Today's medical educators readily acknowledge the importance of students acquiring facility in global health issues, cross-cultural skills and volunteer service. Thus, international training has become an expectation in medical school. In addition, many students are fascinated with images of medical missions, and would dearly like to taste such an experience. It is also these very students who will be most likely to integrate medical missions into their professional careers.

Significant obstacles prevent well-meaning students and residents from completing international electives. These include funding the costs, accrediting of the learning experience, and locating a quality preceptor. The Institute for International Medicine was established to overcome these barriers and to assure quality training. INMED provides electives at 47 medical mission sites in 22 developing countries, as well as a comprehensive didactic curriculum in international medicine."

I applaud the enthusiasm of beginning students who wish to explore the world of medical missions. Little could be more fascinating! But I also caution that there are significant obstacles to doing such an elective too early. Like a musician who is assigned a solo, having a certain skill level is essential so that the performance is a triumph and not a catastrophe.

Most medical missions sites are stretched in every dimension, and they do not have medical personnel with ample time to instruct beginning students. As a consequent, such students often report feeling embarrassed at their lack of clinical skills, and their mentors express frustration that they can't provide adequate mentoring. I experienced this scenario first hand as a junior medical student on elective at Honduras' Clinical Evangelica Morava. This hospital performed many deliveries, but I had yet to complete my core obstetrics training. I felt so disappointed that I was unable to participate in this important component of the work.

Medical students do best if they schedule their international electives after passing Step One and completing their core clinical training in internal medicine, pediatrics, OB/GYN, and surgery. In the meantime, I would recommend taking advantage of non-medical international service-learning opportunities. And, I strongly encourage students to expand their understanding of international medicine by attending the Exploring Medical Missions Conference.

The short answer is, choose the specialty that most interests you. There exists the misconception that only primary care specialties are appropriate for medical missions. While it is indeed true that the greatest needs in developing nations are in public health and primary care, there is also an important role for specialists. Ophthalmologists, orthopedists, plastic surgeons, for example, all have unique talents to offer people in low-resource nations. Teaching opportunities - better suited for specialists - are constantly expanding in developing nations and offer influential positions to multiply one's skills among nationals. There also is a real possibility that at some point you will practice back home. For all these reasons, medical students do better when they pursue specialties in which they are genuinely interested, and then apply these skills to the context of medical missions.

The diseases of poverty that plague low-resource nations are almost entirely preventable, and effective interventions require community-wide and often nation-wide responses. For both of these reasons, any physician in international service should draw upon skills in public health. However, such skills need not be advanced to be very effective. Proper application of the principles of prevention, cost-effectiveness and health leadership acquired in medical school can yield enormous results.

For these reasons, I do not routinely recommend physicians pursue a degree in public health. Formal training in public health is more appropriate for those who intend to be leaders and educators in the field. Personally, I began my career by serving in Angola following family medicine residency, and did not complete a public health degree until after returning to the United States. In Angola, I led a very basic but effective community health project, and in retrospect I don't believe I would have developed the Angola project any differently.

Only for those genuinely interested in surgery. Many remarkable physicians in international service are surgeons. But there is an important role for a variety of specialists. What's more, surgical diseases and procedures in low-resource communities frequently demand skills far different from that learned in a North American-style surgical residency. Often, the very best surgical training is to be mentored by a colleague on site who already has surgical experience in that particular setting.

Debt related to medical school is a heavy burden and must be eliminated before moving to another nation. Consider the following advice:

• Keep loans to an absolute minimum. This often means renting instead of buying a home or driving a recycled car when peers are buying new ones.
• Following residency, plan a period of time to pay back loans prior to departure and to save up a financial reserve. It may seem like a "delay," but there are virtues to every season of life.
• Consider a loan repayment program connected with your service. Project MedSend, for example, offers to pay back student loans in return for international service.
• Consider employment with a firm that stations you in a developing nation. While working hours will likely be in service of the firm, the income earned may eliminate financial concerns, and free time can be used to serve local people who are marginalized.

Medical training is a very long process. In the meantime, take full advantage of your opportunities to grow as a person and to develop your relationships. Connect with God, engage your family and friends develop meaningful hobbies, and serve people in the context of your community today.