Reciprocity in International Clinical and Research Electives
First Drafted (2014):
Ashley White (McMaster University Michael G. DeGroote School of Medicine)
Approved: Date
Revised: Date(s)
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FINAL DRAFT FOR CFMS/FEMC AGM REVIEW
Executive Summary
Medical learners in Canada can pursue clinical and research electives in all ten provinces, three
territories and almost any other jurisdiction in the world, with the exception of those that pose
imminent safety concerns. The value of these experiences lies with the learners’ improved ability to
understand and navigate the world, enhanced cultural competency and deepened resilience in the
face of resource constraintsi. Medical learners from low-income settings are often excluded from
reaping the benefits of clinical experiences in high-income settings by way of institutional policies
and procedures. In order to attain a clinical elective placement at a Canadian medical school,
international students from low-income settings that do not hold Canadian citizenship or permanent
residency face a large financial and paperwork burden. Though inadvertent, electives in medical
education may reflect and reinforce longstanding global health inequities.
Principles
1. All health is global health.
2. Medical learners benefit, through improved skills and sensitivities, from clinical experiences
in a variety of high- and low-income health systems.
3. International electives are a recognized form of professional capital that helps medical
learners attain important clinical positions (i.e. residencies, fellowships).
4. Reciprocity in the establishment and uptake of international clinical and research elective
opportunities in high- and low-income settings is a critical to global health equity.
5. It is both reasonable and fair to provide enhanced support and resources to medical learners
from low-income settings in order to ensure that these learners can fully capture clinical and
research elective opportunities in high-income settings.
Recommendations
1. Canadian medical schools should ensure one-to-one reciprocity for all international clinical
electives undertaken in low and lower-middle income countries by their home students as
part of their commitments to global health equity and global health education.
2. Canadian medical students undertaking clinical electives in low-income settings should
support their home institutions in identifying barriers and facilitators to uptake of clinical
electives in Canada for medical learners from each particular low-income settings.
3. Canadian medical schools should engage partner institutions in low-income settings to
establish longitudinal, sustainable and equitable clinical exchange agreements so as to ensure
maturation of the clinical elective opportunities and optimized benefits to both clinical
settings.
Canadian medical schools are increasingly invested in global health education and equity. The
establishment of reciprocity in clinical and research electives between Canadian and low-income and
lower-middle income medical students is a rational and pragmatic first step for Canadian medical
schools.
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Background
Medical learners in Canada can pursue clinical and research electives in all ten provinces, three
territories and almost any other jurisdiction in the world, with the exception of those that pose
imminent safety concerns. The value of these experiences lies with the learners’ improved ability to
understand and navigate the world, enhanced cultural competency and deepened resilience in the
face of resource constraintsii. Further, clinical and research experiences are a form of professional
currency that are recognized in competition for various residency and fellowship positions. Clinical
training in remote, often poor, countries also serves to build the learner’s cache of lived experiences,
lending them the necessary credibility to discuss the core themes of global health which are
evermore embedded into the institutional visions of Canadian medical schools. Participating in
intensive global health training programs, even without an international elective component,
strengthens “residents' acquisition of professional skills”iii.
Demand for elective opportunities in Canada far outweighs the current available capacity, and
accommodating each applying international medical student would be impossible. However, thirty
percent of American and Canadian medical students studying in North America participated in
global health electives in 2010 representing approximately 7200 students, an increase from 2006iv.
That is, low-income countries around the world accommodate thousands of medical students from
high-income settings annually, despite severe shortages of health care providers in these settings.
For most low-income settings that receive Canadian medical students for training electives, the
burden of proof placed on the Canadian or American medical student seeking clinical electives in
low-income settings is remarkably low. By corresponding directly with supervisors over email,
arranging a visa, getting a few immunizations and paying a relatively small fee, Canadian medical
students can spend several weeks training alongside a physician in a low-income setting. That same
physician, and their local students, is rarely afforded a similar opportunity in Canada. As Erikson &
Wendland assert, “Although it may be inadvertent, clinical electives policies reinforce a global health
divide.”v
Medical learners from low-income settings are often excluded from reaping the benefits of clinical
experiences in high-income settings by way of institutional policies and procedures. In order to
attain a clinical elective placement at a Canadian medical school, international students from lowincome settings that do not hold Canadian citizenship or permanent residency face a large financial
and paperwork burden. In addition to basic visa requirements, the eligibility criteria for visiting
electives at Canadian medical schools by international students are reviewed in Appendix 1, but the
following are common criteria:

Home institution recognized by the
Liaison Committee on Medical
Education, International Medical
Education Directory and/or
Foundation for Advancement of


International Medical Education and
Research.
Malpractice Insurance Coverage for
$1-5 million CAD.
Personal Health Insurance
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


Non-Refundable Application Fee
($50-200 CAD)
Elective or Administration Fee ($220800 CAD)
Immunization Record



English/French Language Proficiency
Temporary Licensure with appropriate
College
Criminal Record Check
Of the seventeen medical schools in Canada, two require the applying student to be a Canadian
citizen and two more require the applying student to be a resident of a specific province. There are
two Canadian medical schools that require applicants to be studying in the US, and one that only
permits applicants studying in select English-speaking Commonwealth countries. These geographic
restrictions, in particular, reflect institutional prejudice towards the readiness to learn of medical
learners from low-income settings. The net effect of the burden is exclusion of learners from those
poor countries, mostly in Africa, that would most benefit from clinical exchange and professional
development opportunities.
Globalization has resulted in the rapid, and increasingly free, exchange of information, goods and
services across political and economic boundaries. With globalization comes an improved ability to
assess the extent and scale of global health inequity, which is the unfair, avoidable differences in
health (and the social determinants thereof) across and between groups. A core plank in the effort
to address global health inequity is the development of a global health educational ethos that helps
medical professionals understand themselves as stewards of a global, and increasingly transient,
communities. It is critical that medical schools engaged in global health education ensure reciprocity
in international clinical electives in order to help address global health inequity.
One concern related to hosting international medical learners from low-income settings is that the
learners will not return to their home country, where they are most needed. However, there is
evidence demonstrating that this concern is unwarranted. In their piece exploring clinical reciprocity
between teaching hospitals in low- and high-income settings, Erikson and Wendland point to the
near thirty year experience of the post-graduate bilateral, reciprocal training exchange program
between the University of Michigan in Ann Arbor, University of Ghana in Accra, and the Kwame
Nkrumah University in Kumasivi, “The result? Thirty seven of 38 Ghanaian medical school
graduates who completed specialty training in the program stayed in-country—a huge improvement
over Ghana’s other postgraduate programs.”vii Known as the Ghana Collaborative, the program
began in 2001 after the Ghana College of Physicians and Surgeons identified major deficits in
emergency medicine expertise in the country. The Collaborative is a major, multi-million dollar
partnership dedicated to training and retaining new health care workers in Sub-Saharan Africa,
strengthening medical education systems and building clinical and research capacity in Ghanaviii.
An additional concern regarding medical learners from low-income settings is that they are
unprepared for work in a Western clinical setting. Indeed, learners from high-income settings may
also be unprepared to learn in low-income settings given that local languages, pathogens and ways of
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knowing may be entirely foreign to the student. This is rarely, if ever, a reason to not pursue clinical
electives in the ‘global south’ and these opportunities are actually encouraged, despite the students’
knowledge deficits, by their home medical schools. One way to mitigate this risk is to limit clinical
exchanges to students from host institutions recognized by FAIMER, or another inclusive body
with rigourous inclusion policies. Further, according to Erikson and Wendland, “Concerns about
student readiness for clinical electives are legitimate. These concerns should not preclude careful
evaluation and training of students from poor countries, nor should such concerns be dismissed
when the students are from wealthy countries.”ix
In Canada, the International Federation of Medical Students’ Association (IFMSA) partners with
CFMS-FEMC to facilitate bilateral exchanges between Canada and other member countries.
Clinical electives are available to Canadian students in Austria, Chile, China, Czech Republic, France,
Germany, Ghana, Greece, Hungary, Indonesia, Israel, Japan, Jamaica, Korea, Malta, Mexico,
Morocco, Norway, Portugal, Serbia, Sweden, Switzerland, Taiwan, Thailand and Turkey. Research
electives are available to Canadian students in Brazil, Catalonia, Chile, Germany, Greece, Israel,
Japan, Korea, Mexico, Netherlands, Norway, Poland and Taiwan. There are dozens of other
countries, many low-income, that do participate in IFMSA exchanges but not with Canada due to
restrictions on country of origin for exchange students (Appendix 1). While the burden of
documentation is significant, the financial cost is usually subsidized by the host country’s medical
student association.
Principles
1. All health is global health.
2. Medical learners benefit, through improved skills and sensitivities, from clinical
experiences in a variety of high- and low-income health systems.
3. International electives are a recognized form of professional capital that helps
medical learners attain important clinical positions (i.e. residencies, fellowships).
4. Reciprocity in the establishment and uptake of international clinical and research
elective opportunities in high- and low-income settings is a critical to global health
equity.
5. It is both reasonable and fair to provide enhanced support and resources to medical
learners from low-income settings in order to ensure that these learners can fully
capture clinical and research elective opportunities in high-income settings.
Recommendations
1. Canadian medical schools should ensure one-to-one reciprocity for all international
clinical electives undertaken in low and lower-middle income countries by their
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home students as part of their commitments to global health equity and global health
education.
The CFMS/FEMC recommends that for every Canadian medical student that completes a clinical or
research exchange elective in a low-income or lower-middle-income setting, as defined by the World
Health Organization’s region groupingsx, the medical school of origin should establish a clearlydefined and accessible elective opportunity for a medical learner from the same low or lower-middle
income setting. The CFMS/FEMC asserts that the establishment of reciprocity in clinical or
research exchanges by Canadian medical schools is essential for the elimination of global health
inequities in medical education. Canadian medical schools that have made a commitment to their
students of a robust global health curriculum should lead the way in adopting reciprocity as part of
this educational commitment.
Currently, there are few examples of reciprocity in clinical or research electives between Canadian
medical schools and those in low or lower-middle income countries. This position paper does not
establish formal guidelines for reciprocity in clinical or research electives. However, the
CFMS/FEMC recommends that the exchange programs meet a few general criteria:



The elective specialty does not need to be consistent between institutions. That is, if a
Canadian medical student works in a pediatric hospital in Kigali, Rwanda, the Rwandan
medical student need not complete a pediatrics elective in Canada, but one of their choosing.
The elective duration should be consistent between institutions.
Special resources should be made available for the student coming to Canada for an elective.
For example, Canadian medical schools should take on the cost of personal health insurance,
malpractice insurance and accommodation of the student while in Canada. Canadian
medical schools may even establish bursaries covering travel and board for students from
low and lower-middle income settings. The host schools may even establish a buddy
program where the Canadian student who completed an elective in their country lends peer
support to the exchange student. Further, an orientation session covering key aspects of
medical training in a Canadian facility should be offered, just as they are for Canadian
medical students undertaking electives at different medical schools within Canada.
2. Canadian medical students undertaking clinical electives in low-income settings
should support their home institutions in identifying barriers and facilitators to
uptake of clinical electives in Canada for medical learners from each particular lowincome settings.
Pre-departure and post-departure training and orientation sessions are standard practice for
Canadian medical students taking on electives in low and lower-middle income settings. These
trainings cover cultural competency, personal protection, emergency and evacuation protocols and
scope of practice restrictions among others. If a medical school adopts reciprocity in their electives
programs, the CFMS/FEMC asserts that these sessions are key opportunities to both learn to
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analyze and share barriers to access to electives at their medical school for the students they
encounter on their global health elective. If a student from Uganda is able to pay for their flight and
living costs for the duration of an elective in Canada, what else prevents this student from benefiting
from this experience? How can Canadian medical schools and students address these barriers and
enact facilitative guidelines to support these students?
In this way, a genuine commitment to reciprocity will also strengthen the skills of Canadian
exchange students in conducting higher-level analyses of core topics in global health, such as health
human resources, health systems and medical education.
3. Canadian medical schools should engage partner institutions in low-income settings
to establish longitudinal, sustainable and equitable clinical exchange agreements so
as to ensure maturation of the clinical elective opportunities and optimized benefits
to both clinical settings.
The CFMS/FEMC does not diminish the additional organizational burden imposed by one-to-one
reciprocity in clinical and research elective exchanges. However, visiting elective students from lowand lower-middle income countries are highly motivated and, in some cases, desperate for
opportunities to train in high-income settings.
The most efficient approach to reciprocity is through institutional partnership between medical
schools across income settings. Like the Ghana Collaborativexi, partnership programs ensure mutual
accountability for the exchange opportunities and allow both institutions to embed higher-order
global health goals, like system strengthening, into the exchange agenda. In addition, exchange
programs ensure that each institution is, in a way, ‘looking out’ for their respective student.
Exchange programs also help medical students limit global health elective disasters wherein
supervisors are absent, facilities are closed or not equipped for students, or the medical student is
asked to operate far outside their responsible scope. Exchange programs can also help medical
students learn to communicate, at least rudimentarily, in local languages in advance of arriving and
to understand local context with much more nuance than if going in blind. Additionally, exchange
programs are better equipped to establish electives longer than two weeks, the typical length of
clinical electives in Canada, which better supports relationship building and learning in both
contexts.
As an example, consider a Canadian medical school establishes partnerships with a school or
hospital in one French-speaking African nation, one South or East Asian nation and one South
American nation. Each year, the incoming class of medical students is made aware of the three
possible clinical elective opportunities and medical students at the partner institutions are made
aware of the Canadian elective opportunity. Each school accepts applications from their students,
and a cohort is selected. Scheduling is determined by core rotation and holiday schedules, but the
elective program runs for the majority of the year. For Canadian students with a compelling reason
to complete an elective outside of the partnership countries, such as family ties, previous training or
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experience or language expertise, efforts should be made to accommodate them and the medical
school should prepare to accept an ad-hoc elective from a student from that country.
Over several years, these partnerships become valuable relationships that can be leveraged for
research and post-graduate training opportunities that are deeply beneficial for both institutions.
Participating students can return as residents or attending physicians to consolidate their learning
and communications skills in a pseudo-familiar environment. Through these long-term
partnerships, global health education and ethical principles in global health, for both sets of students,
is taught through lived experience and augmented by theory.
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Memorial
University
Sherbrooke
University
University of
Montreal
McGill University
University of
Laval*
University of
Ottawa
Queen’s
University
University of
Toronto
McMaster
University
Western
University
Northern Ontario
School of
Medicine
University of
Manitoba
University of
Saskatchewan
University of
Calgary
Dalhousie
University
Independent Curriculum Review
of Home Institution
Home Institution recognized by
International Medical Education
Directory (IMED)
Home Institution recognized by
the Foundation for
Advancement of International
Medical Education and Research
(FAIMER)
Home Institution recognized by
the Liaison Committee on
Medical Education (LCME)
where bilateral exchange has
been established.
Home Institution recognized by
the Liaison Committee on
Medical Education (LCME)
Letter of Attestation from
Clinical Supervisors
Exchange program in place with
home institution.
Malpractice Insurance Fee
Students Required to purchase
insurance coverage of $__
million per claim.
OR
Fee associated with university
sponsored malpractice
insurance.
Health Insurance
X – Required
Xa - Recommended
Non-refundable Application Fee
University of
Alberta
Criteria for
International Visiting
Elective Students
University of
British Colombia
Appendix 1: Criteria for International Visiting Elective Students at Canadian Medical Students
X
3 mil.
X
3 mil.
X
X
X
X
X
X
X
X
X
X
X
X
$325 fee
X
2-5 mil.
Xa
Xa
$150
$100
$100
Elective or Administrative Fee
X
X
X
2 mil.
X
5 mil.
X
$325 fee
X
$325
fee
X
1 mil.
X
5 mil.
X
3 mil.
X
X
($71/
month)
$184.9
1
X
Xa
X
X
X
$200
$50
$100
$75
$500
(refundable)
$450
$400
$400 800
$200
$600/
week
$220290
X
X
X
$100
$200500
$30
$100
$300
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English or French Language
Proficiency
Immunization Record
Medical Examination Prior to
Arriving in Canada
Temporary Resident Visa
Temporary Educational Licensing
with affiliated College
Criminal Record Check
Funding available to support
international elective students
from low income countries.
Bilateral exchange programs
established for medical students
from low income countries.
X
Meet CIC
criteria.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
$50
X
X
$100 + $125
/week
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
$105
X
X
$110
X
**
X
Canadian Citizen
Studying medicine in the
USA.
X
X
Canadian Citizen
X
Resident of Northern
Ontario
X
Resident of
Saskatchewan
X
Studying medicine in the
USA.
Country/Province Restrictions
The applicant must be/a:
X
Studying medicine in the
UK, Ireland, Australia,
New Zealand or South
Africa.
Non-refundable Application Fee
Paid by Credit Card
Accommodation To Be Arranged
by Student or Fee
X
$75
X
X
X
X
X
*University of Laval - limited information regarding fees, health insurance, etc., as exchanges are coordinated through the partner universities
and the information may vary between institutions. Students are not permitted to send direct requests for electives to Laval.
**Amount not stated.
i
Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on US and Canadian medical students and
residents: a literature review. Acad Med 2003;78:342-7.
ii
Thompson MJ, Huntington MK, Hunt DD, Pinsky LE, Brodie JJ. Educational effects of international health electives on US and Canadian medical students and
residents: a literature review. Acad Med 2003;78:342-7.
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iii
Castillo J, Goldenhar LM, Baker RC, Kahn RS, DeWitt TG. Reflective practice and competencies in global health training: lesson for serving diverse patient
populations. J Grad Med Educ 2010;2:449-55.
iv
Association of American Medical Colleges. Medical school graduation questionnaire report. Washington, DC: AAMC 2010;12. www.aamc.org.
v
Erikson SL, Wendland C. Exclusionary practice: medical schools and global health clinical electives. Student BMJ 2014;22:g3252
vi
Clinton Y, Anderson F, Kwawukume EY. Factors related to retention of postgraduate trainees in obstetrics-gynecology at the Korel-Bu Teaching Hospital in
Ghana. Acad Med 2010;85:1564-70.
vii
Erikson SL, Wendland C. Exclusionary practice: medical schools and global health clinical electives. Student BMJ 2014;22:g3252
viii
University of Michigan Health System. (2014). About the Ghana Collaborative. Retrieved from http://medicine.umich.edu/dept/emergencymedicine/ghana-emergency-medicine-collaborative/about-ghana-collaborative
ix
Erikson SL, Wendland C. Exclusionary practice: medical schools and global health clinical electives. Student BMJ 2014;22:g3252
x
World Health Organization. (2014). Health statistics and information systems: definition of region groupings. Retrieved from
http://www.who.int/healthinfo/global_burden_disease/definition_regions/en/
xi
University of Michigan Health System. (2014). About the Ghana Collaborative. Retrieved from http://medicine.umich.edu/dept/emergency-medicine/ghanaemergency-medicine-collaborative/about-ghana-collaborative
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