Table 1 20 possible learning outcomes relevant to an IHE described in pre-post IHE reports. Ordered according to related domains (Roy et al. [12]) and GH competencies (Battat et al. [18])

Cultural development

Scientific and societal consequences of global change

‘’Nicaragua is still developing a lot and I am curious [to find out] how this affects the health care system, what strengths and weaknesses are, and how people are trying to improve it as well as trying to see it from the perspective of the local population.’’

Appreciate contrasts in healthcare delivery systems and expectations

“Sometimes I felt unprepared and I was very surprised about the course of events: the limited resources and treatments, the dismissal of mental illnesses, belief in herbal medicine … but you cannot prepare for this and you learn to deal with it during the experience you gain”

Understand healthcare disparities between countries

‘’It added a lot to my personal development. I never worked in a developing country. It gave me a good insight into how to cope with less materials and medicines. The healthcare system in the Netherlands is well developed, and we can be proud about it. It was sometimes hard to see patients who couldn’t afford any treatment and there are still women dying of bleeding after pregnancy. This was shocking to see sometimes, but I would never have such an experience in the Netherlands.’’

Primary healthcare within diverse cultural settings

‘’Learn from their culture and the way they function as a nurse or doctor. I also want to learn to handle cultural or religious differences in habits, opinions and interactions, both in a general way and in a medical setting.’’

Skills to better interface with different populations, cultures and healthcare systems

‘’I learned how poverty and traditional medicine influence access to regular health care; the importance of proper health education on the decision-making of patients; a different culture with a different mindset [sic] about health and illness; dealing with death, as relatively many patients died of their illness.”

Employability and career

An understanding of immigrant health

“We also went to the nearby refugee camp a few times, where we helped out at the clinic and saw our own patients.’’

An understanding of travel medicine

“Learned a lot about tropical diseases such as malaria, TB and HIV. For example, I experienced myself how patients with these diseases present themselves. I learned about the treatment, but also about possible additional complications and comorbidities [sic]. I would never have been able to learn this in the Netherlands, given that it does not occur very often. Even if I start working in the Netherlands, this is very relevant for me as a future doctor’’

Cost consciousness; using physical diagnosis without high technological support

‘’The importance of the patient’s economic status and trying to reduce expenses showed me a new perspective, which I will always keep in the back of my mind. Their resourcefulness in some cases to reduce costs and help even the poorest patients is astonishing.’’

Taking adequate patient histories and physical examination in resource poor settings

‘’My physical examination and clinical reasoning skills improved, both because it became one of the most important tools to rely on and because of the far advanced diseases I have seen.’’

Training of (new) practical skills^a

‘’For me the one thing that stands out is that I was able to see about twenty vaginal deliveries, plus another twenty caesarean sections. I would have never been able to see this in any Dutch hospital as a trainee.’’

Career perspective^a

‘’Prior to this internship, I had no ambitions to work abroad. This internship taught me that foreign healthcare has become more accessible to me. After this internship, the plan arose to go to Surinam for six months after completing my studies to gain work experience.’’

Personal development

Skills to better interface with different populations, cultures and healthcare systems

“During the preparation of our recommendations, we had to take into account the interests of all different parties….the financial and ethical aspects of this project also deserved the necessary attention. In addition, we had to take into account the local culture and vision of the local population in order to determine where the profit could be made.’’

An understanding of the burden of global disease

“It has not changed my plans for the future, but I think it complements being a doctor and I now have a better understanding of why, for example, HIV is still such a big problem and that it is really not that easy to deal with.’’

Develop a sense of social responsibility

‘’I know we cannot solve all the problems there, but I think we can help the community in Uganda with our knowledge.’’

Evolving global governance issues

‘’A lot of things were not what they seemed or brought in a way to favor [sic] one opinion over the other. This made me realize very well that things are not always what they seem and that some people high up in the governments might be really bad.’’

(Learning) to set personal boundaries^a

‘’Intern doctors in Africa have a lot more responsibilities in the hospital compared to Dutch trainees, it is very important as a Dutch medical student to show your boundaries in treating the patients.’’

Creativity in problem solving^a

‘’It gives you great experience in improvising, but in a safe, medical way. A lot of medication here is not available so you have to really think what the next step is instead of just reading what treatment is supposed to be given and give it. The same goes for equipment, e.g. how to stabilize complicated fractures, how to keep a leg up in the air if the bed cannot be moved upwards, how to clean and dress wounds with only the normal gausses we have here.’’

Reflection on own behavior (at home and/or during elective)^a

“It put my feet back on the ground and made me realize that living the way we live is not the standard there, but how happy and cheerful people are without everything we have … I've learned not to just take things for granted.’’

Gain confidence in own (medical) actions^a

‘’I really learned to interpret nonverbal communication and focus on the way the patient was looking: ill-looking, fair, stable, pallor etc. thereby I learned to trust more on clinical judgment and use less advanced diagnostics, simply because it was not always possible there.’’

Growth in cultural awareness^a

‘’The internship also gave me a different perspective of the world. Hard working is important in the Dutch culture, but in the African culture it is more about communication/community and family. There is more in the world than working. This was an eye-opener for me.’’