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Implementation of an international medical student pen-pal club:


survey outcomes of perceptions in cultural competency and global
health

Max J. Goodman , Jennifer Livschitz , Ji Won Kim ,


Megan L. Schultz

PII: S2414-6447(24)00004-6
DOI: https://doi.org/10.1016/j.glohj.2024.02.004
Reference: GLOHJ 160

To appear in: Global Health Journal

Received date: 30 September 2023


Revised date: 21 December 2023
Accepted date: 6 February 2024

Please cite this article as: Max J. Goodman , Jennifer Livschitz , Ji Won Kim , Megan L. Schultz ,
Implementation of an international medical student pen-pal club: survey outcomes of per-
ceptions in cultural competency and global health, Global Health Journal (2024), doi:
https://doi.org/10.1016/j.glohj.2024.02.004

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RESEARCH ARTICLE

Implementation of an international medical student pen-pal club: survey outcomes of

perceptions in cultural competency and global health

Max J. Goodmana,*, Jennifer Livschitza, Ji Won Kima, Megan L. Schultzb

a
Medical College of Wisconsin, Milwaukee, WI 53226, USA

b
Department of Pediatrics, Division of Emergency Medicine, Medical College of Wisconsin,

Milwaukee, WI 53226, USA

*Corresponding author: mgoodman@mcw.edu

Article history:
Received 30 September 2023
Received in revised form 21 December 2023
Accepted 22 January 2024

Abstract

Background: Pen-pal clubs (PPC) are used worldwide for students to learn about different

cultures and other skills without the need for travel. Many medical students are interested in

global health opportunities abroad but costs, scheduling, and other barriers allow few to

participate in such experiences. It is important that medical students have nuanced global

medical perspectives and can contribute to the global medical community.

Objective: The purpose of this study is to demonstrate that international medical student PPC

improve medical students’ perspectives of cultural competency and global health engagement.

1
Methods: In 2021, a novel medical student PPC was established that began between an American

and Japanese medical school. Following a shareholders meeting, it was decided that the number

of medical schools involved globally be expanded through previous institutional affiliations and

online presences. In total, the club connected 50 American medical students and 52 medical

students from 17 high- and middle-income countries. The primary form of communication was

online; pen-pals were encouraged to communicate monthly using provided topics although

frequency and way of communication was their discretion. In February 2022, American PPC

members were emailed a qualitative survey to assess the PPC’s impact.

Results: The survey was completed by 42% of American PPC members, 95% of which were 22‒

26 years. Participants were preclinical medical students, 60% whom were female and the

majority either white (47%) or Asian (43%). Overall, the PPC positively influenced American

medical students’ perception of global medicine, medical education, and their cultural

competency after joining the PPC compared to prior (P = 0.004).

Conclusion: PPCs encourage medical students to think from a global perspective and foster

open-mindedness within varying social and cultural contexts. Having a global communication

platform for students during medical school education may be an additional way to train aspiring

global leaders.

Keywords: Pen-pals; Medical student; Global health; Cultural competency

1. Introduction

Pen-pal programs are used at many educational levels for participants to learn about

cultural and societal differences between their respective communities and others and to expand

students' worldviews without the need for travel.1 While medicine is a global phenomenon, only

a minority of American medical students have global health experiences, often due to costs, lack

2
of faculty oversight, and curricula that either do not include a global health component or require

students to develop their own global health opportunities.2-4 In fact, more than 75% of medical

students graduate without any form of international medical experience,4,5 even as it becomes

more commonplace for nations, corporations, and organizations to expand across borders and

markets. Medical education is often highly localized to regional or national customs;6,7 this can

extend from different pedagogies to disease pathologies to bedside manners. As globalization

continues to contribute to interactions between different languages, cultures, and customs, in

addition to the spread of infectious disease, it is important that medical students have a nuanced

understanding of global medicine and are capable of practicing in the global medical

community.8 Research also suggests that medical students highly desire training in global

health.9 However, there is a perceived deficiency in culturally competent care among healthcare

providers that may also originate from a lack of cultural competence education strategies in

medical school.10,11 Researchers argue, following the coronavirus disease 2019 (COVID-19)

pandemic, that powerful nations have not been committed enough to collaborations in global

health.12-14 This is concerning as incomplete international commitments in health and education

can lead to global medical hazards, yet efforts can be made to thwart this possibility and

encourage global health cooperation and coordination at the level of the medical student.15 One

potential way to encourage greater global health participation, cultural competency learning, and

global networking for medical students is international medical student pen-pal clubs (PPCs).

2. Methods

2.1 Implementation

In January 2021, we established at the Medical College of Wisconsin (MCW) the MCW

International Medical Student Pen-Pal Club as an interest group. The PPC is believed to be the

3
first of its kind in the country. As of March 2022, the PPC has 50 MCW medical student

members and 52 medical students from around the world. The PPC was started at MCW by three

medical students, one global health faculty member, and one global health staff member in late

October 2020. We sent an interest survey to all MCW medical students, which received 31

replies out of 995 (3%). The club was initiated subsequently, and for a period of time, only a

medical school in Japan had agreed to participate in spite of efforts to reach out to medical

schools from MCW’s previous international affiliations that would have included medical

students from middle and low-income countries. A medical university in Japan surveyed medical

students at their school’s English club and found 12 out of 20 (60%) would be interested. Once

interest at both institutions were gauged, suggestions/goals were made from shareholders

consisting of two faculty and two staff from MCW, two faculty from the Japanese medical

school, 31 medical students at MCW, six medical students from the Japanese medical school,

and the MCW student government. Questions to faculty included ways to logistically establish a

PPC, requirements and details relevant to the maintenance of a PPC, potential grant funding for

developing a PPC, and means of connecting with medical school affiliate programs and other

medical schools with or without guaranteed Internet access or who may not speak English.

Questions to medical students included how many pen-pals they desired, if they wanted to be

paired by regional preferences, languages, hobbies, gender, culture, or other, if they would write

physical letters to their pen-pals if needed, and if they would be comfortable with being paired

with a student who may not speak their language.

Overall, medical students desired one pen-pal who they could be in contact with through

online communication, ideally with similar interests. MCW students also desired pen-pals from

regions that interested them, whether because of language, culture, or their own family lineage.

4
Students from the Japanese medical school desired similar components, though many were

specifically interested in improving their English language skills. The top priority for faculty at

both medical schools was logistically establishing a PPC, and the top priority for MCW medical

students was being paired with someone from their region of interest. The top priority for

medical students from the Japanese medical school was being in contact with their pen-pal

online. The lowest priority for medical students at both schools was how many pen-pals they

would be paired with.

We then held an orientation meeting in late January 2021 for MCW medical students to

learn more information about the PPC. Firstly, the PPC’s aims were to create international

networks, engage in the sharing of cultures, learn from others irrespective of borders or distance,

and to make lifelong international friendships. Expectations included communicating with one’s

pen-pal at least once a month based on the international pen-pal’s preferred means of

communication as well as to utilize topics, activities, and questions to foster engagement. Further

expectations were to include being mindful of each other’s backgrounds, cultures, native

language, and to be forthright regarding each other’s interests and schedules. The goals of the

PPC included cultural exposure and growth as well as to enhance medical education by learning

from one another’s experiences regarding health care systems, school systems, regional diseases,

medical practices, and more. Another important goal was for this program to be an additional

resource for medical students to support one another given the difficult nature and rigor of

medical education globally. In regard to rules, there was an absolute no harassment or bullying

policy. This meeting was required for students at our institution who were interested in having a

pen-pal. A total of 31 medical students attended. Another orientation meeting was held in

5
November 2021 and included additional sections on cultural competency and leadership

positions.

Those who attended the full orientation meeting were given an online application form

using the application software Google Forms that included their name, year in medical school,

gender identity, world region of interest, languages spoken, language of interest, and hobbies.

Students were also asked if they wanted a pen-pal with the same gender identity and who spoke

English. The application form for the second orientation meeting was converted onto Qualtrics,

another application software for organization purposes. The international medical student

application is similar with the exception that region of interest was replaced for a question if

international medical students would prefer their pen-pal be familiar with their native language.

The international medical student application was hosted on Qualtrics.

Because medical students from our institution desired to have pen-pals from various other

regions, cultures, and economic backgrounds, there was a greater effort to recruit international

medical students after the PPC was initiated and medical students had joined. To recruit more

international medical students, we requested faculty members with connections to international

medical schools to email an advertisement in English about the PPC to their international

colleagues. International medical schools affiliated with MCW were also emailed once at the

beginning of the club’s founding and again after the first orientation meeting. Emails were

written in English, Spanish, or Norwegian based on available proficiency. Medical schools with

public email addresses connected to the International Federation of Medical Students'

Associations (IFMSA) were also recruited via email. For two medical schools in Japan and

South Korea, short YouTube videos were made explaining what PPC was in their respective

languages and shared with those schools based again on available proficiency. Finally,

6
international medical students found on medical school subgroups through the social media sites

Facebook.com and Reddit.com were individually approached. Overall, the most powerful

recruitment methods of international pen-pals were through affiliations our institution already

had with medical schools (47%), followed by IFMSA emails (46%), and then social media (7%)

in terms of the number of international medical students that joined. A total of 52 medical

students across 17 countries and 5 continents excluding the United States and North America

joined. Of the 17 countries, there were 2 in Africa, 6 in Asia, 6 in Europe, 2 in Oceania, and 1 in

South America. Finally, 5 of the countries were considered middle-income with 2 in Asia, 2 in

Africa, and 1 in Europe; the other 12 countries were high-income.

Once two students were paired as pen-pals, they would be notified together via email in

English. Descriptions included the pen-pal's name, gender identification, medical school,

country, and time zone. We encouraged students in the email to communicate by including a

prompt that asked them to write a description about themselves and to include a photo of

themselves doing something they enjoy. While students were encouraged to communicate with

their pen-pals at least monthly, a prompt was also included in the email that discussed

expectations regarding frequency, method, and way of communication. Though a majority of

pen-pals chose to communicate via email, it was the responsibility of the American medical

student to accommodate to their pen-pal’s method of communication. The reason was meant to

mitigate the risk of medical students not being able to participate with their pen-pal because of

irregular Internet access or other barriers. Other methods could have included texting, social

media, videotelephone software, handwritten letters, and more. Beyond this, pen-pals were

emailed monthly with questions in English on topics related to global health, medical education,

current events, and culture. This was to encourage pen-pals to engage in discussion and to

7
strengthen the pen-pal relationship, however, pen-pals were not required to utilize these topics.

To promote discussion about global health as a career path, we hosted a global health panel with

faculty and international affiliate members on Zoom. All MCW medical students and students of

medical schools with pen-pals could attend, regardless of PPC membership. This event was

hosted in English. Finally, all pen-pals had the club’s primary email and were encouraged almost

monthly to contact if they had feedback, recommendations, concerns, or wished to opt out.

2.2 Survey methodology

We created a qualitative survey which was approved by the MCW Institutional Review

Board #5. The survey was peer reviewed and designed by the authors which include an expert

researcher. The perceptions of global health, medical education, and cultural competency in the

survey were determined by evaluating the respondents' perspectives, beliefs, and experiences

related to various aspects. For example, in regard to global health, statements were asked related

to international connections, experiences abroad, perception of the global impact medical

students can make, opinions on the unity of the global medical community, and the availability

of opportunities to engage in global health. In regard to medical education, this was assessed

through exploring beliefs about how well their medical school prepares them for global health

and medicine, anticipation of working with more international colleagues, understanding of

global medical affairs, familiarity with medical education outside their country (specifically the

United States), and knowledge of different healthcare systems worldwide. Finally in regard to

cultural competency, this was determined by analyzing responses regarding self-awareness of

one's own cultural, ethnic, and racial identity, recognition of assumptions and stereotypes about

different cultures, acknowledgment of how personal culture influences judgments, comfort levels

in cross-cultural situations, understanding of the impact of culture on patients' lives, and self-

8
identification of limited knowledge about certain cultures. The cultural competence framework

of Hanley provided the basis of cultural competency for developing the survey.16

We emailed PPC members from our institution a Qualtrics link to the survey; they were

notified it was voluntary to participate and that their data would be de-identified. Demographic

information was analyzed descriptively. Statements were assessed on a 5-point Likert scale, with

1 representing “completely disagree” and 5 representing “completely agree.” The data was

analyzed using Microsoft Excel 2016 (Redmond, Washington) for macOS. The Wilcoxon

signed-rank test was used to determine if there was a statistically significant difference between

students’ perceptions of statements made in the survey while reflecting on before and after

joining PPC. Results with a P-value of less than 0.05 were considered significant.

3. Results

The survey was completed by 42% of PPC members from our institution. 20 (95%) of all

survey participants were 22‒26 years and 1 (5%) was 18‒21 years. 10 (47%) were first-year

medical students and 11 (53%) were second-year. Note that the aforementioned finding is

unsurprising because in American medical schools, club participation is primarily in the

preclinical years of the medical school curriculum which is often the first and second year.17 60%

were female. 10 (47%) of participants were white, 9 (43%) were Asian, 1 (5%) was African, and

1(5%) was more than one race; 4 (19%) students identified as Hispanic.

Overall, it was found that the PPC positively influenced medical students’ perception of

global health, medical education, and cultural competency (P = 0.004). See Table 1.

9
Table 1: Survey statements including medical students’ ratings before and after joining the pen-pal club in regard to their

perception of global medicine, medical education, and cultural competency (n = 21)

Before Joining After Joining


Number Survey Statements P
Mean Median Mode Mean Median Mode

Q1 I have/had a pen-pal(s) 2.55 1 1 5.00 5 5 < 0.001

Q2 I have/had an international friend(s) 3.67 4 5 4.90 5 5 0.004

Q3 I know/knew a foreign medical student(s) 2.00 1 1 5.00 5 5 < 0.001

Q4 I know/knew a foreign physician(s) 3.05 3 5 2.76 3 1 0.24

Q5 I have lived abroad 2.76 1 1 2.65 1 1 0.41

Q6 I have traveled abroad 4.29 5 5 4.14 5 5 0.32

Q7 I have volunteered or worked abroad 2.52 1 1 2.48 1 1 0.79

Q8 I believe cultural competency is important 4.00 4 5 4.95 5 5 0.002

in medicine

Q9 I believe medical students can make a 3.19 3 4 4.43 5 5 0.004

global impact

10
Q10 I believe the medical community 2.33 2 2 3.57 4 4 < 0.001

worldwide is very united

Q11 I believe the global medical community 3.90 4 3 4.86 5 5 0.002

should be more united

Q12 I believe international networking is 3.05 3 3 4.48 5 5 < 0.001

important as a student doctor

Q13 I believe my medical school prepares me 2.33 2 3 3.71 4 4 < 0.001

for global health & medicine

Q14 I believe I will work with more 3.43 3 3 4.62 5 5 < 0.001

international colleagues than physicians of

previous generations

Q15 Medicine is a global phenomenon 4.00 4 5 4.95 5 5 0.002

Q16 There are many opportunities available to 2.62 2 4 4.05 4 4 0.003

become involved in global health as a

medical student

11
Q17 I foresee myself a career in global 2.10 2 1 3.38 4 4 0.002

medicine

Q18 I am knowledgeable of global affairs 2.76 3 3 3.86 4 4 0.002

Q19 I am well-versed in how medical school is 1.62 1 1 3.95 4 4 < 0.001

conducted in areas outside the United

States

Q20 I have a good grasp of how different 2.24 2 2 3.90 4 4 < 0.001

healthcare systems outside the US function

Q21 I have a clear sense of my own ethnic, 3.48 3 3 4.38 4 4 0.003

cultural, and racial identity and how others

perceive them

Q22 I can identify assumptions/stereotypes I 3.57 4 3 4.52 5 5 0.003

have of others of different cultures

Q23 My culture influences my judgment of 3.71 4 3 4.62 5 5 0.004

lifestyles, ethics, and values

12
Q24 Cross-cultural situations are 2.71 3 3 2.14 2 1 0.04

uncomfortable to me

Q25 I can identify how culture and society 3.57 4 3 4.57 5 5 0.002

impact patients' lives

Q26 My knowledge of certain cultures is 4.19 4 5 3.38 4 5 0.01

limited

Overall 0.004

4. Discussion and Limitations

Overall, the qualitative survey was completed by 42% of PPC members from our institution and found that the PPC had

positive impacts on medical students’ perception of global medicine, medical education, and their cultural competency. It is

worth noting that the survey includes statements that pertain to medical students’ perceptions and did not evaluate objective

improvement in the aforementioned topics. Whether or not a PPC can be an intervention that is associated with an increased

engagement in global medicine as a career or an improvement in medical school examination scores or cultural competency

assessments remain a gap in the literature.

In an increasingly interconnected world, global health education is more important than ever. While such education is

vital to fostering globally competent healthcare physicians, the number and breadth of global health opportunities at all stages

13
of training are insufficient, especially at the medical student level.18 To address this gap, PPC was created for medical students

to connect with one another, share their culture, learn from each other, and make friendships. The main goals of this PPC are

cultural and medical exposure for medical students as well as to be an additional support resource for them. Because so few

medical students engage in direct global health experiences, a PPC may offer itself to be a method for students to think and

engage in aspects of a global health perspective regardless of certain situational or financial restraints. We suspect that the

inherent bidirectionality to a pen-pal relationship via communication exchange may promote an equality in learning from both

parties which has the potential to address unconscious biases.19 Finally, having a global communication platform for students

during their medical school education may be a significant way to train and inspire students to become aspiring global leaders

and promote health and wellbeing.20-22

It is also necessary to discuss how a PPC that is primarily online is well situated after the COVID-19 pandemic.23

Because many global health electives and study abroad programs for medical students were cancelled during the pandemic,

many students did not receive appropriate experiences internationally.24-26 Online initiatives like this project are less likely to

be disrupted by global events and can be integrated into virtual learning for medical students. Additionally, as medical school

tuition increased during the pandemic, students and medical school facilities would likely appreciate free learning activities

like this which costed nothing to create while otherwise strengthening global ties without the need for travel.27-29 This last point

is particularly advantageous to medical schools in middle and low-income countries but applies to any medical student of low

socioeconomic background.

14
To effectively establish and cultivate a PPC, we have some recommendations. Initiation should commence by reaching

out to the medical student body or a medical school’s student government to gauge interest in PPC participation. Forming a

committed board of medical students is paramount; they can collaborate with their institution's global health department to

leverage existing connections with international medical schools. Recruitment of additional international schools can be

facilitated through personal connections and leveraging social media platforms as well. Crafting an advertising flyer to provide

to international medical schools and their medical students should be informative and eye-catching; tailoring it to an

international medical school or their respective country or culture may also increase its effectiveness. To organize the pen-pal

matching, an accessible application should be designed that gathers basic information including contact information, name,

gender, language, academic year, specialty interests, and personal hobbies. Matching students based on these criteria ensures a

personalized and engaging pen-pal experience. As new members or institutions join, maintaining robust communication among

board members is vital as well as delineating clear responsibilities. Finally, we recommend providing topics for pen-pals to

discuss in order to foster engagement and discourse among members on pertinent healthcare subjects.

This program can also be scaled up or down based on a total number of members and participating international

medical schools. Additionally, it can be modified by extending membership eligibility to residents and fellows or to different

professional career paths including but not limited to nursing and pharmacy. Residents would likely benefit greatly by

participating in such unique, global medical education.19

5. Limitations

15
This survey was limited to first- and second-year students from our institution and not international medical students.

Further research is needed to understand the impact of a PPC on a wider audience. Additionally, response bias may be a factor

in the results, although the survey was voluntary and the average time necessary to complete the survey according to Qualtrics

was less than five minutes. Because a majority of PPC members did not participate, possibly due to lack of interest or other

time commitments, there existed selection, self-selection, and non-response biases which may have impacted the results of the

data. Finally, because the survey asked questions regarding before and after joining, there may exist recall bias as well; future

investigations will need to have a different experimental design to reduce this risk.

Another limitation was that the initial implementation stages of PPC were limited to shareholders from high-income

countries. Medical schools in some middle and low-income countries who had affiliations with our home institution were

invited to participate early on but no response was met until three months after the club was founded and orientation had

already occurred. 5 middle-income countries’ medical students would join subsequently. To abet the lack of early

representation as shareholders, the club frequently messaged all pen-pals concerning ways to improve the experience so that

their voices and concerns could at least be addressed in some fashion. However, at this time, medical students from low-

income countries have not joined the club, with speculation for why being related to difficulties with Internet and mailing

access as well as English illiteracy. The lack of medical students from low-income countries being involved in a PPC is a

significant barrier and remains a gap in implementation; ways to mitigate this inequity may include mail-in invitations as well

as advertisements in more languages than English, among others.

16
6. Conclusion

Altogether, a PPC is a novel extracurricular activity for medical schools and offers a global communication platform

for medical students to learn from others, irrespective of borders and travel costs. Implementing a medical student PPC may

improve medical students’ perception of global health, medical education, and cultural competency.

Acknowledgements
We thank Ayami Hou and the Saitama Medical University English Club faculty as well as Tifany Frazer for their
assistance in helping first create the cross-cultural bridges needed for the International Medical Student Pen-Pal Club to
commence.
Availability of data and materials
The data and materials can be acquired by contacting the corresponding author.

Competing interests
The authors declare that they have no known competing financial interests or personal relationships that could have
appeared to influence the work reported in this paper.

CRediT authorship contribution statement


Max Justin Goodman: Conceptualization; Formal Analysis; Data Curation; Investigation; Methodology; Writing –
Original Draft; Writing – Review & Editing. Jennifer Livschitz: Conceptualization; Investigation; Resources; Writing –
Review & Editing. Ji Won Kim: Conceptualization; Investigation; Resources; Writing – Review & Editing. Megan L.
Schultz: Formal Analysis; Investigation; Methodology; Project Administration; Resources; Supervision; Writing – Review &
Editing.

Ethics approval and consent to participate


Ethics approval was made by the Institutional Review Board #5 of the Medical College of Wisconsin (protocol
00041972). Informed consent process utilized an information letter to subjects immediately prior to participation.

17
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Declaration of interests

☒ The authors declare that they have no known competing financial interests or personal relationships that could have
appeared to influence the work reported in this paper.

☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

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