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DOI: https://doi.org/10.1016/j.glohj.2024.02.004
Reference: GLOHJ 160
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
a
Medical College of Wisconsin, Milwaukee, WI 53226, USA
b
Department of Pediatrics, Division of Emergency Medicine, Medical College of Wisconsin,
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
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
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
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.
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
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
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
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
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.
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
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
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
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
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.
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
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
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
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
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
in medicine
global impact
10
Q10 I believe the medical community 2.33 2 2 3.57 4 4 < 0.001
Q14 I believe I will work with more 3.43 3 3 4.62 5 5 < 0.001
previous generations
medical student
11
Q17 I foresee myself a career in global 2.10 2 1 3.38 4 4 0.002
medicine
States
Q20 I have a good grasp of how different 2.24 2 2 3.90 4 4 < 0.001
perceive them
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
limited
Overall 0.004
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
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
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
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
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.
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:
23