Two separate semi-structured interview guides for patients and physicians were developed based on a review of existing literature on IMEs in addition to Nepali faculty input. The finalized interview guides for patients and physicians each included demographic information, in addition to twelve semi-structured questions with probes to understand the benefits and drawbacks of hosting visiting students. Purposive sampling was used to identify 15 physicians who supervise visiting medical students from a variety of medical departments and ranks of academic appointments, including medical officers, instructors, assistant professors, and associate professors. Purposive sampling was also used to identify 15 patients who had recently undergone a consult with a visiting medical student across various departments (Table 1).

Surveys were administered to visiting medical students before and after their medical elective. The survey items were derived from the authors’ experiences working with visiting medical students, as well as previous studies with surveys administered to medical students and residents participating in international experiences.^26,27 The pre-elective survey had 23 questions divided into four sections: (1) Demographics, (2) Medical Training, (3) Knowledge of Nepal, and (4) Clinical Competencies. The post-elective survey repeated questions in section (3) Knowledge of Nepal and (4) Clinical Competencies and added a fifth section with 14 questions: (5) End of Elective Feedback. Whenever possible, questions asked participants to respond on a 5-point Likert scale. For the Knowledge of Nepal scale and Clinical Competencies scale, the scoring range was 1 to 5 with a higher score corresponding to a higher level of knowledge or competency. For the End of Elective Feedback scale, the scoring range was 1 to 5 with 1 representing “strongly disagree” to 5 representing “strongly agree.” All survey items also included a free-response section. The survey was piloted with four visiting medical students to ensure the clarity of each question.

This study took place in Nepal at the non-profit and non-governmental Dhulikhel Hospital, the flagship hospital for Kathmandu University School of Medical Sciences (KUSMS). The hospital attracts over two hundred elective students each year from various HICs. Visiting students request elective placement either through their university partnership or by finding the program online. Each student is assigned to a hospital department, where they are supervised by the attending physicians of that department. Their main activities include observing patient consultations, ward rounds, assisting procedures or operations, and attending conferences. Physicians speak English fluently while most patients speak Nepali language only. At the time of the study, participation in any elective less than six weeks was 200 USD.

The study was reviewed in full and approved by the Dhulikhel Hospital Institutional Review Committee (IRC). Written consent was obtained from all students and physicians, and verbal consent was obtained from patients prior to study participation. Author DM conducted 30 to 60 minute digitally recorded, semi-structured interviews in English with supervising physicians regarding IMEs. A Nepali research assistant conducted interviews with patients regarding visiting medical students in the Nepali language. Interviews with patients lasted from 10 to 30 minutes. All interviews were subsequently transcribed in English. Authors SS and DM administered a pre-elective paper survey to all visiting students on the first day of their medical elective during the orientation process, and then post-elective paper surveys on their last day of the elective. Surveys took an average of 15 minutes to complete. Survey results were manually uploaded into Microsoft Excel and cross-checked for accuracy. All 56 students who completed a clinical rotation at Dhulikhel Hospital between Jan 1 and June 7, 2016 were approached to participate in the study. The visiting medical students came from sixteen medical schools across six European countries and the United States. Students stayed an average of 3 to 4 weeks, with the majority of students rotating through the Pediatrics, General Surgery, Emergency, or Internal Medicine departments (Table 1).

Interview transcripts and free responses to survey questions were transcribed verbatim, translated into English when necessary, and uploaded into NVivo (Version 11, 2016) for qualitative analysis. A conventional content analysis approach was used in order to extract major themes during the first round of transcript analysis.²⁸ Emerging themes and coding structures were discussed by the authors, and then a finalized coding scheme was applied to the transcripts. These themes were grouped and reported with descriptive analysis and representative quotes. Descriptive statistical analysis was performed in Microsoft Excel to understand the demographic characteristics of students, physicians, and patients. For Likert-scale survey questions, data were entered into SPSS (Version 23, 2015). Means and standard deviations (SDs) are presented for scale data, in addition to p-values for scales that were administered both before and after the medical elective. Paired t-tests with p<.05 were used to determine statistical significance. The independent variable was pre- versus post- medical elective, while the dependent variables were knowledge of Nepal and clinical competencies.

Enhanced reputation of hospital in the community: Multiple patients and physicians believed that Dhulikhel Hospital’s reputation in the community was enhanced by the presence of visiting students. One patient stated that “When foreign doctors come to treat patients, then the patients will be cured…so yes, more patients will come here.” Physicians also thought that their patients were eager to have visiting students, with one physician reporting: “Our patients are always happy to see white faces and will trust our department more even though the foreigners are just students.”

Increased international collaboration: In addition to improved local reputation, many physicians also believed the IME improved the international recognition of the hospital. This relationship was seen as mutually beneficial for both host physicians and visiting students, with one physician commenting: “It is good to have the students come here, because then we can make relationships with foreign universities and even go there.” These international partnerships allowed for professional development opportunities for Nepali physicians, with six of the physicians interviewed attending conferences or completing advanced fellowships in the USA or Europe.

Financial benefits for the hospital: A few patients and physicians mentioned the financial benefits of hosting visiting students, both in terms of directly assisting the hospital, and tourism in Nepal more broadly. Visiting students were required to pay a 200 USD program fee, which physicians reported was helpful to the hospital generally, but did not necessarily go to specific departments. A patient stated, “Having the students come is a good thing… They will spend some money here and may go for tours around Nepal.” One physician reported that, “sometimes students bring some donations, like blankets, heaters and other equipment.”

Knowledge, culture, and language exchange: Patients and physicians reported that one of the strengths of the IME was gaining a better understanding of medical practice in HICs, including new advances in diagnostics and treatment. Patients specifically reported that visiting students may bring knowledge of novel treatments, technologies, and sanitation. Some patients also believed that visiting students could help in the hospital’s development, so that “Dhulikhel Hospital will become more like foreign hospitals.” Most supervising physicians regarded the visiting student elective as a chance to practice their English and learn about how medicine training and practice occur in HICs. Many physicians echoed the sentiment that: “It’s always good to have people from different cultural and medical backgrounds because we are able to learn from each other.”

Patient Satisfaction: All of the 15 patients interviewed felt comfortable interacting with visiting medical students and felt positive about having visiting students working at Dhulikhel Hospital. As one patient stated, “half of curing disease is making the patients happy, so the foreigner’s presence has a positive impact on our health.” The doctors also felt that their patients liked having visiting students observing. One physician believed that the patients “will feel better about coming to our hospital because they think the foreigners will offer better care.”

Time burden: For physicians, the major drawback of the program was a lack of compensation for extra time spent in assisting with translation, orientation, and teaching for visiting students. Although visiting students paid a fee for the elective, individual physicians and departments were not directly compensated. Some individual faculty and departments faced a much larger teaching burden than others, especially those in internal medicine, pediatrics, and general surgery. During one month of the study, the pediatrics department hosted six visiting students at once, leading one pediatrician to comment, “we don’t mind having [visiting students], but sometimes if many come at once, it can be quite busy to balance teaching them with our other duties.”

Visiting students detract from local student learning: When probed for drawbacks of hosting visiting students, one patient commented that “extra students can make the hospital feel crowded.” Another patient mentioned that visiting students may interfere with Nepali student learning by “taking away opportunities from Nepalis.” Two physicians also commented that the visiting students may take away Nepali students’ opportunities in the hospital. One surgeon stated: “I want them [visiting students] to help do the operations, and scrub-in with me, but some Nepali students may be upset that their opportunity has been taken by the international student.”

Language barrier: For patients, one of the biggest drawbacks was their inability to communicate in English with the visiting students. None of the patients interviewed spoke English with proficiency but were often communicated in English by visiting students. One patient said: “I could not completely understand the foreigner due to the language barrier, but she gave me good advice to do a chest X-Ray and blood test.” Another patient said that he was unsure about what the student and physician were talking about in English during his consult, though overall he still felt positive about the care he received.

Excess vacation: Physicians were frustrated that most visiting students only stayed for a few weeks, with one stating, “We don't know what they're interested in, and some don't have much training. They just come for a very short period of time.” Three physicians in particular perceived the visiting students as coming to Nepal for vacation and working minimal hours at the hospital. Students engaged in tourist activities such as Himalayan treks without notice, making it difficult for departments to accommodate them. One physician lamented that “Sometimes it seems like their main motive is just to roam around the countryside, and at that time we feel really bad.”

Patient misconceptions: Although none of the patients interviewed felt mistrustful of the students, many of the patients had misconceptions about whether the visiting students were students or doctors. For example, one patient said, “The foreigners may be doctors, or they may be students, I cannot tell.”

Critique of medical practice: One physician complained about visiting students’ criticism of how medicine was practiced at the hospital. He shared that, “Some students will blame us for prescribing too many antibiotics. They are completely unaware of the situation.”

Visiting students found the elective through their university (46%), online (44%), or through friends (9%). Only 4% of students received pre-departure orientation for their elective and 34% of students had prior medical experience in a resource-limited setting. Around 70% of students financed their travel with a university scholarship, which covered from 700 to 1,000 USD. Visiting students’ main objectives included experiencing a new healthcare system (86%), engaging in Nepali tourism (86%) and learning about diseases endemic to Nepal (72%).

In the self-reported knowledge section of the survey, students demonstrated a significant increase in knowledge of Nepali language, Nepal’s culture, Nepal’s politics, Nepal’s health system, and Nepal’s epidemiology after the medical elective (Table 2). In the clinical competencies section of the survey, there was a self-reported increase in students’ ability to communicate with health professionals from different cultural backgrounds and ability to practice in resource-constrained environments; however, there was no significant increase in self-reported ability to conduct patient histories, perform a physical exam, reach a diagnosis or prescribe appropriate medications (Table 3).

In the post-elective feedback part of the survey, students were overall satisfied with the diversity of medical cases and teaching by the faculty. However, students did not feel that the rotation provided appropriate skills training and many felt there was a lack of supervision. Most students conveyed that the benefits of the rotation included that it increased their appreciation for the impact of health on culture and that it was personally rewarding. However, many students did not feel adequately connected with the hospital or broader community and overall did not believe they were making a difference in patients’ lives (Table 4).

In written feedback, visiting students most appreciated experiencing a culture and healthcare system different from their own. A few participants felt they wanted to return to Nepal to engage in further clinical, service or research opportunities, with one student writing: “I've been fascinated by the country. The language, people, and different diseases have made me think I may be interested in gynecology. I want to come back here as a doctor and be able to make changes.” However, other students realized the challenges that working abroad can pose, and decided that focusing on disparities within their own countries would be more fulfilling.

Students often felt “lost” during their electives, especially in departments where students were not assigned to a particular supervisor. Although all students were able to observe patient consults and procedures, most wished they could have played a more active role on the team. In the words of one respondent, “We learned a lot by watching. The supervisors always answered all our questions, but we could not do much practical training.” This mirrored interviews with physicians, where the majority of physicians said that the students were only allowed to observe. A minority of students also had trouble adapting to the hospital environment in Nepal, which had different follow-up, privacy, sanitation, and prescribing procedures than they were accustomed to.

The authors would like to acknowledge Suraj Makaju for assistance with conducting interviews and translation. This project was funded by the US Student Fulbright Research Grant, Nepal.

The authors declare that they have no conflict of interest.