Medical Electives in Resource-Poor Settings: Are We Doing More Harm Than Good?

Review
a peer reviewed article

Abstract

Medical students from around the world desire ever-increasing global health experiences and education, particularly from international medical electives. However, while elective experiences offer a number of potential benefits for students and sending institutions alike, recent evidence suggests that significant practical, social and ethical challenges may result, specifically in resource-poor settings. Ideally, there should be an opportunity for students to engage with elements of a global health program or some form of pre-departure training prior to undertaking a medical elective, with the aim being to engage with social determinants of health, and aspects of service learning. Furthermore, additional research is required to ensure that medical electives do not detract in any way from the pursuit of global health equity and the provision of care in these locations.

Introduction

Interest in international medical electives is burgeoning, with medical students from around the world desiring global health content in their curricula,[1] and greater discovery traversing international socio-cultural borders.[2-8] In the United States, for example, of ninety-six medical schools surveyed, 87% reported availability of international clinical electives, 45% offered preclinical research abroad, and 61% offered international opportunities over school holidays.[9] Here in Australia, international health is often explored in medical schools through compulsory elective terms, which typically occur over a period of 6-8 weeks and may take place in developing countries.[1]

Medical electives may involve experiences in developing nations with pronounced inequities in health and socio-economic development.[1, 10] Such electives have been described in the literature with various terms – from ‘international medical experiences’, ‘global health programs’, ‘medical electives’, and ‘global health experiences’, to the use of other, more controversial definitions, such as “medical voluntourism”, “fly-by medical care”, or “duffel-bag medicine”.[6] While elective experiences offer potential benefits for medical students and sending institutions alike, recent evidence suggests the potential for significant practical and ethical challenges, exacerbating global health inequities.[2-4, 7, 8, 11-14]

Motivations

Certain factors appear to influence student involvement in medical electives. These include altruistic intent, curiosity, having a sense of adventure and hopes of language development, as well as the allure of the opportunity to experience medical practice outside the scope of one’s normal hospital and community setting.[15] Other benefits which may result from experiencing a medical elective include the prospect of improving clinical skills, enabling personal transformation,[12] increasing tropical medicine knowledge, gaining cross-cultural competency, and improving overall confidence, independence and resourcefulness levels.[5]

Benefits

Electives may offer an ideal setting for students to engage with preventative health measures that are utilised around the world.[9] Students can develop a greater understanding of effective resource management and public health strategy implementation, improve their awareness of the social determinants of health, and improve their competency as global health advocates.[5] There is also evidence that students’ increase their willingness to assist underserved populations and levels of social responsibility when they experience medicine in another country, particularly in the developing world.[9, 16]

International medical experiences are also said to facilitate the process of service learning- that is, a structured learning style incorporating community service, experiential learning, as well as adequate preparation and reflection.[9, 17] Consciousness-raising, self-efficacy, and networking capability, are three notable outcomes which may be facilitated by this service learning style.[14]

Institutions hosting medical students may also benefit through improved international partnerships, promoting a potential workforce of international health workers in the future, reciprocal training opportunities for local staff and students to work abroad, equipment donation, and/or potential financial compensation.[5]

Concerns

Nonetheless, medical electives have the potential to cause serious ethical breaches, particularly those resulting from a medical student practising medicine beyond their level of competency.[4] There have been growing concerns that students are utilising elective opportunities to practise skills, enhance their resumes, and to travel to ‘exotic’ places, which can result in vulnerable communities serving as a means for students to merely fulfill selfish ends, as opposed to students serving to address the needs of the community.[7, 14, 16] Some have argued that electives in resource-poor settings are being used as a glorified form of tourism, with no known sustainable benefits for the receiving community.[13] Furthermore, any form of pre-departure training or global health education as a pre-requisite for such an elective is often missing, limited, or narrow in focus.[15]

For the student specifically, there may be health risks involved, substantial costs assumed, the potential for cultural shock, and the likelihood of experiencing ethically-challenging situations, which may include pressure to exceed the student’s role, and also perform procedures without adequate supervision.[5] There may be uncertainty about how best to contribute, working beyond the student’s scope of practice, navigating through unknown medical cultures, and leaving a subsequent gap in care provision when the student returns home. There are various other issues which may result, including failure to obtain truly informed consent due to language, cultural or other barriers, lack of adequate medical knowledge, and a lack of cultural awareness, which can all potentially lead to patient harm.[5]

In the case of elective work in Honduras, for example, medical tourism is considered harmful, entrenching paternalism and inequitable relationships.[14] It is argued that while educational and social benefits may potentially occur, they are not natural consequences of these international experiences, but instead, examples of practical outcomes which must be nurtured and developed through significant education, reflection, and long-term relationship building.[14]

Recommendations

Healthcare practitioners may provide effective input during a short-term medical elective only if they have adequate knowledge, skills and ethical preparation prior to their departure.[18] There must be a shift in focus from the ill-prepared student who faces significant ethical dilemmas in global health on an international medical elective, to greater provision of support by teachers and institutions, prior to such an experience, given they ultimately have a responsibility to provide global health training and awareness of potential challenges.[4, 15, 19, 20]

Students should be given pre-departure training, which may involve reflecting upon potential ethical challenges and discussing issues regarding resource shortages and other cultural or professional differences.[17] There should be an opportunity for students to engage with elements of a global health program prior to their undertaking of a medical elective, with the deliberate aim being to engage with social determinants of health.[7, 12, 13, 15] This may encourage students to question social inequities and shift the experience of a medical elective into a period of transformative learning.[19] This may in turn contribute to social change within the medical realm – which is a vital need for improving global health.[15]

Further, student-led groups, databases and/or forums could be utilised to facilitate conversation, mentoring opportunities, and more personalised pre-departure training. Discussion amongst students who have been on an elective previously may allow for reflection upon these experiences and any challenges faced, as well as the sharing of knowledge with future cohorts who have not yet undertaken their placements.

A global health curriculum would ideally examine ethical issues associated with working with vulnerable populations, and incorporate potential health and personal safety challenges associated with working in resource-poor environments.[3, 4, 20, 21] Experiential data suggests that ethical dilemmas are often part of medical electives and that, in most cases, medical students are not adequately trained to negotiate their way through ethically-troublesome situations.[19] There is a clear necessity for training so that students are able to recognise when to ‘say no’ during such experiences, and are able to learn from challenging situations.[3, 4, 16]

The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) has developed a set of guidelines regarding ethical issues and best practice for global health training. It simultaneously encourages efforts to continuously assess and evaluate the potential benefits and harms of programs being undertaken worldwide.[2] Trainees must understand their personal responsibility during a global health experience, to ensure it is a primarily positive one, and to recognise that their actions and behaviours can have far-reaching long-term implications.[2]

Evidence suggests that one of the most effective ways of teaching skills relating to global health – such as ethical and cultural competency – is through service learning.[17] Service learning incorporation relies on increased academic programming, fostering sustainable hospital partnerships, and encouraging mentorship and reflection for students involved, prior to, during and after their elective experiences.[21] Reflecting on the purpose of their volunteer experience, as well as their capacities and goals, will inform a more culturally-appropriate provision of care abroad, and will allow the student to recognise that good intentions alone are not necessarily sufficient preparation or justification for volunteering or working overseas.[20] Thus, the application of a simulation-based approach to global health ethics education prior to an elective may be useful in dealing with the tensions which exist between service learning and the respect of patient rights and well-being.[17]

Social justice-oriented approaches to service learning, coupled with active critical reflection, also serve viable pedagogical approaches for learning the health advocate role.[10] This means that students should be able to better recognise and address relevant ethical and professional issues, with a greater understanding and appreciation of altruism, social justice, autonomy, and integrity as a result.[10] When a student does undertake an elective in a developing country, such experience leads to higher levels of community health knowledge on return, a greater sense of what it means to be vulnerable, a heightened awareness of the social determinants of health, and an appreciation of the importance of socially responsible approaches for community engagement and health advocacy.[10]

Another important consideration is to enable bi-directional flow of medical students through formal partnerships between university institutions. This can facilitate more positive elective experiences through sustainable relationships and effective involvement in medical care, as well as encouraging an international medical workforce in the future.[5] Along with fostering such connections, skills building in cross-cultural effectiveness, long-term sustainability planning, and local capacity building may help to produce more effective overseas opportunities with meaningful outcomes.[7]

Global Health Programs Abroad

  1. 1. University of Saskatchewan, Canada: the ‘Making the Links’ program provides an opportunity for undergraduate medical students to participate in a local student-led inner-city clinic, a Northern Aboriginal community health initiative and a long-standing service-learning project in Mozambique over two years. This includes the provision of a supplementary clinical curriculum, guided and facilitated reflections, as well as a complementary global health course and language courses.[15]

2. University of British Columbia, Canada: ‘First, Do No Harm: Global Health Initiatives, Ethics and Social Responsibility’ is a piloted series of interactive workshops.[16] Participants analyse case studies exploring different ethical dilemmas. Results have indicated that this approach to learning and reflection is necessary before participating in a global health initiative, and that problem-based learning is effective in teaching students to engage in the process of identifying and addressing ethical issues.[16]

3. University of Arizona, United States: a four-week immersion program undertaken by students prior to an overseas placement covers a range of international health topics.

Discussion

Overall, there is a clear need for individuals who wish to undertake medical electives in the future to reflect upon ethical and best practice guidelines prior to departure,[2] and to subsequently decide whether the experience is right for them.[12] It would also be of benefit to engage in conversation with previous cohorts about their elective experiences, enabling a baseline understanding of any challenges that lie ahead. Pre-departure, students should aim to gain as much contextual knowledge as possible in relation to their host country, including the language, the specific local needs, the details of the participating institution and the work being carried out. Students must recognise the possible ethical consequences of the work being done, and appreciate the potential impact they might have during such an experience.[12, 16]

By incorporating a greater emphasis on learning and on reflection prior to, during, and after an international medical elective experience, students will be better placed to question their values, assumptions, and beliefs to help mitigate the potential harms which their placement may cause.[15] Students must actively question themselves and their surroundings, consider the ways in which healthcare is being delivered, and engage with potential ethical dilemmas and broader social, political and economic concerns underlying their medical provision, without necessarily being engaged in the direct provision of medical care.[11] Indeed, practising beyond one’s capabilities as a medical student is central to the potential harm which may result during an overseas elective in a resource-poor environment, particularly when this is coupled with a lack of adequate supervision.

Education and planning are essential in minimising harm to host communities.  It is necessary to have well-defined objectives and structured clinical experiences in place for students while abroad, which may be promoted by institutions and educators through mandatory global health education to ensure medical electives are carried out to the highest ethical standards.[8, 19] At all stages, electives must be completed in a way that acknowledges any underlying power balances, ethical challenges, and resource differentials to provide community-led efforts which are focused on sustainable development and community health gains.[7]

There is an undeniable need for more global health education to be incorporated into the curriculum for medical students around the world, with rubrics containing detailed expectations and outcomes that are applicable to global health experiences.[21] Educators have a responsibility to their students to facilitate the development of skills in cultural competency, compassion, and public health, as well as encouraging them to understand the potential ethical challenges they may encounter.[9]

Additional qualitative research is required to ensure that the expectations, attitudes, and experiences of healthcare institutions accepting elective students are clearly understood. Recognising the benefits and concerns of elective programs in resource-poor settings in greater depth will ensure that electives do not detract in any way from the pursuit of global health equity and the provision of care in these locations.[6]

Gabrielle Georgiou

Gabrielle is a final-year medical student (VI) at the University of New South Wales. She has a particular interest in global health and medical education.

Acknowledgements

None

Conflict of Interest

None declared

Correspondence

gabbygeorgiou@gmail.com

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