Rethinking your elective

Your elective can be an exciting experience. But have you ever considered it from an ethical perspective? J Jaime Miranda and Sarah Finer offer some tips on making your elective a productive and beneficial experience for all

For many medical students, the elective is a long awaited part of medical school. Scheduled in the final year in nearly all UK medical schools for an average of six to eight weeks,¹ it is a chance to get away before house jobs and provides freedom from other ties.

Most literature about electives has focussed on health safety and personal problems,^2-13 with little focus on the ethics of this experience. Only few people--and worse, few teachers and students--have thought about electives in a broader ethical context. But your responsibilities on elective are possibly more significant; you are ambassadors overseas.

One way process

It is well known, and surprisingly accepted, that most UK medical students do their electives abroad with a significant number going to developing countries in resource-poor settings.

Students who go abroad use the host countries' facilities and teaching resources. In the United Kingdom, people recognise that resources are scarce and that hospitals and universities are functioning under constant constraints--the lack of tutors and teachers is particularly apparent. This is also the case for institutions in poorer countries. But, under the current situation, the elective period is a one-way process, with its benefits and balanced towards those who can afford to go to a foreign institution - namely students from wealthy nations.

Elective costs highlight this imbalance between students from different countries. Student loans and debts do add financial stress. However, students in developed countries are almost certain that they will get a job, and a well paid salary as soon as they finish their training. On the contrary, students from the developing world do not get loans to pursue a career and the costs of their education have to be totally covered by their parents. When they graduate the prospects of getting a job with a reasonable salary may be scant. And, there are few opportunities to access bursaries to give them the opportunity to do their electives in a different context.

Getting hands-on experience

Although this should be your first question, in all honesty, this is not the case for a large number of people--it is more likely to be "where should I go?" Nevertheless, you may want hands-on experience, but have you thought ethically about your role on elective?

At this stage in your career, your experience of practical procedures is likely to be pretty limited. Consider if you would let someone who does not have the experience to do a procedure on your body. Although most people in resource-poor settings need care, this does not mean that they need unqualified or substandard care. People that you will meet during your electives are not guinea pigs for richer students. Doing procedures should come only after you have been able show your competence on your elective, after gaining the confidence of the person responsible for patients' care. If you have proved yourself, you should get informed consent directly from the patient for the procedure, as you would in the United Kingdom.

Logistics

The application process requesting to be considered for a rotation takes some time. You may need to send a letter to an organisation, such as a foreign medical school, a hospital or clinic, or a non-governmental organisation. Despite recent improvements in communication via email, delays still occur and may be frustrating and stressful. You must consider the setting in which these communications are made, however. The health system may be under-resourced. And, although most organisations will try to provide a rapid response to a request, the person dealing with your letter in another country might be one doing the tasks of several workers in institutions of the developed world.

Preparation for the elective

It has been argued elsewhere that a preparation process for the elective period would help to avoid medical tourism.¹⁴ The lack of preparation before the elective as well as the lack of analysis of clear educational objectives and possible benefits for the hosting institution, has lead some people to dub this medical tourism, whereby, the most affluent students can afford to have such experiences.¹⁴

Initiatives that tackle this issue have been reviewed, highlighting the value of exposure to international health education.¹ An essential guide for international health has been produced by the International Health and Medical Education Centre attempting to overcome the lack of training options in this area and is freely available on the web.¹⁵

Another commonly underestimated problem is language. With some exceptions, UK societal norms expect that foreign people will speak English in the United Kingdom, whereas UK people do not necessarily fulfil the same expectations when abroad. The creation of confidence and trust--central to a good doctor-patient relationship--is established through communication. If you do not have a high level of competence in the local language of the country, city, or village you visit, the amount of practical help you can offer will be severely limited. Worse still, if you travel to areas of limited resources under the assumption that you are helping, you may be a burden rather than a help without knowledge of the local language.

On the elective: tutorials and teaching

When you are on the elective you may find yourself faced with ethical dilemmas, such as "Am I prepared to do this procedure?", "Shall I act as a doctor when I am still a student?", or "Should I expect them to translate the ward round discussions just for me?"

If you go to a public hospital, you may notice that supervised tutorials are available only for a limited number of hours during the day. Those paying fees will rightly question the appropriateness of such charges compared with the amount of supervised education they receive. But it is important to remember that doctors in other settings need to do two or three jobs, usually between the public and private sector, to generate a decent income for their families. Neither should you expect preferential treatment when local medical students receive only a limited supervised tutorial time.

You should also bear in mind that to have an active role you need to build a rapport with local staff and adapt to the culture--a process that usually builds up over some time.

STEVE HORRELL/SPL

Are you experienced?

This may be a problem if you want to experience different clinical specialties, or even different cities or countries. An important motive for undertaking an elective abroad is to learn and benefit from it. This intention is a good one, however it is important to realise that electives are almost invariably performed in a unidirectional way, and that these motivations could be perceived as selfishness. One way around this is to think of your elective in a productive and fair way, and consider what you have to share and contribute during the elective period. Before going on elective, research the local needs and attempt to do something, albeit minimal or symbolic, to tackle them. For example, if you devote a few hours to local medical students--also known as peer education--you would be contributing to a two way learning flow. Students in the developing world may feel geographically and academically isolated in resource-poor settings, and travelling students on elective may be able to bridge the divide between developing and developed world by the sharing of knowledge and experience. There are some examples that this works, such as the peer mentoring programme on information and computer technology skills between UK and Tanzanian medical students. In this scheme UK medical students teach computing skills to their host peers as part of their electives.^{16 17}

You may also be expected to do a project during your elective. For an ethical collaboration, you should include a local team in the planning process to define what the local needs are. Instead of doing a project that is only of interest to the students and the tutor at your medical school, you could do something that is of interest to your hosts. In this way, you learn from the locals, but also do something that is needed by the local staff. Students may be able to get involved in research partnerships that cross the north-south divide in academic medicine, helping to do research of local and global relevance and implementing evidence, some tasks that have been given to the new concept of academic medicine.¹⁸

J Jaime Miranda, Wellcome Trust research training fellow, London School of Hygiene and Tropical Medicine

Sarah Finer, senior house officer in medicine, Newham General Hospital, London


studentBMJ 2005;13:45-88 February ISSN 0966-6494

1. Miranda JJ, Yudkin JS, Willott C. Travel Medicine and Infectious Diseases. In: International health electives: Four years of experience. (In press.)
2. Cossar JH, Allardice GM, Whiting B. Health surveillance of Glasgow medical undergraduates pursuing elective studies abroad (1992-1998). J Travel Med 2000;7:314-8.
3. Franklin GF, Gray K, Nathwani D. Provision of drugs for post-exposure prophylaxis of HIV for medical students on overseas electives. J Infect 2001;43:191-4.
4. Gamester CF, Tilzey AJ, Banatvala JE. Medical students' risk of infection with bloodborne viruses at home and abroad: questionnaire survey. BMJ 1999;318:158-60.
5. Green ST. Medical student electives and infectious diseases: risk of hepatitis C is greater than HIV. BMJ 1999;318:1146.
6. Greenwood BM. AIDS and student electives overseas. Lancet 1987;1:1374.
7. Markle WH. Protection against HIV infection for medical trainees outside the United States. Fam Med 1999;31:495-500.
8. Moss PJ, Beeching NJ. Provision of health advice for UK medical students planning to travel overseas for their elective study period: questionnaire survey. BMJ 1999;318:161-2.
9. Tilzey AJ, Banatvala JE. Protection from HIV on electives: questionnaire survey of UK medical schools. BMJ 2002;325:1010-1.
10. Wilkinson D, Symon B. Medical students, their electives, and HIV. BMJ 1999;318:139-40.
11. Banatvala N, Doyal L. Knowing when to say "no" on the student elective. Students going on electives abroad need clinical guidelines. BMJ 1998;316:1404-5.
12. Sheather J, Adams K. Elective ethics. studentBMJ 2001;9:307-8.
13. Torrens JK. Medical students' electives abroad: those who are qualified to help should help. BMJ 1998;317:1528.
14. Miranda JJ, Shiner A. The global health elective: avoiding medical tourism. In: Proceedings of 10th International Congress on Public Health. Brighton: World Federation of Public Health Associations, 2004.
15. Hope R. The elective pack: the medical student's guide to essential international health and development. London: International Health and Medical Education Centre, 2004. www.ihmec.ucl.ac.uk/IntHealthElective/Resource_Pack/index.htm (accessed 4 Jan 2005).
16. Samuel M, Coombes JC, Miranda JJ, Melvin R, Young EJ, Azarmina P. Assessing computer skills in Tanzanian medical students: an elective experience. BMC Pub Health 2004;4:37.
17. Chawla R. Students teaching IT skills bridge digital divide. studentBMJ 2004;12:442.
18. Sewankambo N. Academic medicine and global health responsibilities. BMJ 2004;329:752-3.

       

           

Responses published this month Articles Responses LIFE Rethinking your elective       J Jaime Miranda, Sarah Finer (February 2005) Sandeep Goyal (February 11, 2005) Read this response LIFE Rethinking your elective       J Jaime Miranda, Sarah Finer (February 2005) Claire Proctor (March 31, 2005) Read this response LIFE Rethinking your elective       J Jaime Miranda, Sarah Finer (February 2005) Sandeep Goyal (February 11, 2005)       Intern, Maulana Azad Medical College, New Delhi India mnaprag@sancharnet.in Thanks to J Jaime Miranda and Sarah Finer for this article. I was unable to resist my urge to write a response to this article, maybe because I belong to a developing country & I have experience of working with few students who came here for their electives. As stated in this article people in poor countries are not considerded guniea pigs neither for richer students nor for thier own students. Even there very little if any invasive procedures are performed by medical students. I performed my first venepuncture on day 1 of my internship. Then why should they go to poor countries? Well, they can learn a lot by observing & assisting because patient load is far more in poor countries. People there would be more co-operative and you can examine even sickest of patients, this doesn't mean disrespect of patient's rights. Rather it is the reflection of heavy patient load so that 10 medical students don't have to examine a single patient rather you will always have enough no. of patients that you can examine them in 1:1 ratio. The other thing that you can learn is that how to diagnose & treat when best of laboratory & radiology services may not be available, a great exercise to your "clinical accumen". So next time you plan your elective to a developing nation you don't have to discouraged by lack of "guniea pig" tretment to patient even there, You can learn a lot within limits of ethics & humanity LIFE Rethinking your elective       J Jaime Miranda, Sarah Finer (February 2005) Claire Proctor (March 31, 2005)       President, Medsin-UK president@medsin.org Thank you very much to Sarah and Jaime for this article addressing many of the issues which are important in working abroad not just on your elective. I felt compelled to write and say that we have the solution! IFMSA exchanges solve many of the issues addressed in this article. Medsin-UK is the UK member of the IFMSA and we have been trying to set up the IFMSA exchange program here in the UK for a few years now. We have had some success but have faced many hurdles. We have hundreds of students from all across the globe begging us to offer them an exchange each year. We say our students are taking advantage of the host countries resources - well lets invite a student back here so that the country still has the same number of students to teach. The IFMSA system allows students from all countries to take part in a rotation in another country because they only pay a fee related to the cost of living in their country. So, someone from the UK pays significantly more than someone from Rwanda. The money paid covers the cost of hosting the incoming student - the accommodation and food so that the students do not face expenses when they get there. The system is all run by students who are volunteers and therefore there are not huge administration costs faced by universities offering electives. The logistics of organising the placement are all taken care of by trained students who are experts at running these exchanges (8000 a year are currently happening - only 40 of those involve the UK). Lets give students from the developing countries a chance to improve their job prospects and experience the UK health system and culture. Other issues which exchanges help to address include knowing what students in that country can/should do, language, teaching and working with your peers. Students on exchange join with the students there so do what they do, the teaching is all in English and is set according to what happens in that country - the students are not taking away from the local students. We do not believe that exchanges should take the place of electives - a great deal can be gained from both experiences. An exchange is about undertaking a rotation in a particular topic with defined aims and objectives. There are strict assessment criteria and there will be a high standard of teaching (but you get to experience a new culture and health care system as well). It will also be restricted to 4 weeks (unless you underatake a research project). An elective will be a more general experience of another health care system. Lets get the system working to give more students a chance to experience an exchange! For more information on setting up IFMSA exchanges in your medical school please contact exchange@medsin.org