Globalization, migration health, and educational preparation for transnational medical encounters

The first principle of TC education is patient-centered learning. The medical consultation is approached as a partnership, with the patient participating as teacher as well as learner and the student valuing the learning and mentoring dimensions of his/her role [58, 71]. The patient's voice is treated as an indispensable source of expertise and experiential insight [37, 72]. Rather than ignoring the perspectives of the least advantaged, [64] preparation for the TC encounter revolves around patient-oriented inquiries that are designed to promote congruent perspectives among care seekers and care providers on health status and health promotion – regardless of differences in national origin, ethnicity, cultural identity(ies), and socio-economic (and political) status. Findings from clinical studies consistently show that, when treated as an interactive, partnership-based process, [73] the medical consultation directly and indirectly improves the outcome of health-care interventions [74, 59, 58, 71]. The TC approach anticipates, therefore, that health-care outcomes will be enhanced when patients also possess transnational competence [75] and demand and inspire corresponding skills on the part of the clinicians who consult with them.

TC's second core principle holds that patient advocacy is an indispensable physician activity. A TC education aims to move learners beyond patient sensitivity into responsiveness to patient needs. Across its five skill domains, the TC framework remains focused on two interconnected objectives: improved short- and long-term health outcomes for patients in spatial transition and reduced health inequities for dislocated populations and disadvantaged communities. Both objectives lie at the core of the People's Charter for Health that emerged from the People's Health Assembly held at Savar, Bangladesh, in 2000 [76].

A third TC principle centers on the resilience of underserved patients and families. TC preparation starts from the premise that patients in spatial transition are resilient and searches for ways to reinforce and expand their capacity to tap into potentially rich reservoirs of family, community, and transnational health-care resources.

The TC framework explicitly encompasses five discrete, but mutually reinforcing, skill domains. Transnational competence involves mastery of analytic, emotional, creative/imaginative, communicative, and functional skills. Each skill domain encompasses multiple dimensions.

The analytic domain of TC preparation focuses on developing the ability to gather and analyze evidence related to the patient's health rather than on stored knowledge, while recognizing that a knowledge-based approach can be useful for specific and limited purposes [27, 48]. In particular, TC education recognizes the necessity to probe beyond ethnicity/culture. As Moustafa Bayoumi observes, "by obsessively focusing on culture, we avoid talking about history, economics and politics" [[77], p.A4]. In short, an exclusively ethnic/cultural observation "obscures the social and structural basis of the need ..." [[37], p.34]. The interweaving of ethnocultural, socio-political, and medical analyses is required for comprehensive assessment of each patient's health-care needs.

To avoid misinterpreting messages and explanations offered by patients in spatial transition, medical students must develop expanded receptors for discerning political and socio-economic determinants of individual health; [78‐82, 62] that is, they must learn how to perceive health situations through what Mary Duffy refers to as the patient's "global lens" [[36], p.489]. In particular, it is important that medical practitioners elicit and explore the longitudinal dimensions of spatial transition given that established as well as recent migrants often are dealing with "unfinished endings" that preceded their arrival in the current locale [[38], p.89, [83]] and continue to shape their lives [84, 85]. Physicians possessing transnational analytic skill are able to comprehend and critically appraise the internal and external forces that affect migration health [86, 87] by expanding the medical discourse to include linked macro-structural and micro "origins of personal suffering" [[63], p.276] – such as war, [48, 88, 89, 84] manipulations of national and subnational economies by powerful global institutions, [87, 90‐92, 12] foreign policy, [86] powerlessness, [93] persecution, and the type, combination, and frequency of trauma experiences [94].

Transnational analytic skill further involves unraveling existing linkages between migrant health and post-migration constraints and stressors associated with receiving-country reception practices and new developments in the country of origin [95‐97]. For instance, a patient's capacity for self-care can be limited by ongoing "cultural and linguistic isolation, fragmentation of the family, deformation of social relationships, chronic absence of adequate support systems, poverty, prejudice, and unemployment" [[98], p.32, [59], [63, 99‐103]] – all rooted in migration and post-migration experiences. Furthermore, political and family events and conditions in the sending country often continue to affect the mental health and physical well-being of service users who possess transnational ties and identities [104, 84].

Another critical transnational analytic skill in migration health is the ability to ascertain the role of ethnocultural and other nonstandard health-related beliefs, values, practices, and paradoxes. The "transnational healing" practices of some contemporary migrants even include return to the country of origin for medical attention and treatment [105, 106]. TC education prepares students to assess the role of nonbiomedical considerations in the pre- and post-migration explanatory model and decision-making processes of specific patients and/or families [107‐112]. Box 1 presents illustrative TC-preparation components in the analytic domain.

Transnational emotional competence includes the ability to express interest in different cultural patterns – language, family life, dietary practices, [119] customs, etc [120] – and the ability to gain and maintain genuine respect for a multiplicity of values, beliefs, traditions, experiences, challenges, preferred communication styles, and feelings of satisfaction and emotional distress stemming from social circumstances [63, 34]. Among medical students preparing for encounters with patients of multiple nationalities and diverse identities, the emotional skill domain is developed through interest in interacting with ethnically, culturally, and economically diverse patients. The application of transnational emotional skills requires a "willingness to try" to decipher the patient's thoughts and perspectives [[32], p.1058, [121]] – including his/her beliefs regarding the mediating effect of "luck, chance, randomness and personal destiny" on healthy lifestyles [[122], p.679] – and to respond empathically with an appropriate emotion of one's own [123].

In the migrant-health interface, it is particularly important that care providers learn to respect rather than dismiss lay expertise [72, 37] as well as nonbiomedical practices that affect acceptance of and compliance with treatment protocols and, therefore, influence outcomes [124‐127, 112]. Emotionally skillful participants also appreciate that every clinical encounter is a multidimensional interaction among the cultures of the patient, the physician, the support professional(s), and the health-care contexts/systems that surround them [128, 107, 48, 62].

The emotional-competence domain of a TC education further emphasizes appreciation for the ability of people in spatial transition to regain emotional strength and functional capacity following adversity [129]. Many "refugee patients and their families bring to health consultation stories of incredible human resilience in the most extreme circumstances" [[130], p.27, [110]]. Studies show that a sense of personal, family, and/or group efficacy constitutes a powerful determinant of the adoption and maintenance of health-promoting actions and is associated with a host of health-enhancement and illness-prevention outcomes [131‐133, 58]. Under the vulnerable and stressful environmental conditions that migrants face as the result of formidable language and cultural constraints, discrimination, the threat of long-term unemployment, and/or lack of social support, clinician appreciation for patient/family health-care assets, capabilities, and responsibilities reinforces individual and collective perceptions of transnational efficacy and strengthens confidence, perseverance, and power to sustain new and demanding psychological and physiological health-enhancing behaviors [132]. Capable self/family illness management is particularly valuable in treating many chronic diseases [134]. Among medical students, emotional competence also involves self-monitoring and reflection; that is, life-long openness to critical self-appraisal, to learning in place of stereotyping, [135] and to promoting emotional growth [136]. Box 2 presents illustrative TC-preparation components in the emotional-skill domain.

The freeing up of imaginative capacities is a powerful force for positive health outcomes in the transnational medical encounter [145]. A key creative skill for medical students preparing for migrant-health care is the ability to initiate fruitful new connections among distant and proximate parts of the patient's experience [146]. Skillful transnational clinicians are "creative synthesizers" [[147], p.17, [148]] who value collaboration with, and are able to inspire, participants of diverse identities (patients, family members, and transcultural mediators) in the co-design and nurturing of innovative and contextually appropriate health-action plans [149].

A substantial proportion of all health care is provided "outside the perimeter of the formal health care system" [[150], p.251]. In the migrant-health arena, innovative approaches to managing demands for medical treatment and wellness promotion include complementary integrations of biomedical and ethnocultural explanatory frameworks and health-related practices [107, 124, 109, 151‐153, 108, 96] and incorporate multilevel linkages of individual, socio-political, and ecological considerations [154, 155]. In the interest of preparing creative medical practitioners, TC education emphasizes flexibility and adaptability when confronted with unique and unfamiliar situations [37].

Imagination "makes empathy possible" by lending "credence to alternative realities" [[146], p.3]. Medical practitioners must be prepared to relate physical and emotional experiences and perceptions that shaped the decision to leave the country of origin, as well as those that arise during migration and resettlement processes, both to approaches that effectively address the patient's current health-promotion needs [152, 155] and to promising social changes and policy alternatives [63]. Box 3 presents illustrative TC-preparation components in the creative/innovative domain.

Effective provider-patient communication is widely perceived as "a core competency in the health care profession" [[59], p.27, [58, 48]]. While personal linguistic fluency in the patient's first language is an immense behavioral asset, [157‐161, 48] achieving it is impractical in transnational health-care situations involving multiple first languages [32]. In New York City, for instance, patients might speak one of 150 different languages [162] Thus, TC education emphasizes skill in using an interpreter, the importance of employing trained medical interpreters, [163‐166, 153, 158, 160, 111, 157, 48] and host-language preparation and communication training for patients [134].

Transnationally skillful actors also develop proficiency in nonverbal-communicative behavior. In medical encounters, "nonverbal communication skills ... are as important as verbal skills, if not more so" [[167], p.2445]. In transnational medical interactions, interview pace, speech-simplification strategies, and the use of "continuers" ensure that participants are not rushed, prematurely interrupted, ignored, or incompletely understood [168‐170, 164]. In addition, communication-recovery skills, such as humor, apology, and admission that one does not know everything, "reinforce confidence as well as competence because, when it is known that there is something to fall back on, one is less likely to avoid interactions that may prove difficult" [[96], p.245, [135]].

The capacity to engage in meaningful dialogue and to facilitate mutual self-disclosure via questioning is particularly important in transnational health-care situations characterized by vast social distance [168]. Similarly, a prerequisite for negotiating appropriate treatment plans and commitment to agreements is that participants – especially migrant patients – are comfortable expressing serious doubts and constructive challenges [168, 63, 58]. Box 4 presents illustrative TC-preparation components in the communicative-skill domain.

Functional competence involves the interpersonal as well as technical ability to accomplish tasks and achieve objectives. In transnational medical encounters, the functional skills of both patients and clinicians affect illness management and wellness promotion [171, 172]. In migrant-health-care consultations, effective functional interventions take into account both the individual's condition and the social context affecting health behavior [155].

Skill in establishing positive interpersonal relations is particularly valuable for the functional domain of migrant-health care. Keys to success in building fruitful transnational relationships include demonstrating genuine and sustained personal as well as professional interest in the care recipient as an individual, commitment to the patient's cognitive and instrumental needs, [137] and support for his/her social inclusion [36]. TC preparation emphasizes that, in the case of migrants who lack voice in the socio-political context they find themselves in, concern for patient well-being can be demonstrated by actions that address factors responsible for personal suffering [63]. Valuable relationship-building TC-provider interventions include helping with transportation to medical appointments, facilitating access to traditional healers, medicine, and nutrition, promoting ties to community support networks, identifying and enhancing the development of "new roles that provide a sense of meaning and structure to daily life," [[173], p.294] and assisting with host-country language training, further education and credential (re-)certification, employment, and the maintenance of (children's) healthy practices.

The functional dimension of transnational competence also is promoted by establishing clinician/patient partnerships, or "therapeutic alliances." [135] In the transnational therapeutic alliance, "the process of negotiation between practitioner and patient involves developing courses of action that are consistent with the patient's values and goals and that also satisfy the physician's values and goals ..." [[168], p.13, [33]]. For many migrants, transculturally sustainable agreements must include involvement by (extended) family members and/or migrant-community support networks [111, 150].

In the interest of equitable health opportunities for migrant patients, transnational functional adroitness necessitates advocacy competence; that is, recommendations/actions that will generate upstream and downstream changes in domestic and international economic, social, institutional, and policy conditions that produce the systemic disparities that constrain individual health and preclude the realization of health gains [23, 174‐177, 92, 48, 76, 94]. It is likely to be particularly rewarding for functional skill development to focus students' advocacy attention on local "hot spots" where migrants tend to congregate. In this part of functional TC preparation, medical students can be guided to develop specific interventions that address context- and site-specific conditions that are conducive to elevated risk-taking behavior [47]. Box 5 presents illustrative TC-preparation components in the functional domain.

Along with introductions to challenging new material and helpful insights regarding contemporary medical practice, it is critical that future physicians be "taught in a way that works better" [182]. For maximum effect, the core elements of a TC education need to be longitudinally woven into required pre-clinical and clinical education through instructional approaches that encompass lectures, small-group discussions that include reference to the consequences of patient stereotyping, analysis of written and videotaped case studies, constant reference to clinical applications, interaction with community leaders, training in interviewing skills, as well as experiential approaches such as role plays, [27] encounters with simulated patients, overseas immersion, [8, 36] involvement in community service-learning projects, and carefully designed clinical clerkships. The didactic components of the longitudinal and integrated TC approach would establish the need for adaptable skills in the contemporary context of globalization and health, would build a comprehensive foundation of five skill domains, would highlight the special value of experiential learning and reflective practice when attending to migrants, and would emphasize the centrality of collaborative efforts to promote social justice in health care through multi-dimensionally sensitive and individual-patient responsive transnational medical encounters. Resources from the humanities (e.g., art, literature, autobiographical accounts of migrant-patient experiences) can be especially useful in the initial effort to awaken the student's imagination [146] and to convey TC concepts that are inherently important in caring for migrant patients [183]. To facilitate stakeholder buy-in, the instructional and experiential dimensions of TC medical education also require attention to faculty-selection criteria, resources for faculty development in skill-deficit domains and in unfamiliar pedagogical approaches, and institutional as well as external support for materials development, contributions by specialists, assessment exercises, and logistical arrangements. Medical schools and teaching hospitals also will need to reinforce or establish linkages with often fragmented migrant-community associations and with community-health advocates.

In contrast to educational methods that center on mastery of ethnic patterns of disease or lists of cultural characteristics, the predominantly inductive TC approach focuses on the patient as the starting point for discovery and avoiding mistakes [27, 184]. When health-care providers work with diverse service seekers, skill development occurs through "bottom-up" information and evidence gathering that places primary emphasis on contextual insights derived from proximate and current sources – the patient himself/herself and family, friends, and/or community members [185, 48]. In light of the existence of national subcultures and the presence of intracultural (and changing) variations that occur due to "age, gender, income, education, acculturation, individual differences, and multiple other factors," general epidemiological evidence about the patient's country and its endemic diseases, ethnic group, or religious affiliation needs to be "regarded as having some bearing but requires further validation to be considered immediately useful" [[185], p.251–252, [186, 96, 27, 33]]. As Melanie Tervalon and Jann Murray-Garcia point out, "only the patient is uniquely qualified to help the physician understand the intersection of race, ethnicity, religion, class, and so on in forming his (the patient's) identity and to clarify the relevance and impact of this intersection on the present illness or wellness experience"; that is, "how little or how much culture has to do with that particular clinical encounter" [[135], p.121].

For TC preparation, therefore, skill development is expected to be especially robust during the student's clinical-clerkship experiences. In a TC-informed medical education, exposure to transnational medical encounters would constitute an integral part of all clinical clerkships. Clerkships that involve migrant patients present students with a variety of stimulating medical challenges framed by diverse cultural perspectives and social backgrounds [65] and, simultaneously, provide problem-solving opportunities for students to articulate helpful recommendations and rewarding interventions. When designing each TC clerkship experience, faculty would arrange for students to work closely with patients and family members from distinct and diverse cultural, ethnic, subcultural, generational, and socio-economic backgrounds. Gerrish, Husband, and Mackenzie warn that "a de facto emphasis on cultural competence, with a resultant neglect of intercultural competence, must be resisted" [37, 134, 135]]. Thus, TC clinical placements and preceptor-supervised encounters with patients [121] would avoid focusing on a single local population. Clinical assignments also should proceed to levels of increasing complexity and be linked to reflective seminars that involve sharing and group discussion of case-specific and transnational issue-related insights gained from interviews with multiple patients of diverse backgrounds and from students' health-promotion and social-context (advocacy) recommendations. For educators working at institutions in the few rural areas or population centers that remain relatively untouched by migration, the experiential component might need to supplement a relatively homogeneous patient base through student participation in out-of-country immersion programs, cooperative arrangements with urban medical schools, and/or videoconferencing [187].

TC clerkships would emphasize the validation and promotion of factors that facilitate health recovery/maintenance, transnational adaptation, and survival. When working with ethnoculturally discordant patients, "the ability to identify assets in a family beset by overwhelming liabilities" as well as vulnerabilities "often produces the turning point toward successful interventions" [[188], p.269]. The bases for resilience vary among patients and are subject to change over time [189]. Possibilities for students to explore include: hopeful vision for the future; religious faith; self-reliance; personal history of overcoming adversity; roots; finding meaning/purpose in life; [189] and community mutual assistance and support [190]. In TC clerkships, students would learn that unduly pathologizing the migrant's experience [118] exaggerates deficiencies, risks fostering dependency, [191] and "removes the matter from the political and social context that produced ... [the] anguish and loss" [139]. TC clinical education also aims to provide the future physician with a toolbox of ways of reinforcing and expanding resilience (especially preparing patients to take responsibility for self care and problem solving in a confident manner, which often involves family and nonbiomedical supplements and addressing resource needs), reversing devaluation and disempowerment by providing opportunities for patients to demonstrate and develop role competence and increased control over their life both in and beyond health-care situations, [192] and enabling migrants to resist the adoption of health-adverse behaviors practiced by members of the receiving society [193, 194]. Furthermore, TC clerkships would demonstrate that the extra time spent on caring behavior (estimated at 5–7 minutes per encounter until the caring relationship is established) results in multiple benefits for both practitioner and patient [137, 181]. Increasingly, managed-care providers recognize that providing such quality attention more effectively contains health-care costs than does limiting services [115].

A central component of inductive TC pedagogy and the TC clinical clerkship is a "mini ethnography" of health, illness, and migration/adaptation experiences [80, 195]. In the transnational medical encounter, the patient's narrative of lived experience – including the migrant's stressful social and environmental situations, network of transnational social relations, and emerging identities [95] – is particularly valuable [145, 96]. Genogram construction [178] constitutes another illuminating tool that can be built into the ethnographic interview. The ethnographic-learning experience should include observations in the patient's social territory; critical reflection on the medical impact of power relations, institutionalized constraints, and patient/family strengths; opportunities for the patient to comment upon the student's initial findings; preceptor feedback regarding the strengths and limitations of each student's interviews; and facilitated discussions with faculty in small-group settings of the students' findings as well as possible hidden social, economic, legal, and cultural contributors. The ethnographic approach reduces prospects that decisions will be based on stereotypic oversimplifications and/or insufficient information [196, 48, 128, 112] and helps medical practitioners avoid the overgeneralized tendency to perceive and treat migrants as traumatized victims [95].

Ethnographic interviewing also needs to be linked to skills in documenting how patient/family perspectives and insights that bear upon the patient's physical and mental health as well as his/her current social, economic, and legal circumstances will be addressed in the recommended health plan. In her case study of Lia Lee's treatment by U.S. doctors, Anne Fadiman reports that Lia's medical chart "grew longer and longer, until it contained more than 400,000 words. ... [Yet] not a single one dealt with the Lees' perception of their daughter's illness" [[81], p.259].

The TC approach involves explicit expectations that students act as the patient's advocate by forging partnerships with community organizations and advocacy groups and by making social-context recommendations that address both short- and long-term challenges to health [180, 197]. Preceptors would be expected to provide feedback to students about documented results that arise from their recommendations. TC's advocacy emphasis further suggests the value of integrating community-based [156, 64, 36] experiential or service learning into the medical student's education [198].

Assessments of TC-learning outcomes would include student course and clerkship evaluations, student self-evaluations and instructor appraisals of pre- and post-classroom learning (e.g., the student's ability to explain why the unique migration history of a refugee from Afghanistan is important for the patient's health care [199]) and humanistic-values enhancement, review of randomly videotaped/audiorecorded encounters with patients of diverse backgrounds, [27] preceptor evaluation of each student's applications of the five TC skills (e.g., the ability to delineate and document a comprehensive plan of action that connects the patient's socio-cultural background, perspectives, and context with his/her current health challenges and promising medical and nonmedical responses), and TC-relevant OSCEs [27, 184]. TC skill assessment would be incomplete without eliciting and incorporating patient reflections on the interview process, the accuracy of insights reported in the mini-ethnography, the efficacy of the student's proposed and initiated actions in terms of health-promoting interventions and personal health outcomes, [27] and the attending student's overall TC strengths and deficits.

Successful implementation of a TC educational initiative requires additional resources. The training and employment of medical interpreters, the conduct of ethnographic interviews, the professional development of medical-school faculty who are qualified to offer TC-informed courses and to supervise TC-centered clerkships, and the construction and execution of systematic evaluation studies constitute critical components of the educational framework presented here that will be well-served by supplemental external funding. This is particularly the case for resource-scarce universities in Southern countries. In addition to internal reallocations, a variety of national and international funding sources can be mobilized for program support. Ideally, the World Health Organization would assume responsibility for driving, and coordinating funding for, the TC initiative. The faculty-development and evaluation components also would be promoted by national government incentive programs carried forward in partnership with higher-education institutions, including the United Nations University. Foundations and associations of medical professionals could usefully contribute to the global TC educational initiative, with some programs specifically devoted to the preparation of professional medical interpreters, transnational navigators, and patient advocates along with TC training for migrants. Grounding in TC, along with receptivity to continued mutual South-North learning, could be fruitfully incorporated into the Bill and Melinda Gates Foundation-supported "E-learning Certification Programme in Global Health" initiated through Oxford University [200] and into the post-graduate educational programs offered by the Department of Global Health at The University of Washington that will be launched in 2006 thanks to another Gates Foundation grant.