Current Practices in Hosting Non-US Pharmacy Students at US Pharmacy Schools in Experiential Clerkships

Student Selection Criteria.

Selection criteria for U.S. students attending global/international rotations are expounded upon in Dornblaser and colleagues’ article on preceptor and student considerations.² While selection criteria are generally similar, additional considerations are necessary for a non-U.S. student entering the United States. Currently, international clearinghouses for bilateral student exchanges exist within pharmacy organizations. Among these are the International Pharmaceutical Sciences’ Federation³ and Christian Pharmacists Fellowship International.⁴ Participating in a consortium of universities and countries for processing and screening applicants provides the advantage of a standardized approach and shared resources. Institution-to-institution exchanges typically have more tailored selection criteria.

Generally, the selection criteria are regulated by the home (sending) institution in agreement with the host institution and vary from country to country and institution to institution. Among the criteria to consider is adaptability to the United States, familiarity with the U.S. health system, knowledge (clinical or research) as it pertains to the rotation-specific goals and integration of the experience into long-term career goals. Many of these criteria may be reviewed in a formal statement of interest or during an interview process.

Students engaging in the exchange should understand that the experience is for a pre-specified duration, as defined by the limits of the visa granted to them. Students should also exhibit both personal and professional attributes that will ensure a positive educational outcome for the experience. Maturity, adaptability, emotional stability and cultural sensitivity related to the American culture are key from a personal perspective. Professionally, students should have demonstrated good academic standing and achievements, a responsible attitude and good communication skills. For many students, a U.S- based experiential rotation may be their first, and only, experience in the U.S. Additionally, financial feasibility is an important consideration with interested applicants.

The assessment of English language proficiency (ELP) of non-native English speaking students varies from no testing at all, to extensive testing using a combination of methods. Factors influencing the requirement of ELP testing may be related to the length of the educational program, or the goals of the learners and/or the clerkship. Longer stays, such as full-time educational programs or residencies provide the greatest examples of ELP testing, as do programs offering shorter visits, such as elective clinical rotations or exchanges.^5-8 The rationale cited for requiring ELP testing is that English proficiency provides not only a more positive experience overall, but also allows for successful integration of visiting students into the U.S. health care setting, and to better meet learning objectives.^9,10

Methods to assess ELP include both standardized and non-standardized methods. The Test of English as a Foreign Language (TOEFL) is most commonly used in U.S. programs. While many health care education articles cite usage of the computer-based TOEFL, it is important to note that the TOEFL is now only offered via its updated internet-based test (iBT) or paper-based test, for those test-takers without internet access.¹⁰ Minimum required scores may also vary according to the needs of the program. For example, one nursing exchange program notes that their required score for the former computer-based test was lower than scores required for college entrance.¹¹ As a reference point for the iBT, the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences currently requires a minimum composite iBT score of 89 and preferred reading, writing, listening and speaking sub-section scores for applicants to their full-time international trained PharmD program.^12,13

Health care education programs have used the TOEFL alone for testing ELP, or in combination with other methods, such as a live (in person, telephone or web-based conferencing) interviews.^10,13 Many students outside the U.S. may have taken the International English Language Testing System (IELTS) test, another well-recognized standardized exam.¹⁴ Comparisons of the TOEFL iBT and IELTS scores are provided in Table 1. For example, a TOEFL iBT composite score of 89 is approximately equal to an IELTS composite score of 6.5. While the testing for ELP varies among programs, the methods of assessment are varied allowing for testing to meet differing needs and expectations. Scoring of the different types of tests vary, so the reader is encouraged to seek online equivalency charts when comparing methods.¹² The American Council on the Teaching of Foreign Languages (ACTFL) has been used as a pharmacy school entrance exam for some PharmD programs and as a supplement to other testing measures.¹⁵ While it could be used to assess students coming to the U.S. for clinical rotations, it requires greater resources in the form of an ACTFL-trained interviewer and a live (in person or telephone) interview of at least 30 minutes. Its use has not been commonly reported in the health care education setting.¹³

Non-standardized methods of testing are also commonly used to assess ELP, including live interviews by telephone or web-based conferencing. Interviews may be used as a sole method of assessment, in place of a TOEFL or in combination with standardized exams.^8,10,13 Host schools may also choose to forego ELP testing for those students visiting the U.S. from schools where the language of instruction is English.^10,13 In such cases, it is common for the U.S. school to require an official transcript or formal letter from the home institution, such as from the dean or registrar, stating the language of instruction is English.¹³

Pre-Departure Orientation.

A key aspect to any successful student exchange is the pre-departure orientation. Students should be required to attend a mandatory orientation process to address the educational, cultural and personal aspects of the experience.¹⁷ Specific attention should be paid to legal requirements for entering the U.S. and acting within the limitations of the entry visa. Addressing the importance of adherence to U.S. laws and customs is the framework for many online pre-entry orientations to the U.S. Orientation activities should include an explicit and detailed communication of rotation expectations.

As further details on the agreement are discussed and put in writing, research into the visiting institutions will assist in determining how much orientation will be needed for the students as they rotate through the U.S. health care system. To minimize surprises, a preparation sheet or packet with web links, detailing the unique aspects of the host institution, could benefit visiting students. This could also be used to identify specific immunization requirements. In general, the information shared should be tailored to the visitor’s experience of the U.S. and the health care system.

Importantly, an information packet detailing the unique aspects of the visiting student’s country is also helpful for the hosts. The Institute of International Education and Education USA (https://educationusa.state.gov) provides fact sheets which include topics such as economics, culture, religion, safety, education, beliefs, health issues, and sample pre-departure orientations for international students attending experiences in the United States.¹⁸ Site-specific orientation topics include city orientation, key aspects of host institution, expectations, safety tips, professional behavior, cultural issues including identifying and managing culture shock, and dress code. The host institution should be consulted about all the above aspects as they relate to the U.S. in general but also in the state and city in which the student will reside.

Various orientation programs for international students are offered at both the university and college level. Successful orientation activities may be faculty led, student led or through a formalized program with the office of international students. Programs offered via the university provide the student opportunities to be introduced to student life as well as network with other international students. A college- and rotation-specific orientation should follow the general pre-departure orientation.

Financial.

Reciprocity of exchanges with cost structures providing for faculty precepting in-kind reduces the financial burden on the international student and the home institution. U.S.-based experiences can often be cost prohibitive, thus limiting the number of students who may participate. Arif and colleagues conducted a survey among U.S. institutions hosting international students in which they identified several barriers with financial barriers cited most often (75%).¹⁹ Several means to circumvent the cost include local fundraising as well as host institution fundraising/sponsorship. Formal Memorandum of Understanding’s (MoU) often include a section on expected responsibilities, both in terms of educational objectives as well as financial cost sharing where applicable. Financial considerations should be noted when deciding upon housing, transportation, reciprocity of fees and even a food budget. Financial limitations, or even a more liberal financial allowance, should not be the driving force when deciding on the core elements any successful exchange can offer.

Health Issues.

Alsharif and colleagues described in detail the health issues, including the need to designate an individual as an emergency contact person at both the home and host institution.¹ A health screen to ensure the student is capable of completing the rotation as well as a record of all additional immunizations, as required for educational and health care facilities, should be completed months in advance of the anticipated travel. Necessary prescription medications should be acquired prior to travel and comfort items should be packed and appropriately labeled. Personal prescription medication must be labeled and accompanied by the physician prescription even for those acquired in countries where prescriptions are not necessary. Such documentation or a letter from the provider may be required at the point of entry into the U.S. and should be available in the student’s carry-on luggage.

Emergency Issues.

As part of the orientation, students should be provided with specific information on how to obtain help in an emergency situation. A contact person in the home and host institutions should be identified with contact information. Standard emergency procedures in the host country should also be explained. Orientation to emergency services, such as calling 911 and locations of the nearest hospital or police station should be part of the orientation process. Many U.S. institutions have emergency notifications via text messaging and email alert systems.

Recommendations.

Students traveling to the U.S. for research or educational experiences should be adequately prepared by the home institution prior to departure. Considerations for student preparedness include orientation to U.S. laws, visa requirements and culture. Students should be oriented to the learning objectives of the experience and should understand their roles and responsibilities as they pertain to the health care environment and the college/university environment. This requires appropriate orientation to the city, college, university and health institutions that the student will interact with during the rotations. In order for successful interactions to take place, host institutions should consider assessment of English language skills using one of the many options available. Lastly, practical issues such as financing, health care records, and points of emergency contact should be reviewed and finalized prior to departure.

Memorandum of Understanding (MoU).

Details of establishing an MoU are described by Alsharif and colleagues.¹ An MoU signing is typical at the university level and should be vetted by legal counsel. Usually, the MoU is written in general terms to cover the broad areas of collaboration. Signing of the MoU will need to follow the specific host institution guidelines. If one does not exist, consider involving the dean of the school and president/chancellor of the institution or his/her designate from academic affairs at a minimum (a sample process is provided in Appendix 1).

The affiliation agreement typically includes expectations around the partnership between two parties. It serves as a reference should a situation arise with the visiting student and provides documentation on what the parties are agreeing to do in addition to their individual responsibilities for the duration of the experience. Such documentation covers the following: who is responsible for housing; student insurance: health and malpractice; liability in case of injury; general communication details; immunization expectations; duration of the agreement; terms for terminating the agreement and what to do if one of the parties defaults on the agreement. It is imperative to involve key faculty and staff to ensure communication and institutional buy-in to the program. Communicating the process details to a broader spectrum of school administrators, faculty and students is also essential to allow broader input.

Administrative Support Structure.

Generally, to host international students, sufficient administrative support is required to ensure a successful exchange. A lead administrator who communicates the vision and builds and maintains the necessary alliances with international colleagues and local stakeholders is critical. This individual also oversees the execution of the program and abides by any legal stipulations for the university or state in which he or she resides. Additionally, an academic coordinator or program manager dedicated to keep track of the communications and the paperwork is very helpful to the smooth running of the program. The number of full-time equivalents also depends on whether there is a centralized process for all international students at the school, if it is handled at the campus level, or if it is handled in the individual department housing the academic program. The type of employee and the qualifications/expertise he or she brings to the position is dependent on the size of the program, documentation, communication, assessment, and planning needs of the institution. Programs are encouraged to seek counsel from institutions with similar purpose, structure and size to determine what works.

Scope of Practice and Boards of Pharmacy.

Prior to embarking on any exchange to host international students, the state board of pharmacy website must be reviewed. The majority of boards of pharmacy do not allow clinical practice without a formal intern license. Intern licenses are often issued based upon degree evaluation for foreign pharmacy graduates or participation in an ACPE-accredited school or college of pharmacy. Activities of pharmacy interns are carefully regulated and require direct pharmacist supervision. Opportunities for intern-exemption exist if the international student is deemed a “pharmacy assistant” or if citing participation in the clinical setting is highly controlled. If the student is invited as a “clinical observer,” then the terminology implies that the student will not be providing direct patient care. Like all other interns and students, all activities occur directly under the supervision of a clinical preceptor. If the intent of the exchange is training in research or instruction and does not involve patient care activities, then the activities of the student fall solely under the auspices of the MoU and limitations of the issued visa.

Visas.

There are various types of visa offered by the U.S. Department of State for short- and long-term exchange students (Table 2). For the purpose of this paper, students attending an exchange of three months or less will be applying for a “Nonimmigrant Visa.” Under this category, students may obtain a B1 or B2 visa. The B1 visa (business visa) allows individuals to participate in scientific or educational conferences, attend as a non-paid speaker or non-paid researcher, or participate in a training program that is not designed to provide employment. The terminology is broad enough for the student to participate in a host of activities that can successfully be completed during a short stay. In contrast, the B-2 visa (tourism and visit visa) does not allow for the training model outlined in the B-1 visa and is not recommended for training or research based visits. Formal study and employment are not permitted under the B-1 or B-2 visa. Therefore, wording in the letter of invitation must include that the student will not be receiving credit from the host institution toward their degree requirements, as this would require a J-1 visa.²⁰

If credit is earned toward a degree, the J-1 visa allows students whose stay is being paid by the U.S. government, the home government, an international organization that the U.S. is a member institute or any funding that is not from a personal source. This allows students to enroll in degree and non-degree programs. Students may also engage in part-time employment while under this visa, such as university-funded research. It also covers the necessary requirements for paid or unpaid internships at host U.S. institutions. Most MoUs cover the necessary wording to have a student be sponsored under a J-1 visa. The application process for visas is generally lengthy and the J-1 visa is more lengthy than the B-1 visa and for most countries requires several months prior to the date of the exchange to be approved. The H-3 visa makes special reference to advanced training but excludes medical training specifically. The F-1 visa is obtained for those non-U.S. students enrolled full-time in a U.S.-based program. H-1 visas are intended for employment of foreign workers in specialized fields and should not be used for study or training exchanges. Visa information is better understood by meeting with the immigration or international student’s officer for the campus. Visas can take a significant amount of time to attain and may be for only a limited time once granted, so careful attention must be paid to starting the process early (up to six months prior to the visit) and being sure the visa is valid for the entire length of the experience.

Logistics.

Communication.

Given the potential differences in cultural expectations and communication preferences, it is critical that the mode of communication with the student is explained ahead of time. Meeting with the rotation preceptor to discuss expectations is also helpful for specifics of the rotation experience. For example, the following is a sample list of questions the visiting student should have an understanding of before the rotation experience: What is the appropriate chain of command (in the pharmacy, lab or rounds)?; What is the role of technicians in the U.S.?; When a problem or conflict situation arises, what should be done and who is the first to be called?; What is the preferred mode of communication for the (preceptor, administrator and other key contacts and support staff during the experience)?; When is the best time to use email, phone, texting, pager?; and What is the best way to reach the visiting student or educator?

Cultural Competence and Immersion.

Students coming to the U.S. should undergo training regarding cultural differences either prior to arriving or shortly upon arrival. Topics to cover may include not only issues related to the local area, language, and differences in the general U.S. health care system, but also regarding caring for patients in the U.S.²¹ Visiting students should be aware of the diversity of patients in the U.S. from a variety of factors, such as diversity of racial/ethnic groups and religions. Understanding that there may be great variability in common clinical conditions of varying racial/ethnic groups seen in the U.S., as well as how U.S. patients view health care, may impact the visiting students’ understanding of the delivery of care practiced or witnessed on their visit to the U.S.^22,23

Institutions hosting international students should also be mindful of the cultural adjustment phase of the visiting students. The “U Curve of Cultural Adjustment” is frequently cited when describing the adjustment of visitors to a new country.²⁴ For example, the “honeymoon” stage of immersion in a new culture may occur within the first few months of the visit, followed by hostility or cultural shock at three to nine months, and on to acceptance. While the phases and timing may vary, it is important to be aware of this situation and how it may impact the visit.

A recent article by Oh and colleagues noted that the local information needs of international students vary over time.²⁵ For those students new to the U.S., information most helpful was related to survival, such as location of the international student office, bank and mobile phone/electronics stores. The longer international students were in the U.S., needs changed to those toward recreation. In addition, a decreased sense of inclusion can be an impediment to student learning.^26,27 Consideration of these needs should be considered when hosting international students.

Cultural sensitivity and preparedness of U.S. preceptors will not guarantee a positive experience for visiting students but may be critical in responding to perceived negative experiences. This may also help prevent misunderstandings in the educational experience of visiting students. An understanding of the visiting student’s culture may help preceptors lead discussions that explore the norms of the U.S.-based site and help visiting students move toward the acceptance stage of cultural adjustment.

Cultural immersion activities organized by the host site are an excellent mechanism to maximize the U.S. rotation experience. Examples of successful immersion activities are student organization social gathering, home visits, local cultural excursions, local conferences and meetings. These cultural exposure activities should be granted a level of importance in the schedule. Pre-structured activities also should not overcloud responsible and self-directed exploration by the student.

Site Details.

A detailed description of the site (or sites) in which the student is expected to complete his or her experiences should be shared. Additional information should include pertinent policies and procedures for visiting students, forms to be signed and any formal mandatory orientation. Activities the student will participate in, grading categories and the corresponding evaluation criteria for the experience should be shared upfront. If the student will be learning alongside a U.S. student, it is important to explain how the experience will go and if there will be slight differences in activities and why. Ideally, a learning management system with capabilities to post relevant documents (such as syllabi, evaluation tools, list of activities and policies and procedures) ahead of time, with specific instructions, so the student can take the time to browse and note areas for clarification is desirable.

Preceptor Training and Qualifications.

As outlined by Dornblaser and colleagues, preceptors involved in training international students should possess all necessary qualifications to precept PharmD students.² In addition, the preceptor should undergo cultural competence training in general as well as specific to the area of the world from which the student is coming. Ongoing training should be done at the beginning of each new exchange cycle.

Practice Model Considerations.

Depending on the practice model at the home institution, the specific goals of the syllabus may need to be modified depending on whether the student comes from a more, or less, regulated country. Much of the developing world has more liberal policies toward medication distribution and management. A U.S.-based experience may be used to expose the student to opportunities for pharmacists to maximize pharmacovigilance and open discussions regarding the regulatory process and structure. If a student comes from a more regulated country, like the U.S., the rotation should offer opportunities on discussions for exchange of ideas on how pharmacists maximize and expand on their professional contributions in the existing health care model. It also provides opportunities for both the host institution and the international exchange student to share what models have been and have not been successful.

Opportunities for mixed model approaches also exist. The primary goal of an exchange is a reciprocal, bilateral exchange of ideas and practice methods. Mixing students from different areas of the world and different practice models may create an additional layer of complexity, but the benefit of diversity of viewpoints may assist in overcoming this.