It is the first day of your elective. You are on your own on a strange ward. In front of you is your first patient. She seems like a nice woman but you have just been asked to certify that she is “fit to be flogged.” Elsewhere in the hospital your new colleagues are doing the same thing, without batting an eyelid. What do you do? Or perhaps you have been asked to perform a medical procedure. You have never done it before. You have a sick patient but you have no confidence. At home you would have asked your senior—you would have had to—but here you are alone. What do you do? These may sound like horror stories but they are not. They are real life examples and they happened recently to medical students on their electives. What would you do if they happened to you?

For most medical students the elective is the highlight of their clinical training. Free to travel to remote places, exposed to fascinating and unfamiliar cultures, to new health systems, and to diseases they never have seen before, the elective can be a rich and rewarding experience. It can encourage self reliance, professional confidence, and personal insight. Well organised and supported, the elective can rekindle the altruism that first led students into medicine. For many it encourages a lifelong interest in developing countries, and their passions and problems, and many doctors will return later in their careers. Unfortunately, not all electives are as happy.

Students often find themselves confused about their role, as do their new colleagues. Given the limited resources available in many developing countries, and the reputation of British medical training, students often feel under pressure to act as doctors. Students may also feel that, given the scale of the health problems they are confronted with, they are justified in assuming the role of qualified doctors.1 And this is when ethical difficulties begin. Students have a duty, wherever they are in the world, to make sure that their patients know that they are student doctors, not qualified doctors. Their patients, likewise, also have the right not to participate in medical education.

Medical students who carry out procedures for which they are inadequately trained or supervised, or for which they have not secured consent, are abusing their patients. The General Medical Council makes this clear: “In providing care you must recognise and work within the limits of your professional competence.”2

Cultural sensitivities notwithstanding, patients in developing countries have exactly the same rights as patients in the West. They are not guinea pigs and are not to be practised on. The limitations of healthcare systems are not overcome by the good intentions of students. If in doubt seek advice. Codes of practice and professional boundaries that have been established at home apply abroad.

In truth, however, students on electives are more likely to witness human rights abuses than perpetrate them, particularly where countries are in political turmoil. It has been alleged, for example, that doctors were involved in genocide in Rwanda. Given that the medical profession is often rigidly hierarchical, and that students are unfamiliar with the system, it may be difficult to speak out. Students may also feel they are too junior to complain. In reality, however, as outsiders with fresh eyes and a clear sense of right and wrong, students really can be influential. They can challenge those who have become stagnant and institutionalised in their habits, those who have lost touch with their codes of conduct. It should also be said, of course, that the abuse of human rights is not reserved for developing countries. Students may well see doctors behaving unethically at home. Here again, experience gained abroad can increase a student's confidence, giving them the strength to speak up.

So what of the examples we started with? Well the first student signed the form and the patient was fit to be flogged. Wrong footed by the upheaval she simply went along with the other doctors. She now bitterly regrets her involvement. The second student was traumatised by his experiences. Working with a doctor who had sole responsibility for the health of an entire island, he was expected to anaesthetise patients while his colleague operated. One night while on the labour ward twins arrived prematurely. They emerged floppy and blue and they were not breathing. He struggled to intubate both babies. On the one hand he knew he was not sufficiently experienced to intubate the babies quickly, yet if he did nothing, they would die. It was a harrowing experience and to this day he wonders what happened to them. This is the sort of ethical dilemma students face in countries with under resourced healthcare systems. It was a poorly planned and ill supervised elective and he regrets it.

However, do not let these stories put you off. Just use them as a guide. The elective experience can be positive and educational. Students can gain first hand experience of the big difference that medicine can make to people's lives. For the majority of students the elective remains a powerful influence throughout their working lives, reinforcing their sense of medicine as a vocation. It can expose students to radically different ways of looking at the world. It can challenge students to reflect on their own value systems—their own professional ethics—and enable them to put the shortcomings of the British health system in context. In situations of great adversity students can witness acts of self sacrifice that humble them.

Plan for your elective and plan it well. Look forward to it. But be clear of your role and your boundaries. This way it could well play a key part in your personal and professional development.