Rewarding journeys: exploring medical students’ learning experiences in international electives

Figures & data

Table 1. Japanese medical student profiles (n = 43)

Sex	Male (27), Female (16)
English proficiency (TOEFL iBT)	100 < (=ITP600 <) (0) 90–99 (=ITP 577–597) (17) 79–89 (=ITP 550–573) (26)
Country	Australia (22), Canada (8), USA (8), Thailand (2), Austria (1), France (1), New Zealand (1)
Specialty rotated	Paediatrics (7) [Surgery (3)], Oncology (6) [Surgery (2)], Cardiology (4) [Surgery (1)], Family medicine (3), Dermatology (2), Gastrointestinal med.(2),Haematology (2), Infectious disease (2), General medicine (2), Liver transplant surgery (2), Nephrology (2), Radiology (2),Drug & Alcohol med. (1), Geriatrics (1), Neurology (1), Orthopaedic surgery (1), Palliative care (1), Rehabilitation med. (1), Urology [Surgery] (1)

Figure 1. Overview of students’ management process in academic contact situation

Table 2. Learning outcomes of international electives perceive by students

Theme	Quotations
Medical knowledge and clinical skills
Medical knowledge	In Nephrology, it is important to understand the patient’s condition by fully considering the changes in every examination result. The supervisor always provided me with a detailed explanation of even the complicated cases. … I could learn a lot clinically, thanks to the clinical teachers’ detailed instructions. (Student 28)
Epidemiological differences	During the ward rounds, I could watch and learn about uncommon diseases in Japan, such as Dengue fever, Toxoplasmosis, and Bacterial dysentery. (Student 19)
Clinical skills	I had an opportunity to cannulate and draw blood, which I rarely did in Japan. … Although I couldn’t execute the procedure on patients perfectly, it’s a good experience. I realised it seemed possible theoretically but was hard to perform practically. (Student 14)
Communication
English or other language	The chance to go through the history in English every day made me confident in my English language proficiency. I will be able to communicate with English-speaking patients in Japan without any problem. (Student 6)
Doctor-patient relationships	Doctors in medical oncology devoted a lot of time communicating with patients daily. I was moved by the doctors’ efforts to determine the best care for the patients through regular discussions with those suffering from serious diseases. (Student 17)
Interprofessional communication	Nurses and social workers were actively involved in taking history and patient care, which was not common in Japan. There was no hierarchical relationship among health professionals. … As issues of alcohol and drug use are critical for patients after discharge, interprofessional collaboration is importanrt. (Student 8)
International healthcare
Healthcare system and policy	In Quebec, CLSCs (Centre Local de Services Communautaires), which are free clinics run by the government contribute to providing health and social services effectively in the society (not only remote, but also urban areas). In Japan, the family physician provides home-visit medical care services mainly in suburbs and remote areas. … I consider this system to be a good way of enhancing community medicine in Japan. (Student 39)
Career management and development
Sense of professional identity	I learned the importance of enhancing the sense of professional identity. I observed that doctors remembered the clinical trial results, sample sizes, regions, publication years, and journal names precisely. Based on knowledge from previous clinical trials, they intensively discussed treatment for patients. (Student 6)
Work-life balance	In Vienna, people finished work on time and subsequently enjoyed music at a concert or a café, pictures at an art gallery, and discussed literature with their friends. Watching the citizens enjoy life, I had concerns about life in Japan where people are always hard-pressed for time and tend to overwork. (Student 16)
Society and culture
Healthcare in multicultural society	Hospitals in the US offer a multicultural environment because doctors from China, Korea, India, African, European countries work together. Patients also come from various cultural backgrounds and the demand for medical interpreters is very high. Such multicultural environment allows people to share different perspectives on matters. (Student 18)
Multilingualism	Around 10% of patients spoke Chinese in Australia. Of them, many elderly people could not speak English and we needed medical staff or family members who could speak both languages. … I focused on improving my English language proficiency. However, I realised that Chinese was an equally important language in healthcare. (Student 7)
Medical education
Educational system	Mentor system is well-established in the US. Every resident or fellow had a couple of mentors. A resident told me that he requested for the doctor, who was his role model, to be his mentor. (Student 11)
Educational strategies	In Thai, medical students read many research articles in international journals. In an EBM (Evidence-Based Medicine) class we discussed the best ways of treatment and prognosis of hypertensive patients based on evidence from clinical research and then logically analyzed the process of reaching our conclusions. This was an excellent opportunity to experience EBM education, which I never learned in this way before. (Student 27)
Personal development
Active/lifelong learning	I realised that, under any circumstance, what you gain from experiences depends on your enthusiasm and proactive involvement in practice. This attitude is also essential in practicing as a doctor in future. (Student 15)

Table 3. Noted problems/difficulties in academic contact situations

Theme	Quotations
Linguistic/communicative aspect
Listening	I could express what I wanted to during one-to–one interactions with clinical teachers, but, it was difficult to follow conversations between doctors in the ward and ICU rounds. In fact, I could grasp only around 30–40% of these conversations. I was shocked at how little I understood in the first few days. (Student 34)
Speaking and expression of opinion	[Expression of the detailed nuances] When the doctor questioned me about things like, ‘What do you want to do today?’ expecting my self-directed attitude, I could only respond with, ‘I want to observe surgery.’ I wanted to express more but I could not do so. I was very frustrated with my English. (Student 34)
	[Self-expression] I could not answer questions of the medical staff about clinical issues properly and coherently because I could not fully express everything I had in mind in English. This upset me and I sometimes made me doubtful about my ability to spend time productively in the US. (Student 41)
	[Presentation/explanation] I was so nervous that my voice and hands trembled when I conducted my first medical interview with a patient. My mind went blank and I was at a loss for words. When I was reporting on the patient condition to the doctor, his facial expressions made his discomfort with my English obvious. (Student 6)
Vocabulary/abbreviation	There were a high number of abbreviations compared to Japan. As there were often drugs with different brand-names on patient notes, I was confused and had difficulty in comprehending the information. (Student 23)
Sociolinguistic aspect
Self-positioning	… as a student there, I did not know how actively I could ask for the opportunity to observe a surgery and how I could be involved in the surgery. (Student10)
Relationship with supervisor and other medical staff	My supervisor was very busy with his duties, and I did not know when I could ask him a question. When I did, he spoke too quickly for me to grasp his answer. … I had no idea about how to behave appropriately in this situation in a different cultural context. (Student 13)
Communication with patient	I think that my problem was that I could not conduct medical interviews well by taking the patient’s social and psychological backgrounds into account. (Student 35)
Sociocultural aspect
Different educational culture from their home country	[Student autonomous learning culture] The doctor did not assign tasks to me. Instead, I had to tell him what I wanted to do. As I was unaware of this educational culture, I could not do anything in the first few days. (Student 3)
	[Student responsibility] On the first day, I wanted to observe the doctor during ward rounds, but I was asked abruptly to make a patient note. It was not a SOAP format, and I became nervous because I had no idea about how and what to write on the form. Realising my struggle, a fellow doctor took the patient note from me and said, ‘I can do it.’ I was annoyed by my own uselessness and felt alienated. (Student 17)
	[Different educational systems] The students in North America enrolled in medical school after graduating from college and had already participated in many rotation programs. The responsibilities of local medical students were possibly equivalent to ones of junior residents in Japan … Although we’re all ‘medical students,’ they were much more knowledgeable and had more clinical experience. Consequently, I developed an inferiority complex and lost my self-confidence. (Student 15)
	[‘Competitive’ culture] In the second week onward, some local medical students joined our team … One day, the doctor asked us about the characteristic findings of Crohn’s disease. A student next to me answered immediately while I was still processing the question. It was highly competitive, and I had to invest more efforts into not just improving my English but also my medical knowledge. (Student 36)
Clinical ethics	I was given a chance to be in charge of a patient whose testicular cancer had metastasised to his entire system. Australia had more patients who were informed about their cancer diagnosis compared to Japan. So, at first, I was really worried about how to communicate with a cancer patient in such a situation. (Student 14)

Table 4. Planned and implemented adjustments

Theme	Quotations
Meaning-focused coping
Acceptance of cultural diversity	In Canada, many people were from different cultural backgrounds and some spoke English with a strong accent. So, not everyone spoke clearly and in ‘perfect’ English. I saw them communicating with the native speakers confidently. Since then, I realised it was alright to make mistakes while speaking English in such societies. (Student 1)
Language as a tool of communication	I realised that my English didn’t have to be on a par with native speakers. Language was just a ‘tool’ for communication. (Student 7)
Social relationship building
Supervisor and medical staff	I went to an operation room and observed surgical procedures daily. Not only the surgeon but also the other staff members built a rapport with me and willingly supported my learning there. (Student10)
Resident and interns	Initially, I didn’t know how I could be involved in the clerkship. In case of difficulties, a resident provided me with useful advice on my learning there. (Student 5)
Local medical student	By participating in the clerkship with local students, I could learn what the hospital expected students to do and the socially appropriate behaviour in healthcare. I also learned about their lifestyle. (Student 21)
	I joined the track and field club and trained with local students thrice a week. I enjoyed club activities with local students. (Student 30)
International student	I could befriend international students from Hong Kong. On the first day, they came to talk to me and asked me to go out for dinner and shopping on the weekend. I could not only share my experiences and feelings during the clerkship with them, but also discuss our future planning freely. (Student 13)
Patient	The patients always encouraged me with phrases like, ‘You’ll be all right,’ and ‘Enjoy Montreal!’ This motivated me to actively participate in the electives. (Student 1)
Management of learning opportunities
Seizing opportunities	Initially, I didn’t know how I could ask for the opportunity to be involved in the surgery. The second week onward, I started introducing myself to all the medical staff members each time we met, and I tried to tell them what I wanted to do during the surgical operation. The staff did their best to accommodate my requests. (Student 10)
Making alternative plans	In the second week, my supervisor was replaced by someone who was very busy. When he was busy, I sought other learning opportunities, like training in the skill lab or discussing patient problems with residents. (Student 13)
	Every morning, I could choose a supervisor whom I wanted to observe. Hence, on days when I felt tired, I chose a doctor who would finish his clinical education before lunch time. It was important in terms of my time management. I could spare time to read some papers the doctors recommended. (Student 6)
Language learning and communication management
Request for repetition	I tried to ask the native speakers to repeat themselves until I understood them fully. … this tactic helped me get used to communicating in English, and I could talk to people in English without hesitation. (Student 28)
Showing intention of speaking	I think that if you stay silent and do not ask any questions, you might be regarded as a demotivated person. So, in the outpatient ward, I tried to actively share my opinions and ask questions even if I didn’t know how to express in English exactly. (Student 9)
Non-verbal communication	I tried to maintain eye contact with people while conversing in the second week. I realised that facial expressions conveyed a lot of information, and eye contact was essential while communicating. (Student 29)
Creating a relaxed, safe environment in patient encounter	When I conducted a medical interview with a child and his mother, I was mindful about maintaining a smile. Creating a friendly atmosphere is important. I began with general conversations, such as the kid’s school life, before taking the history. (Student 15)
Self-study strategies	Communicating with local people, I tried to memorise the useful expressions they used. Then, I looked them up and used them in the following conversations. (Student 5)
	Whenever I talked to myself, I tried to speak in English. This was a good way to practice for my English. I took note of useful phrases from conversations between native speakers and repeated them aloud to myself. (Student 38)
Developing approaches to learning
Use of different channel	If you are quiet, no one helps you. So, at least, I tried to ask questions until I understood the diagnostic name. Even when I couldn’t understand what they discussed, I requested them to write the name down on my note and studied this disease. (Student 41)
Emphasis on learning through interaction	I tried my best to ask the doctor questions. He tried to understand what I wanted to know and answered my questions kindly. Since then, I could ask whatever I needed to during ward rounds. I enjoyed communicating with the doctors. (Student 28)
Speech shadowing	I repeatedly shadowed the recorded voice of doctors during CT interpretations to practice English. This was effective because I was gradually getting better at commenting in English in CT interpretations. (Student 35)
Development of learning cycle	I went to the patients’ bedside and took their medical history and conducted physical examination in English. I made my patient notes based on information that I elicited. Subsequently, I compared these with the doctor’s patient notes to identify the areas where I needed to improve. I did this regularly. (Student 7)