Elective Educational Unit: International Exchange Experience in Undergraduate Medical Training

Unidade Educacional Eletiva: Experiência de Intercâmbio Internacional na Graduação em Medicina

ABSTRACT

As part of the integrated curriculum, the Elective Educational Unity (EEU) is a tool to support knowledge construction and student autonomy during undergraduate training. The international exchange for undergraduates therefore aims to explore potentialities and challenges within a pedagogical perspective through the experience and understanding ofdiverse educational institutions and health services, through prolonged contact with other professionals and students. One constructive strategy of an elective internship is in conjunction with student associations. This report intends to contribute to medical education by reflecting on how the international elective internship impacts on medical training, analysing its potentialities and challenges. The reportaddresses the steps in accomplishing the exchange, presenting the activities developed in the experience, highlightingthe observed objectives and results, along with reflections on the experience. It is ascertained that the international exchange stimulates the experience, recognition and understanding of other cultures; it helps students build autonomy and stimulates a critical reflexive view which promotes knowledge construction, raising the student’s awareness of his own social responsibility as a health professional. Therefore, the Elective Educational Unit encourages the student to elect the exchange as a curricular activity, it supports him on choosing a study area and international or national institution of interest, with the option to liaise with other organizations, for example the student organization. Unquestionably, personal growth is one of the consequences through learning about diversecultures and making new friendships and partnerships between different countries. However, there are challenges, such as adaptation to another cultural context, affective detachment and the understanding that different places have distinct historical, social, economic contexts from one another. Thus, advances and changes are proposed to improve the Elective Educational Unit, stimulating greater student participation in international experiences during undergraduate training, as well as underlining the importance of the supervisor’s role in the elective planning process.

–– International Educational Exchange; ––Health Information Exchange; ––Education, Medical, Undergraduate; ––Students; ––Curriculum

RESUMO

No currículo integrado, instituiu-se a Unidade Educacional Eletiva (UEE) como uma ferramenta de construção de conhecimento e incentivo da autonomia dos acadêmicos no processo de formação médica. Nesse sentido, o intercâmbio internacional na graduação busca explorar potencialidades e desafios dentro de uma perspectiva pedagógica, por meio da vivência e compreensão das múltiplas formas de organização de outras instituições de ensino e serviços de saúde, pelo convívio com outros profissionais e estudantes.Uma das estratégias de construção do estágio eletivo pode ser em conjunto com associações estudantis. Este relatopretende contribuir, assim, para a formação em Medicina a partir da reflexão sobre como essa internacionalização do estágio eletivo interfere na formação médica, analisando suas potencialidades e desafios. Aborda os passos para a realização do intercâmbio, apresenta as atividades desenvolvidas nessa vivência, destaca finalidades e resultados observados, comreflexões sobre a vivência. Verifica-se que o intercâmbio internacional estimula a vivência, o reconhecimento e a compreensão das culturas; contribui para o estudante construir sua autonomia e estimula a visão crítico-reflexiva, que impacta a construção de conhecimento, tornando-o ciente de sua responsabilidade social como profissional de saúde. Em vista disso, a UEE tem incentivado o estudante a eleger o intercâmbio como uma atividade curricular, apoiando-o na escolha da área de estudo e instituição nacional ou internacional de seu interesse, podendo articular-se com outras organizações, dentre essas a estudantil. Positivamente tem-se o crescimento pessoal pela compreensão de diferentes culturas, novas amizades e parceria entre diferentes países, mas também há desafios, como a adaptação em outro contexto cultural, o distanciamento afetivo e a compreensão de que diferentes locais têm contextos históricos, sociais e econômicos distintos uns dos outros. Com efeito, pontuam-se avanços e mudanças interessantes para o aprimoramento da UEE, estimulando os estudantes a participarem mais da internacionalização durante a graduação, bem como salientando o papel do orientador no processo do planejamento do eletivo.

–– Intercâmbio Educacional Internacional; ––Troca de Informação em Saúde; ––Educação de Graduação em Medicina; ––Estudantes; ––Currículo

INTRODUCTION

International exchanges allow students the opportunity to place themselves in the global context of health care.Therefore, as well as being an instrument for the acquisition of technical-scientific knowledge, this allows a cultural experience, developing within the medical student, among other skills and purposes, a critical-reflexive vision that raises his awareness of his social responsibility as a health professional.

There are medical school organisations responsible for promoting student exchanges between different educational institutions around the world, such as the International Federation of Medical Students’ Associations (IFMSA) and the Coordenação Local de Estágios e Vivências (CLEV – Local Coordination of Internships and Work Experience) – associated to the Direção Executiva Nacional dos Estudantes de Medicina (DENEM – National Executive Board for Medicine Students), through the Coordenação Nacional de Estágios e Vivências (CEV – National Coordination of Internships and Work Experience) and the Diretório Acadêmico (Academic Administration) ¹ .

At the CEV, one of the internships offered is the Brazil-Cuba Hub (NBC), an exchange program that promotes partnership between DENEM and the Federação Estudantes Universitária de Cuba (FEU – University Students’ Federation of Cuba). To participate in the program, one must apply through a selection process that analyses the student’s involvement in activities related to education in health and medical training ² .

The NBC encourages experience and critical reflection, focusing on the differences in health systems and in medical education.Therefore, visits are made to institutions of the Cuban health system, from Primary to Tertiary Care, as well as visits to the country’s medical schools ² .

The exchange, although it may be considered an optional curricular activity in at several educational institutions, can also be included as an elective for students, affording them a certain degree of autonomy in the decision-making about their training process, with it inserted into the planned and executed curriculum.

In 2003, following the curricular change implemented at the institution in 1997, the Marília Faculty of Medicine (FAMEMA) established the Elective Educational Unit (UEE) as a compulsory activity of the Medicine course, with a predetermined number of hours and period of study in each year – from the second to the sixth years, corresponding to 160 hours in four weeks.In this elective the student has the freedom to choose the area and institution of their interest, with the support of their Student Supervision Program supervisor to discuss arrangements and its feasibility, with the aim of producing a provisional plan of activities to be executed.This includes choice of Brazilian and international health service and/or academic settings, provided that they are relevant to the curricular prerequisites of the course, in accordance with the degree of autonomy for conducting the activities in the academic year in question.This allows the student to learn about and experience new cultures, other teaching institutions and health services with different ways of understanding care and organizing work, thus transcending traditional training ³ .

The UEE takes on significance in the integrated curriculum and in the dialogical orientation of competences as the student is stimulated to construct their performance, related to professional practical scenarios. Their degrees of autonomy and proficiency are constructed, highlighting the contexts and local culture through reflexive practice ^4,5 .

There are some experiences reported in the literature about international exchange, inserted in undergraduate activities ⁶ and, more frequently graduate studies ^7,8 , however they do not constitute compulsory curricular activity in the undergraduate program.

One of the reports describes the role played by international experience in personal development – by virtue of affirmation of personality, acquisition of social and cultural values, contact with people different to those with common affective ties – as well as in professional and theoretical-scientific development.Didactic, pedagogical and interpersonal abilities are developed during undergraduate studies in a program with academic mobility.One can also highlight the overcoming of difficulties, for example, an exchange student needs to deal with the distance from people with whom they maintain affective ties, which can lead to vulnerability in the decision-making process in their private and professional life ⁶ .

In graduate programs, meanwhile, international exchanges are more frequent.Published articles report the importance of internationalization to give rise to the construction of joint projects and the possibility of articulation between Brazilian and foreign lines of research ⁷ . Another article speaks of the importance of spreading knowledge built through study-visits.The experience has also proven to be highly relevant for the professional and personal development of the teachers and reinforces the development of scientific research ⁸ .

This experience intends to contribute to training in Medicineby reflecting on how internationalization of the elective undergraduate internship influences medical training, reviewing the potential and challenges involved in this activity.

EXCHANGE EXPERIENCE IN THE ELECTIVE EDUCATIONAL UNIT

This report initially describes the process for the execution of the medical academic international exchange, followed by the presentation of the activities during the experience, highlighting their purposes and identified results.Subsequently, reflections are developed regarding the exchange practice in the context of the UEE.

The experience began with the opening of Process NBC 2017.2, associated to DENEM through the CEV, which is locally coordinated at the FAMEMA by the CLEV, an agency of the Academic Administration.This agency is responsible for promoting the exchanges offered by the CEV, intermediating between the student and the CEV/DENEM, and enabling the academics from the local institution to participate in the selection processes and be trained if they are selected for the chosen program.Application for process NBC 2017.2 was opened in March 2017 for this exchange.It set out to select 30 Medicine students for the exchange in Cuba in the month of July of the same year.

As soon as online applications were opened, any student who wanted to apply could access the form through a link, published on the process web page, and complete it with personal details.The candidate subsequently included the documents requested by the assessing agency.Once that was done, the candidate had to contact his CLEV to inform them that he had begun the application procedure for the Cuba exchange, so that the agency could validate the authenticity of his registration, carry out the training workshop and receive the application fee for the selection process ² .

Thus, the process was carried out.Following candidate training and presentation of the details of the activities to be developed during the internship, accommodation and provision of meals at university lodgings in Cuba were considered, as well as the amount of money each candidate would require for the exchange period and presentation of the curriculum for points scoring.

Once this process was adequately concluded by the participant CLEVs, the candidates were ranked and selected in order of their point scores.The list of those selected was announced in April 2017. Following all the legal procedures for approval of the elective internship at FAMEMA, the process was carried through to implement the exchange.

The work plan was developed for creation of the report, requesting authorization from DENEM in Brazil and FEU in Cuba.

The exchange occurred in July 2017, in Cuba.The material of the report presented here was registered in a field diary, completed for the 21 days of the internship for the purposes of presentation and analysis though data systematization.A proposal adapted from the reference of Holliday (2006) (Taller de Sistematización CEAAL – Peru) was used, which included data about:what was carried out; how long the activity lasted; the purpose of the activity; who was present; the results; observations and impressions about the activity – which details were completed individually, reporting on the work done each day.

Following presentation of the diary material collected during the exchange, an Excel spreadsheet was created to organize and process the data.The data were fed into the spreadsheet, distributed into their respective categories, and a synthesis was developed per category.Thus, the systematization was rendered more didactic and it was possible to analyse everything that was done in globally, from a critical and reflexive perspective. Firstly, a table ( Table 1 ) was created containing the synthesis of the activities conducted, their participants, objectives and results.

TABLE 1
Activities conducted in the exchange program in the Elective Educational Unit in Cuba, objective and results, Marília, 2018.

What	Why	Results
Activities at the University	- To understand the university entry process; - To understand the Brazilian and Cuban medical curricula; - To learn about how public health services are organized; - To learn about a lifeguard school; - To understand how the graduation ceremony works, and - The role of internationalization in undergraduate training.	- Understanding of three-level division of health care services (primary, secondary and tertiary); - Understanding of the university entry process and distribution of students according to proximity of student’s home to institution and the study focus in the six-year course, standardized in all medical schools; - Existence of agreements with other countries for foreigners to study Medicine in Cuba (either self-financed or with humanitarian aid for vulnerable countries); - Training for lifeguard professionals, with a good pool structure for simulated drowning incidents associated to the health system; - Knowledge of special mentions given during the graduation to students who participated more in extracurricular activities (such as politics and research) and those with the best academic performance.
Visit to the health services	- To observe the ability to provide primary care solutions and its functional importance, considering the distribution of services in the space; - To understand the organizational dynamics of the university hospitals and care compared to what is known in Brazil; - To understand the use of clinical method in Cuba, and - To verify the technology available in tertiary care.	- Observation of the services offered by polyclinics, regardless of their location in the municipality:24-hour accident and emergency service, physical rehabilitation programs for children and adults with physiotherapy, natural traditional medicine and collection of tests; - Understanding of the role of family health practices:they work on spontaneous demand, with one family doctor/nurse for roughly 1,000 inhabitants, in the morning and evening, epidemiological data is collected annually, work on health promotion; - Existence of similarity with Brazil in university hospitals in relation to the organization of the wards and the application of clinical method, and - Recognition of state-of-the-art technology in tertiary care accessible to the whole population free of charge and to foreigners, as long as they pay for the service.
Support Institutions	- To understand and value health care and promotion for the mentally ill, aged and pregnant women.	- To understand the importance of offering activities that stimulate patients’ mental and physical capabilities at the Mental Health Centre (for example:some places simulate a house so that children and adults can develop the ability to carry out everyday tasks; - Review the role of the Casa de Abuelos old people’s home in health promotion for the aged:This is not a long-stay institution.With set opening hours (07:00 to 19:00), it offers three main meals, and activities to stimulate the patients through conversation, musicotherapy and arts and crafts, and - To verify how the Hogares Materno Infantil infant-maternal institution influences maintenance of low infant mortality rates:In these places pregnant women at risk are admitted to the hospital if necessary, or just spend the day there, having consultations, carrying out health promotion activities and having daily meals.
Reflection about the experiences	- To establish agreements for good coexistence and outlining the schedule, and - share impressions and analyses of the Cuban health system and the SUS.	- Understanding of the need to compromise in relation to the agreements to ensure good coexistence and fulfilment of the scheduled activities; - Gathering observations and impressions of each exchange student about the Cuban health system and the SUS; - Identification of the potential capabilities of the Cuba health service – in the family health practices, university hospitals and tertiary care, and - Discussion of the similarities and differences between the Cuban and Brazilian medical curricula in their respective universities, raising hypotheses of possible improvements in each place.
Touristic activities	- To learn about the local culture and promote integration.	- Understanding of the local culture and history, analysis of the conditions experienced by those people and their relations with the health system, and - Bonding between the students.

There were 27 student participants in the exchange, six men and 21 women, from all regions of Brazil, but predominantly from the Southeast region.One of these students was the DENEM representative and responsible for the group, coordinating the smooth running of the activities and organizing the program.The majority of the students (22) were from public Medicine schools and the other five came from private institutions.Accommodation was offered to them at a student residence at one of the Medicine schools of Havana, where they were provided with three meals a day for a symbolic fee.Furthermore, it should be highlighted that each student was responsible for covering the costs of their own return flights and other travel costs, with no provision of any cost allowance or assistance.The activities conducted did not involve any additional cost for the student, as they were included in the exchange program.

Throughout the period, activities were carried out to support integration between the Brazilian and Cuban exchange students.In effect, critical reflection was encouraged, promoting efforts to understand the Brazilian and Cuban realities in various scenarios.At the Cuban medical schools one can learn about, for example, the University entry process, the medical curriculum of the country and the organization of public health services.Visits to the polyclinics, family health practices, university hospitals and tertiary care institutes enabled analysis of the system’s capacity to provide solutions, understanding of the various health services offered at each institution and observation of the technology employed in the different places.Support institutions for specific population groups (mentally ill, aged and pregnant women) demonstrated how health promotion is important for the good operation of the system.All this, as well as touristic excursions, allowed the students to bond and learn about the local culture, seeking to understand the reality lived by the Cuban people.

In general, the participants of the activities presented in Table 1 were Brazilian exchange students, Cuban students, the dean of the Medical Sciences University of Havana, conference participants and teaching staff from medical schools, students who were graduating and their friends, families and teaching staff responsible for the graduation ceremony, lifeguard professionals, doctors and nurses from family health practices, health teams from the polyclinics, hospital wards, Oncology and Cardiovascular institutes, Mental Health Centres, the Casa de Abuelos old people’s care home and the Hogar Materno Infantil infant-maternity institute.

REFLECTION ON THE EXCHANGE PROCESS THROUGH THE ELECTIE EDUCATIONAL UNIT

The opportunity offered through the UEE to partake in an exchange program, either national or international, and thus explore different scenarios to those of the student’s own institution, is a way of exploring potential capabilities and challenges within a pedagogical perspective.The role of the supervisor proves to be important insofar as it builds reflection about the pertinence and learning opportunities when outlining the objectives, activities and actions in the student’s scenarios of choice.

The search to live, recognise and understand new experiences in other settings becomes an important and necessary tool for the construction of individuals’ knowledge and autonomy. Drawing on the results of the experience, with reflections on what the exchange student saw and felt, they can outline important aspects that played a part in constructing a critical way of thinking that positively influences personal, academic and professional growth, such as the abilities built through the potentials of the experience and the obstacles overcome.

Corroborating this thinking, Dalmolin et al. (2013) reflect that international experience leverages knowledge of different and specific habits, opening up new prospects and helping overcome difficulties, as the assimilation process to the environment is a challenge and requires emotional strengthening, as the distance from one’s affective ties at home leads to vulnerability in personal and professional decision making. Thus, the conclusion can be drawn that the exchange student should be prepared, as the experience demands patience, self-sacrifice, overcoming unforeseen events and distance from friends and families, always considering cultural and climatic differences, for example.

Furthermore, international experiences at the university help broaden the student’s horizons in other settings, through the interculturality practices during the experience with students from other countries.Therefore, new friendships, contact with a different language, observing and adapting to different customs and the independence and autonomy stimulated during the experience are important potential opportunities developed during the exchange ¹⁰ .

Considering the potential opportunities of the experience reported here, a scenario is formed both with the Cuban students and the students from the different regions of Brazil, from both public and private institutions.This contact with different approaches to the curriculum and health services (organization, structure and technology), for example, provokes stimulating reflections. Identifying the differences and analysing the positive and negative points of each place are important processes for reflecting on future investment policies and changes in health strategies ¹¹ .

In this regard, the debates held during the exchange encourage the academics to learn more about different curricular activities conduced in the different learning institutions, such as, for example, the practice of dissection for Anatomy students, which is not common practice in most medical schools, and the different organizations of student outpatient practices.When they come face to face with activities and curricular approaches that might have a positive impact on their medical training, students reflect on the possibility of including such practices in their own place of study.Thus, presenting these ideas from the exchange debates to their peers, teachers and course coordinators and discussing the feasibility of introducing some changes in their own curriculum according to the local reality stimulates the student’s autonomy in recognising the potential opportunities and weaknesses at their own institutions, bringing about improvements to their field of work.

Due to this contact with the potential capabilities of the Cuban health system and through discussions with the exchange participants, the students’ understanding of the health practices in the SUS can also be deepened, motivating them to engage in such a way that enables their shared experiences to improve their own practice in health, as well as that of the teams in which they work.

Reporting an undergraduate exchange experience, Patuzzi et al.¹² demonstrated that this experience engages the construction of new management and planning prospects in the SUS, bearing in mind that the doctors and nurses take on this responsibility in their professional role. Furthermore, such internationalization allows the academic to observe possible innovations, for instance, the identification of new ways of acting and thinking as regards health and citizenship.Although the learning process and understanding of how other educational institutions and health services are organized do represent a challenge, as one must transcend preconceived ideas and consider the diverse contexts that culturally and socioeconomically engage each location.

In this aspect, the focus given in Cuba on multi-professional activity in primary care (child and adult physical rehabilitation program with physiotherapy, podiatry, occupational therapy, practice of natural traditional medicine, etc.) and the offer of these services, even in rural areas, stimulated the exchange students to seek feasibility and availability of such services in the SUS for a service user in an inner-state town of São Paulo state.Thus, critical thinking was stimulated during the international experience and engaged the academic, inserted in a regional health context, to construct new perspectives in their field of work.

Another challenging process in this experience is having access to public announcements about international exchanges, for the student should be attentive to information about the application announcement made by the organizing body.In this case, the selection process itself also represents a challenge, seeing as the student needs to have completed extracurricular activities to score points and qualify, as well as having sufficient personal funds to partake in the exchange.

One advantage of the exchange is the internationalization of science. Dalmolin et al.⁶ e Bubadué et al.¹⁰ point out that this experience can be compared to that of researchers and promotes technical-scientific innovation, with the potential of resulting in partnerships for research projects between different countries.Indeed, this fact transcends the university walls and could possibly collaborate toward globally-shared scientific advances.The exchange of experiences is also shown to be a learning opportunity for undergraduate students, triggering reflections on the different technologies used to conduct health and education practices.

Considering the context of integrated curricular organization guided by dialogical competence, the UEE offers experiences based on professional practices, whereby value is put on the student’s autonomy by taking in to account his or her choices in the academic arena as an instrument of curricular training. The international exchange experience is a productive one as it favours reflection with students who have diverse curricular and professional practical experiences, feeding into the teaching-learning process.

FINAL CONSIDERATIONS

International exchange supports the experience, recognition and understanding of different cultures, helping the student build his or her own autonomy and stimulating a critical-reflexive vision that influences the actual construction of knowledge while also raising awareness about social responsibility as a health professional.The UEE, therefore, seeks to encourage students to choose to partake in the exchange as an important curricular activity, supporting them to choose the area of study and Brazilian or international institution of interest.This helps promote the students’ autonomy, making a platform for the construction of knowledge and experience of new cultures, educational institutions and health services, which leads to understanding the particular characteristics of the care and work organization in the chosen place. The case report analysis contributes to medical training by describing the necessary process involved in the exchange, the presentation of activities conducted in this experience (knowledge of the Cuban medical curriculum, university entry process, visits to polyclinics, family health practices, university hospitals, tertiary care institutes, support institutions, touristic excursions), highlighting its objectives and identified results as well as reflections on how the international elective internship in undergraduate studies impacts on medical training, analysing the potentialities and challenges of this activity.

Such potentialities and challenges involved in an international exchange experience were effectively identified from the reported experience and literature review.This experience leads to personal development (impact on the personality with understanding of new social and cultural values, by being encouraged to live and mix with people of different common affective ties), and to possible international partnerships on scientific projects between different countries that could contribute toward technical-scientific innovation.It promotes reflection on new ideas regarding curricula and work organization thanks to the contact with academics from other institutions and health services, which can lead to improvements in one’s own institution through debate with peers, professors and course coordinators.

The exchange also constitutes a challenge, as it is necessary to have access to its divulgation by the organizing agencies, and have the personal or institutional financial resources to be able to participate.It also demands observation and adaptation to different customs, the need for independence and autonomy within a context of vulnerability (considering the differences in climate, culture, language and distance from one’s affective ties) and understanding of the multiple forms of organization of other educational institutions and health services, bearing in mind that different locations are inserted in different historical, social and economic contexts to one another.

It is interesting to indicate which advances and changes would be important for the improvement of student training through curricular organization in a UEE, as a source of knowledge and stimulation for student autonomy.The institution needs to broaden and diversity its relationships and agreements with other institutions, as this increases the possibility of exchange and further incentivises academics to go to new places.Furthermore, with the aim of stimulating the practice of exchanges, the fact that the institution has a specific internationalization department means that students are provided with greater support in the different legal processes involved and encourages students from other places to come to the institution in question, thus reinforcing international partnerships.

The incentive for students to obtain financing to subsidise their stay outside their own institutions in the elective is also important, seeing as many students do not have their own funds to carry out this practice.There is a need for the exchange students to have the opportunity to share their experiences, encourage their peers and bring ideas for possible local improvements through debates, for the UEE to organise a space for the experiences to be shared among the students.

For the students to be strengthened in the construction of their performance in a manner coherent with the stage of their training and considering their degree of autonomy and proficiency in professional practice, the role of the supervisor is of fundamental importance at the time of choosing the scenarios for the elective, stimulating the search to fulfil the undergraduate learning needs and outline the practices to be conducted.

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Publication Dates

• Publication in this collection
  23 May 2019
• Date of issue
  Jul-Sep 2019

History

• Received
  22 Oct 2018
• Accepted
  21 Feb 2019