Clinician's Commentary.

In this issue of Physiotherapy Canada, Crawford et al.1 provide an excellent overview of the growing phenomenon of international clinical education in physical therapy (PT) education programmes in Canada. The increased availability of international clinical internships (ICIs) reflects the “internationalization” of higher education in Canada and beyond,2–4 defined as “an institutional process that in some way internalizes the concept of openness to the world in all the activities and organizational aspects of the university and that may even launch an internal transformation to prepare the university to act more directly on the international or global scene.”2(p.2) This process affects all elements of a university's mission, including teaching and service.2 Demonstrating the effect of internationalization on teaching in PT education programmes, Crawford et al.1 reveal that approximately 4% of graduates from Canadian PT programmes from 1997 through 2007 participated in ICIs and that the number of destination countries multiplied threefold during this time.1 A 2006 study of international service-learning in PT education programmes in Canada and the United States supported the idea that internationalization may have influenced the element of service as well.5 Unlike a traditional clinical internship, service-learning includes an equal focus on community service and student learning.5,6 According to the results of the 2006 survey, 50% of Canadian faculty respondents (n=4) reported offering international service-learning in the previous 10 years, as compared to 28% (n=24) of US survey respondents. However, a significant limitation of the study was that no questions were asked specifically about international clinical education, which means that ICIs may have been included in the service-learning data. Canadian PT education programmes have included international opportunities—whether ICIs, international service-learning, or a combination thereof—in PT curricula in a greater proportion than US programmes. A 2009 survey that specifically investigated the use of international clinical education in US PT education programmes6 found that only 41% (n=46) of US programmes offered international clinical education opportunities to their students,6 as compared to 86% (n=12) of Canadian programmes, as reported by Crawford et al.1 Discussions among members of the Canadian Physiotherapy Association's International Health Division (IHD) and their US colleagues on the American Physical Therapy Association's Cross Cultural and International Special Interest Group (CCISIG) discussion list have revealed some apprehensions about the growth and quality of international service and/or learning opportunities in PT education. A collaborative commentary by IHD member Shaun Cleaver and me summarized many of the concerns shared by IHD and CCISIG members on the list about sending students to international sites, especially in developing countries where power imbalances may place disadvantaged populations at greater risk of unintended harm.7 Echoing views expressed in the medical education literature,8 we called for a critical examination of the complex ethical issues in global health initiatives in PT education. We proposed that PT educators need to (1) develop a broad and ongoing dialogue about ethics, (2) incorporate formal programme evaluation for the protection of students and of the international community partner and its clients, and (3) participate in research in order to guide best practices in international service and/or learning in PT education.7 Dialogue among many IHD and CCISIG members is ongoing on the CCISIG discussion list, but not all physical therapists involved in global health initiatives in PT education are members of this list. Similarly, although Crawford et al.1 and others9,10 have offered recent input on how the PT profession may expand its role and its positive impact in the global health arena, the body of literature is limited, and best practice guidelines have not yet been developed. The need for further in-depth inquiry into PT's role in global health is clear. Canadian programmes are arguably the North American leaders in incorporating ICIs into PT education curricula. No doubt Canadian faculty and researchers will play a key role in future research and the development of best practices. Discussing the internationalization of higher education in Canada, Lemasson stated that “Canadian universities, far from being passive institutions buffeted about in a world beyond their ken or control, have been, and will always strive to be, full players in a broad process to which no one can remain indifferent.”2(p.2) These words are equally true with respect to Canadian PT programmes and their involvement in global health initiatives, including ICIs.