Tiago Villanueva: Should medical students spend time in resource poor settings?

Tiago_VillanuevaI believe firmly in the importance of medical students and doctors engaging in international experiences, and in the international mobility of doctors. So I decided to go along to a conference on the 11 October, organised by the Medical Schools Council entitled, “Working together for ethical, educational, and safe placements at home and abroad.”

In the United Kingdom, medical students are entitled to carry out an “elective,” which usually comprises spending a few weeks or months towards the end of medical school learning or working in another country’s health system. According to Ben Kummwenda, who works in the University of Dundee’s Responsible Electives Programme, around 6500 students in the UK go on electives every year, and 50% go to resource poor countries. The average time of an elective is around six weeks.

Electives in low and middle income countries raise a series of important ethical problems, and students often lack awareness of them. This is particularly important when it’s mostly the students who reap the benefits of these experiences, rather than the host countries. Even more worrying are the situations where medical students can potentially cause harm. Julian Sheather said we must ask ourselves what students really get out of these experiences. He mentioned the case of a student who carried out procedures he was not qualified to do during an elective in a sub-Saharan African country, saying he “could get away with it.” It is also important not to forget that medical students can be exposed to dramatic situations like assessing whether prisoners are fit to be punished. Medical students often lack knowledge on how to deal with ethical dilemmas while overseas as well as support on how to organise their own elective.

Electives should be, above all, rewarding learning experiences for students rather than opportunities for students to do things for which they’re not qualified.

Ben Kummwenda carried out a series of semi-structured interviews with staff at elective host sites in three sub-Saharan African countries and said that hosts are usually keen to teach, but do not expect much from elective students, and have no tolerance for those students coming for “medical tourism.” He added that hosts want students from overseas to spend at least six weeks in the host country, and they prefer that students do not come at all if they’re coming for a shorter period. Moreover, he said that the hosts want overseas students that understand about the host country’s “social structure, way of life, and ideologies.”

Maysoon Dahab, head of  global health at the Royal Society of Medicine, described an upcoming programme for global health fellows to complete research projects in five to seven beacon sites. Two placements have been secured so far, and funding is being explored for 20 additional placements in 2014/15. She added that these electives have to be needs based, incorporate reciprocity, consider effects to health systems, include a research component, and be appropriately evaluated. She also stressed the importance of students preparing well for this experience, and they can do that by engaging in online modules and a training day. Students will have to complete pre- and post-elective surveys, follow-up surveys at six, 24, and 48 months after the elective, as well as disseminate their research findings. There are also joint plans with some Royal Colleges to develop databases mapping potential host organisations.

Among other benefits, electives are a great opportunity for medical students to broaden their horizons by learning different healthcare systems and what the needs of patients in resource poor settings are, as well as come in to contact with diseases and health problems they are unlikely to come in to contact with back home. Nevertheless, an elective is something that needs to be done properly, and from what I’ve heard in this conference, the UK seems to be taking steps in the right direction.

Tiago Villanueva is the editorial registrar, BMJ.