reports are available on programs that connect students from different countries to each other [35, 36]. While national and international student networking and travel programs do exist [37, 38], typically they are not based on frameworks orchestrated by medical schools [2, 30, 36].

There is undeniable value to student-run programs via large organizations (i.e., IFMSA). Direct involvement in peer connection via medical schools and senior medical teaching faculty can be of value for quality control and integration into medical school curricula. As globalization will play a larger role in medical education, medical schools should take on an active role in student interactions.

Bidirectional student mobility

Student outbound mobility has long been regarded as synonymous with internationalization in medical education [6]. Eight-seven percent of US medical schools offer international programs for medical students [13, 39] and almost 30% of medical students engage in a reported international activity during medical school [40]. Although there are other elements for IoME (i.e., internationalization at home and “glocal” programs [6, 41, 42]) student travel is still an attractive means to interest students in international and global healthcare issues.

Programs with multidirectional student exchanges are limited [28, 43]. This program offered a bidirectional exchange involving traveling students who subsequently became the hosts for peers that visited them at their home institutions. These visits also boosted internationalization of the host campuses as an element of IoME.

International partnerships

International collaborations in medical education have been presented in various forms and directions [18, 35, 44, 45, 46, 47, 48]. The novelty of the program presented here is that twelve anatomy departments on four continents worked together to enhance medical and dental education for preclinical students and provided them with a platform for international networking, with the goal in mind of helping to create a generation of global citizen physicians and dentists. These types of faculty-driven collaborations in medical education have been reported but are still limited in scope [27]. This lack of reporting may lead to inefficiency, because departments seeking to establish new programs have no references to find best practices and will have to constantly “reinvent the wheel”. Anatomy to date has not been formally linked to GH education. Valuable learning objectives achieved through the anatomy cadaver dissection laboratory include teamwork, scientific thinking, ethics, and professionalism [49, 50, 51]. Despite this, traditional anatomy courses are often regarded as dated, costly, time consuming, and resource draining.

The majority of students in this program supported the idea of having anatomy as an anchor for the international exchanges. Due to the limited amount of time the students could spend with their peers, a significant number of groups decided not to focus on learning anatomy related topics from each other during their small group sessions. This demonstrates that students appreciated the networking opportunity initiated via the anatomy course. With the exception of reports generated by this group of authors there are no reports that link the discipline of anatomy to internationalization of medical education [2, 30].

There are several advantages to choosing anatomy as an anchor for international activities. First, anatomy is a subject field that is taught universally in all medical and dental schools. Secondly, anatomy is typically taught very early in the preclinical phase of medical education. Many US medical schools offer GH experiences between years 1 and 2 of medical school [39]. Therefore, early linking of anatomy with IoME is in line with the concept of early GH exposure. Anatomy can serve as a vehicle to connect schools via collaboration on the faculty level. Because most anatomists are tightly linked with the basic sciences, internationalization efforts helps to attract students with research interests to international work and can open up areas of research that are not typically addressed in traditional research portfolios (e.g., research in the genetics of tropical diseases). Anatomy educators work very closely with students, have dedicated teaching time with them, and personal mentorships are established at an early stage. Through this mentorship the current program provided very individualized, custom-tailored international research laboratory placements for the students in phase 1.

Beyond anatomy

The content of this program differed from many international programs [12, 22, 23] because it mainly focused on acquiring knowledge pertaining to differences in healthcare systems, healthcare education, health ethics and law, public health, and not on clinical knowledge. The program was not meant to provide students with an in-depth study of Public Health, or intended as a replacement for a GH class. The peer-to-peer interaction rather was considered as inspiration and an enrichment, similar to additive courses described in the literature [52].

Intercultural Exchange

Cultural awareness is important for global leaders and should be part of the medical curriculum [53]. The cultural introduction within the large student conferences of this program helped the students to familiarize themselves with cultural differences. Unlike programs which focus on differences with LMIC, phase 1 elected to focus on countries that are of similar economic backgrounds, to ease young students into awareness of cultural differences in a more subtle way.