Family medicine 360°: Global exchanges in family medicine.

OBJECTIVE: The global world of the 21(st) century has created communities and cultures that are interconnected, thanks to the development both in the field of transportation and technology. In this global intercultural community, future physicians, and even more so future general practitioners (GPs)/family physicians (FPs), need to be clinically competent and culturally sensitive and flexible in order to adapt to different social settings while delivering holistic care in multiethnic teams and environments with professionalism. As such, exchange programs are exceptional opportunities for international collaboration and the development of personal and professional competencies of these health care professionals.
MATERIALS AND METHODS: This article presents a review of the literature on the value of exchanges as well as the results of exchange programs with educational content that are aimed at junior GPs/FPs.
RESULTS: Exchange programs have been growing in popularity, especially among junior GPs/FPs. Since its launch in 2013, The "Family Medicine 360° (FM360°) program has been receiving up to 163 inquires till date, promoting global cooperation among the World Organization of family Doctors (WONCA)'s Young Doctors' Movementd (YDMs).
CONCLUSIONS: By participating in an exchange program, future GPs/FPs are given the chance to experience intercultural communication and peer collaboration. They also develop personal and professional skills and thus, actively contribute to the growth and development of primary care all over the world.

Introduction

The developments in the field of information technology (IT) have made it easier for everyone to read about other settings and cultures at a global level. One could question the benefits of experiencing such cultures firsthand;[12345] however, interest for international exchanges has increased among students at all levels and in every field of education, especially medicine. Many schools and universities around the world have acknowledged this need[67] and are now promoting exchanges and the internationalization of academic curricula, wishing to prepare students for a more culturally global world as well as work environment.

The value of exchanges

Health education leaders have been increasingly calling for a major rethinking and reform of the medical education in order to meet contemporary and future health challenges. The socioeconomic conditions of the new century, such as the increased mobility and migration of people, make it important to promote intercultural learning and prepare future health care professionals to work in a global, interconnected, and fast-changing setting where solutions can be met, thanks to prior contact with the problem.[18910] A prime example is the commission on the education of health professionals for the twenty first century, launched in January 2010, that issued the one-hundred-year anniversary of the Flexner Report, a primary revolutionary reform in medical education.[9] In 1910, the Flexner Report based on a series of studies on the education of health professionals produced a major renovation of medical training around the world. A century after that ambitious reform, the Lancet Commission highlights a call from 20 professionals and academics for an extensive renovation in the education of health professionals in the 21st century.

It is known that in the global intercultural community, future physicians, and even more so future general practitioners (GPs)/family physicians (FPs), need to be clinically competent as well as culturally sensitive and flexible in order to adapt to different social settings and deliver holistic care in multiethnic teams and environments.[6891112] Primary care physicians are the gatekeepers in most health care systems. Thus, it is important for these health care professionals to be familiar with different cultural backgrounds in order to be able to offer the best care and support to their patients.

In such a context, the need to harmonize and internationalize medical curricula becomes a global concern and an imperative need. This raises a debate on its implementation, learning methods, and the required educational activities.[91314] One strategy for internationalization that is widespread constitutes the exchange programs. Many postgraduate schools and universities around the world have started to broaden up their curricula to include a more global perspective while at the same time, they offer various intercultural programs (although mainly as extracurricular activities) as part of their core curricula.[1516] These programs have grown in popularity among students at all academic levels.[1017] Consequently, the concept of exchanges shifted from an initial mindset of a “limited, personal, and fun gap year” to an actual opportunity for “learning and development of the professional experience”.

In fact over the last decade, the number of scientific papers advocating the internationalization of higher education while exploring the educational value of exchanges has increased considerably. Studies on international educational exchanges suggest that intercultural exposure, in whichever setting or discipline, may have a positive impact on participants, both at the personal and professional levels.[2101418] Health electives specifically seem to promote a greater understanding of health care systems as well as the different uses of resources.[219] Professionally, students participating in international electives report increased confidence in clinical skills (diagnosis and clinical examination) while stressing the development of their communication skills, both with colleagues and patients.[2320]

Moreover, cultural understanding and sensitivity emerge among the major outcomes of international exposure, along with the ability to show a deeper empathy toward patients.[31920212223] Incidentally, some authors have also noted that the exposure to different health care systems and patients, especially regarding global exchanges, has shown an impact on the students’ career plans as they promote interest toward public health and general medicine.[23181920] At a personal level, the most common developments reported by participants are the opportunity to broaden their perspectives, improve language skills, and increase confidence, and personal growth.[2324] However, most surprisingly, students often refer to “personal growth” and “attitude change” as unexpected gains of their cross-cultural experiences.[20] It seems that when applying for an international experience, applicants tend to mainly focus on the professional values of the exchange. They ignore the fact that the exchange itself is the cross-cultural contact that stimulates the need for learning, development of intercultural competencies, literacy, and collaboration.[2526] Cultural adjustment researchers have presented different development models of intercultural sensitivity and they have concluded that all of them require personal engagement. In fact, it is only by being confronted by a different culture and engaging oneself in a learning process that one can acquire an intercultural identity and develop competencies that include empathy, perspective-taking, tolerance, communication, and promptness to help when required.[25]

Family medicine 360° (FM360°)

Intercultural networking has always been the primary aim of the Vasco da Gama Movement (VdGM)[27] and the network of new and future GPs/FPs, which is part of the European association of the World Organization of Family Doctors (WONCA).[28] Over the past 10 years, this group has been eagerly striving to promote a global mindset of respect and sensitivity to other cultures for young GPs/FPs that range from research and special interest groups [rural FM, domestic violence, IT, and social media in general practice/FM, among others] to exchanges. The exchange group is, in fact, one of the largest and most active groups within VdGM offering different types of exchanges. It all started in 2008 with the establishment of the “Hippokrates” exchange program,[29] which enabled participants to spend 2 weeks in a European general practice/FM practice in an urban or a rural setting. They follow an educational program that is designed by the host according to the learning objectives described by the participant. After the exchange, the participant is asked to reflect on his/her experience by describing the learning outcomes and writing a short report on the experience.

In order to give the “Hippokrates Program” a greater spotlight and promote the value of exchanges, it has been the tradition of VdGM to share prior exchange experiences during the WONCA conferences. It is also the custom to award two prizes to the best exchange participants: the “Hippokrates Prize,” for an exchange in a city and the “Claudio Carosino prize” that is awarded to a rural participant.[30]

In recent years the “Hippokrates Program” has grown exponentially, with the impressive figure of 73 completed exchanges in 2014.

Wishing to take this idea even further, the first global exchange meeting was held on June 27, 2013 during the 20th WONCA World Conference held in Prague.[31]

The seven global Young Doctors’ Movements (YDMs) have been working relentlessly to establish a global exchange program since then. The seven YDMs are organized according to the seven WONCA regions, namely, the AfriWon Renaissance (Africa), Al Razi (the Middle East region), Polaris (North America), Rajakumar Movement (the Asia-Pacific region), Spice Route Movement (the South Asia region), VdGM (Europe), and Waynakay (Central and South America).[32] They’ve worked side by side to create a global exchange scheme for young GPs/FPs based on strong and shared educational values which made way for the establishment of the FM360° program.[3133] It has been a steep learning curve to meet the needs and expectations and respect the different contexts of the various countries. However, it is the common goal that has made the development of this project possible.

The aim of the FM360° program is to promote worldwide intercultural exchanges so as to give doctors an opportunity to learn from each other in different cultural and socioeconomic contexts. Besides being an opportunity to broaden one's professional and personal horizons, these exchanges provide young GPs/FPs the possibility to interact with different primary health care settings and health care systems in general.

The FM360° program is organized as a 4-week program (which may be shortened or lengthened). During these 4 weeks, the visitor is expected to observe the activities that take place in the host's practice and to shadow the host in other community-oriented activities. To provide structure to the exchange, the FM360° program is built on a framework inspired by the “Hippokrates Program,” based on the learning objectives and outcomes. The visitor is given a template where he/she is required to fill in his/her learning objectives for the exchange. These learning objectives are assessed by the host who then draws an educational program accordingly. At the end of the exchange, the visitor is expected to reflect on the learning outcomes and submit a report on his/her activities.

The exchange program is financially self-supported by participants who are expected to cover their travel and accommodation expenses. However, the hosts are very much welcome to assist participants in providing options for accommodation. All visitors must obtain their own travel insurance and sign a legal waiver to take part in the program.

Besides having been granted the support of WONCA, hosts in both the USA and Canada may self-report teaching continuing medical education credits for this activity.

Since 2013, the program has received 163 inquiries, organized 38 exchanges, and is currently arranging 10 exchanges. Figure 1 illustrates that there has been a general increase in the number of enquires by year, the average being 7.2 requests per month. All enquires till now have been from residents, 75% being from the female gender. Figure 2 shows that most inquiries have come from the European region (64%), namely, Spain (54%) and Portugal (28%) followed by the Central and South American regions (27%) where the countries with the most requests are Argentina (29%) and Peru (27%).

Figure 1

Evolution of the number of received inquiries regarding the FM360° program, by year

Figure 2

Distribution of received inquiries for the FM360° program, by region

According to Figure 3, the most requested FM360° destinations are Central and South America (30%), Europe (29%), and North America (27%). Globally, the top three most popular destinations are Spain (15%), the USA (14%), and Brazil (11%).

Figure 3

Distribution of requested regions for exchanges through the FM360° program

Conclusion

Although IT may act as a facilitator for global communication and networking, the FM360° program seeks to become an international educational framework to promote global networking between young GPs and FPs. The exchange program is only the first step by which the FM360° program wishes to promote and develop quality exchanges with educational content in general practice/FM. As such, it is in the best global interest to collaborate with and help promote this program that will further it.

Furthermore, the richness of exchange programs is promoting a bilateral knowledge exchange. This is felt by both the visitors and the hosts and it catalyzes the inspiration for change. New ideas to create health care provision may be attempted first in the clinic and eventually spread out to the community and may even reach policy makers. Consequently, the quality of care is improved as it integrates a multicultural knowledge.

Compared to hospital specialists it is more frequent to find GPs/FPs working alone, especially when it comes to rural settings. The loneliness they may experience during practice hours may trigger feelings of uncertainty and at the same time can be a barrier toward accepting new points of view. However, opportunities such as the YDMs and the activities they promote may help to tackle that challenge and help in developing one's personal networking while integrating new perspectives and approaches into daily practice.

The benefits at both professional and personal levels as well as for the community, locally, nationally, and globally are unique and work as triggers for the development of primary health care, which is in agreement with the World Health Organization's goal of universal health coverage for all. Also, the establishment of these networks allow participants to be more aware of global developments and thus, more prone to question health inequalities.

With the knowledge and participation of all GPs and FPs globally, we can act locally and develop a better future, based on a strong primary care system, for everyone.