Guest blog by: Carolina Severiche Mena MD
Studying medicine is exceptionally challenging. Studying medicine abroad can be even more challenging. Studying medicine abroad in English when it’s not your first language adds another barrier.
Despite this, I have chosen this path.
Every medical student faces weighty challenges, including academic pressure, competition, confronting patient death, and emotional exhaustion. But as an international student, they face additional challenges, such as homesickness, culture shock, language barriers, and different modes of communication.
Regardless of these added challenges, many enthusiastic and motivated students choose study medicine abroad and in a foreign language. Many of the students who study abroad will do so in an English-speaking environment. Common destinations to study in English are the United States, United Kingdom, European nations that offer English programs, Australia, New Zealand, South Africa, and increasingly the Caribbean.
So why do students choose to do this? In my case, I was interested in new learning opportunities, expanding my network, and creating relationships that may help me with my future goals of working abroad. Others do it to study at elite universities like Harvard or Yale, work at world-renowned hospitals like the Mayo Clinic or Johns Hopkins, or conduct advanced research, such as immunotherapy research, at Memorial Sloan Kettering.
Regardless of the reason, most doctors I’ve met who have studied abroad felt it created better opportunities for them, whether they stayed abroad or returned home when they were done. For students who choose to remain abroad, their salary, as well as career advancement opportunities, may be significantly better than in their home country. For others, going back home may still offer an excellent quality of life and the experience abroad will often be a big plus on their CV.
However, there are challenges, and that’s what I want to get into here. I have encountered them myself, and have put together some tips for overcoming them.
Study the Language First, Intensively
It was at the end of my third year of medical school that I decided to study English abroad. I already knew I was interested in studying and working in medicine in the US, and I felt I needed to improve my English to do so. As a native Spanish speaker from Colombia, I struggled with common English as a second language (ESL) problems such as pronunciation, spelling, and grammar. So I enrolled in a one-year scholarship-funded program to study English in preparation for my medical plans.
As part of my program, I enrolled in ESL classes at a college, but my learning didn’t stop there. I took the opportunity to go to medical events, which forced me to network in English, and I purchased new medical texts in English so that I was constantly reinforcing and applying what I was learning.
When planning my free time, I also made sure I was engaging in activities that would not only benefit my English skills but also help me better understand my new host country. I went to museums, plays, and other cultural activities that forced me to practice reading and listening.
My year of studying English abroad was undoubtedly essential in my medical journey. It not only provided me first-hand experience with listening, reading, writing, and speaking English on a daily basis, but also gave me with a foundational understanding of US culture.
Personal tip: I studied English abroad because of the immersion component, which I found to be ideal. If you do study English abroad, try to take advantage of your time and look for any activities that will reinforce and apply your English skills. Also consider taking the Test of English as a Foreign Language (TOEFL) while abroad, since your English will likely be at its best while you’re there. Minimum passing scores vary by school, but target a 100 and you should be in a good position for most institutions.
Finding Medical Opportunities Abroad
During my fourth year of medical school, I knew I was ready for my next immersion experience. I was looking to grow as a medical student, but also as a global citizen. I knew that by conducting a 4th-year clerkship in a US hospital I would have the opportunity to experience a different education system, clinical practices, and medical technologies. I also believed that by working in a major US city, I’d have the opportunity to meet, care for, and learn from diverse patients from all over the world. I felt these two aspects of working abroad were essential to the experience I was looking for, as medicine is as much about our medical skills as it is about our “soft” skills.
Likewise, I applied to participate in an exchange program via the Global Educational Exchange in Medicine and the Health Professions (GEMx). GEMx is a service of the Educational Commission for Foreign Medical Graduates (ECFMG) program, which evaluates the qualifications of international medical graduates and certifies their qualifications before they enter US graduate medical education (GME). I chose GEMx not only because my Colombian school was a partner institution, but also because of the relationship with ECFMG.
I was accepted to the internal medicine program at Interfaith Hospital in Brooklyn, New York, where I was on rotation for two months. While there, I had the opportunity to learn clinical reasoning, presentation skills, and medical writing. But while the overall experience was terrific, it was also challenging as a non-native speaker, despite my previous preparation. During this experience, I came to realize that the application of English to the work environment offered another series of exciting challenges.
Personal tip: There are many 4th year medical elective programs to which to apply in the US, but not all will be the right fit for where you are in your career journey. Some require that you have passed Step 1 already. Others may not, but come at a high cost. Find the right program for you based on your credentials and financial opportunities, and check out GEMx. I was very pleased with the GEMx service, and my program costs were covered. All I had to pay was my flight, housing, and health insurance.
Practicing Medicine in English When English Is Not Your First Language
Within the first week of my clerkship in one of the most diverse cities in the world, if not the most, I had come to a new understanding of the challenges of working abroad. With any language, there are the formal rules, but there are also the countless and nuanced ways the language is applied by native and non-native speakers. Be it medical abbreviations, slang, or unfamiliar accents, I experienced new words and sounds that my formal educational training had not prepared me for.
One day when the attending physician asked me about ABG (arterial-blood gas), I truthfully had no idea what she was asking, because it is not a term we use in Colombia. Similarly, one of my patients who himself was a non-native speaker needed an inhaler spacer, and again I struggled to make sense of the request. But what I came to learn is that it’s OK not to understand something, but it’s not OK to act like you did understand it and let it pass. You have to speak up!
Now in all fairness, I probably didn’t speak up the first week or two, but shortly thereafter I did realize that was the only way I was going to do the right thing for my patients, and for myself. So don’t be shy; working abroad is one of the greatest opportunities you will have in life to grow as a doctor, as well as a person. Asking the necessary questions will help you learn, but it can also demonstrate your shortcomings and vulnerabilities. This helps others realize we’re human just like them.
I found this was very useful when caring for my patients during my morning rounds, but also with the medical team. Be it with the residents or teaching physicians, by demonstrating I cared about my work performance, they in turn made efforts to help me. As a result, I was able to do a better job, learn more about medicine, express greater compassion for my patients, and improve my English in the process.
Personal Tip: It’s OK to ask for help or clarification, but it’s not OK to do the wrong thing because you were too shy to ask. Sometimes, we all need to raise our hand. I appreciate that that’s not always easy, and in stressful and fast-paced situations I was sometimes worried about slowing down the care process, but I forced myself to have the confidence to ask for help and as a result, my patients and I had a better experience.
Homesickness, Culture Shock, and Adaptability
Aside from the language barriers, there are other common challenges that medical students face when studying or working abroad. Homesickness and culture shock are two of the most common. I faced them, and at some point you likely will too if you venture abroad.
Homesickness is the heartache of being away from your home, and all of the comforts of it. Medical students abroad in their first few months often feel misplaced and lost, as they are surrounded by unfamiliar customs, a different language, and new food. This was certainly true for me.
On my first trip to the US, I experienced this. It was the first time in my life that I was away from my family and friends for an extended period of time. Furthermore, I had to leave many of my comforts behind, and so I lacked things like books that supported my passion for reading. To cope with this I practiced my English by started a writing project, purchased some new books in English, and made new friends who were going through similar experiences. By having friends who were experiencing the same feelings, it was easy for us to share with and comfort each other. I also took comfort in activities like exercise, and learning how to cook healthy food that could nourish my body and mind. As a result of my coping mechanisms, I did eventually find myself to be quite comfortable in my new host country, but that didn’t occur soon enough to prevent culture shock from affecting me.
Culture shock is the phenomenon of psychological and physical disorientation that can occur when a person is living abroad. Its four distinct phases are honeymoon, frustration, adjustment, and acceptance. Honeymoon is the first stage and is characterized by an extremely positive feeling with the new culture. A little later, the frustration stage begins. This may be the most challenging stage because cultural differences create a negative impact and there are feelings of discomfort and dissatisfaction. But slowly, in the adjustment phase, people begin to feel more familiar and comfortable with their new environment. Acceptance is the final stage of culture shock. This happens when people successfully integrate into the new culture. It is quite normal to experience these stages at different times and to different extents.
Culture shock may be particularly relevant among international medical students, as they often face difficulties coping with the patient’s personal and social experiences with illness and health, as well as professionalism and workplace relationships. In my case, working at Interfaith Hospital in Brooklyn, I encountered firsthand the ravaging effects of the social inequality grounded in ethnicity in a way I had not quite experienced in Colombia. These included health inequalities among African Americans and Hispanics, lack of access to mental health care among vulnerable populations, and high prices of essential medicines. This really helped to educate me on the importance of understanding the social determinants of health.
I also found the workplace cultural norms in the US were substantially different than I was accustomed to. In Colombia, our culture tends to lean toward openness. It’s no big deal for teachers to hug or text their students; whereas in the US that is clearly frowned upon. Even coworkers in the US seemed to have a significantly greater distance between them than I am accustomed to, and this applies within and across genders. While I didn’t necessarily make any major errors in my relations with my coworkers, I was a bit shocked, and possibly even offended at first by the distance they kept. This did lead to a bit of discomfort initially, as I pondered if it was something I was doing wrong or if this is just the way things are in the US. But eventually, I came to learn that what I was experiencing was normal; it was just different than the professional environment I was used to.
If you’re a medical student planning to study or work abroad, it is helpful to understand the effects of homesickness and culture shock, and to develop strategies for dealing with these feelings prior to leaving. Doing so will make your clinical experience more enjoyable and productive for all parties involved. Prepare for your clinical practice by reading about cultural norms, values, and beliefs in your host country. Read about the most commonly occurring conditions, local clinical guidelines, and seek advice from other international students about what resources are the best to use for each rotation. Finally, be open and empathize. We are all human.
I found that the gap was closing between myself and my coworkers by the end of 2 months, but it was still not like in Colombia on day one, and that was a big lesson to learn. Your host country, in countless ways, will not be like home.
Personal Tip: On reflection, and with some reading behind me, I realize many of the factors that influence homesickness and culture shock can be somewhat averted by studying the host country and your role prior to departing. Read an ethnography about the country, or even the region or city, you’ll be residing in. Also, read up on the terminology and work practices of your new role, and last but not least, read up on the cultural norms for interpersonal interaction. From the greeting you share with someone upon first meeting them, to the distance people have between them while speaking, it’s all relative. I found that the books in the anthropology category on Amazon as well as travel books such as those in the Frommer’s series are a great place to start.
Integration, Cultural Sensitivity, and Workplace Culture
Successful integration of international medical students in a foreign country is a challenge. Integration depends on many factors that involve yourself and the others around you in your new host country. Some things you’ll be able to control, others you will not. One aspect you can control is your own cultural sensitivity, which is a critical factor for successful integration in a host country.
Cultural sensitivity is the awareness of cultural differences between people exist without assigning them either a positive or negative value. While you are studying medicine abroad, cultural sensitivity is beneficial for many reasons, including: improving collaboration and acceptance among peers, creating a shared understanding of the goals and objectives with your healthcare team, and offering culturally sensitive care to patients.
I can’t even begin to convey how important cultural sensitivity was for me. I was not only working in a new national culture, but also a new work culture, and the majority of my cohort was as well. In fact, my team was made up of medical students from India, South Korea, and South Africa. Furthermore, the majority of patients, while historically similar to my Afro-Latin background, were by no means culturally the same, as they were in many ways shaped by the tough urban culture of Brooklyn, New York.
The result of all of this made for a diverse environment that required acceptance and sensitivity; but that was not always easy. Some days I was unable to truly understand the needs and expectations of my patients and coworkers, as working with or caring for people with different sociocultural background can be a challenge. It’s one thing to want to be culturally sensitive, it’s another to execute on it flawlessly. And despite the Hippocratic Oath, we’re all humans. If a coworker or patient is being disrespectful to you, it can be hard to be respectful back. However, we must try to be cultural sensitive; much like empathy, feelings of acceptance are something you can cultivate.
Respecting that culture is relative, and being open to those differences will go a long way to allowing you to bridge the gap between yourself and others. And while you still can’t control how others feel or act, leading with empathy and kindness will almost always get you closer to acceptance than distrust and judgement.
Personal tip: To practice being culturally sensitive, start small. I’d suggest embracing being open to new experiences, be they music, art, food, or anything social. For example, I grew up listening to cumbia, bachata, and other Latin American forms of music. But prior to my visit to the US, I looked up American blues, jazz, soul, and country to begin immersing myself in the “American way of life.” Similarly, when I got to New York, I took the opportunity to try food from different restaurants to understand the flavors and smells of other cultures. Finally, as it relates to medicine, I even tried out other healing systems such as acupuncture and acupressure to gain a sense of methods of healing individuals from other cultures believe in, so that if any patients came to the hospital with these in their background, I would have a better sense of their historic healing systems.
Research and Publication
Research throughout medical school is often an important element of your residency application and professional pathway. Research demonstrates motivation and your curiosity about the medical field. Whether you’re studying or working, don’t hesitate to seek out opportunities.
If you’re studying, visit the medical or science department, look for posted flyers, or talk with other students to identify what opportunities might exist. Similarly, if you’re working abroad, network with your coworkers to find potential volunteer opportunities. Even if your hospital doesn’t offer any positions, look for external internships at other local hospitals that you may be able to volunteer for during your free time.
Aside from the practical knowledge gained, a medical research assistant job offers additional benefits. During research training, you’ll experience what it’s like to be a physician-scientist, and you’ll gain a greater perspective of what you’re interested in. In fact, my time participating in oncology research at Colombia has helped form my career goals as a doctor today, and has led me to seek continuing education at Memorial Sloan Kettering in New York City.
Another significant benefit of medical research during medical school is the mentorship you receive from your principal investigator or graduate student. In my case, my oncology mentor helped to develop my critical appraisal of medical science, clinical skills, and growth mindset. Your research mentor will also most likely write you a letter of recommendation, which is hugely valuable for your residency or master applications.
So how do you get started? The first step is to pursue investigatory projects that you’re honestly interested in. You might find background reference sources and gather information on your research idea. Develop a realistic and suitable idea according to your level of training.
Request to work with a faculty sponsor, and set up real expectations to fulfill a research project. Consider your academic burden, clinical activities, and possible collaborations with instructors, advisors, and classmates.
Personal tip: Once you finish and your work is published, there’s still more to do. Try to share your experience and knowledge by attending conferences or meetings in your field. Participating in a conference offers the benefits of improving your presentation skills, getting feedback about your work, and networking with peers. I personally follow hospitals that I admire on Facebook and LinkedIn and use Meetup.com to find out about public health events.
After you complete your study abroad experience, you’ll find different options for where you’ll take your career. Most international medical students will return to their homeland, but some will pursue a career abroad after graduation. Which route you take depends on your economic opportunities, career motivations, and personal preferences.
If you return home, you may feel reverse culture shock, which is characterized by emotional and psychological distress during the readapting process in your home country. This is perfectly natural and it will take effort and time to readjust. It took me a few weeks to get readjusted to Colombia. I found meeting up with family and friends was useful, but staying busy and the passage of time seemed to help the most.
The people you leave behind can probably never truly understand your experience abroad, so though they will likely ask you how it was, don’t expect them to get as excited as you. They didn’t spend a few months to a year abroad experiencing all of what made it so interesting, so share your story but don’t feel down if they don’t seem as interested as you might wish.
I also suggest trying to maintain and integrate the newfound attitude and personal goals you acquired from your abroad experience into your at-home lifestyle. While you’ll never be able to recreate the environment, you can continue to foster all the positive lessons you learned. I personally like to journal about my experience while abroad, and reflect on those lessons when home. It can be easy to forget, so a reminder is helpful.
Another thing to keep in mind if you’re planning to go back home is that in a lot of countries, foreign-trained physicians will need to verify their medical school transcripts and diplomas before obtaining a license to practice medicine in their home country. Plan ahead so this doesn’t catch you off guard. Start to send your required legal paperwork before you go back, so that you get ahead on the process.
However, if you enjoyed your time abroad, consider seeking a postgraduate degree, a job abroad, or volunteering options. There is always more to learn, and doing it in a new and challenging environment is a great way to amplify the learning potential.
Personal tip: There’s no one right way to study or work abroad in medicine. The possibilities are unlimited: from public health research in developing countries, to cancer research fellowships in developed nations. The decision will depend on what makes you the happiest and what will the best in the long run. I’ve known for a long time I wanted to do a medical residency in internal medicine in the United States, and likewise I’m currently preparing for Step 1. Upon completion of a US medical residency in internal medicine, I will seek a fellowship in oncology.
Studying medicine abroad provides a whole new level of global and cultural understanding. It helps medical students to care for diverse patient populations, have effective communication skills across cultures, and it ultimately improves the ability for doctors to understand, communicate, and treat all patients with the empathy and respect they deserve.
This is a truly life-enriching experience and offers a guaranteed reward. You will never regret it, ever!
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Carolina Severiche Mena MD is a researcher, author, and freelance writer.
She is currently partnering with a colleague on genomics research, and in the past has conducted research on the mortality risk factors in patients with hematological neoplasms and the classification of intrinsic subtypes of breast carcinomas.
Her book, Paciente Oncológico En Cuidados Intensivos (published in Spanish), discusses how critical oncological patients represent a medical challenge due to their particular vulnerabilities and the complexity of the treatment. She is active on her Twitter account and her own medical blog, where she discusses her journey from being an MD in Colombia to gaining US residency.