Students whose behaviour causes concern: Am I my brother's keeper?

doi:10.1136/bmj.a2875

Published 29 December 2008, doi:10.1136/bmj.a2875
Cite this as: BMJ 2008;337:a2875

Analysis

Ethical Debate

Students whose behaviour causes concern: Am I my brother’s keeper?

Moses Galukande, lecturer

¹ Makerere University, Kampala, Uganda

mosesg{at}img.co.ug

What should you do when you see a fellow student behaving inappropriately?After a group of students wrote to the BMJ about their experienceduring an elective (doi:10.1136/bmj.a2874), we sought the opinionsof an ethicist (doi:10.1136/bmj.a2882), a dean (doi:10.1136/bmj.a2884),a GMC representative (doi:10.1136/bmj.a2876), and a lecturerfrom an African university

It is increasingly important for future healthcare professionalsto understand and experience health in a global context.¹ ²Many medical schools and colleges in the developed nations havean international elective as part of their training. Increasingnumbers of students opt to spend this time in resource limitedcountries in sub-Saharan Africa, Asia, and South America.

Students’ experiences from such electives are mostly positive³⁴: hands on experience is usually unprecedented; the range ofillness is different; more advanced disease states are encountered.The resources available are mostly basic or absent, making itmore interesting and challenging for students.

The doctors or supervisors under which the students work areoften overwhelmed by clinical and administration work and arenot available to monitor every move of the students. Indeed,the presence of students is often a welcome relief for supervisors,though this is countered by the need to demonstrate, explain,and supervise. This also depends on the competencies of thestudents. Sustainable, round the clock supervision is a challenge.So how can a site that receives students on electives preventthe sort of behaviour described—and what should they doif it happens?

Groundwork

For high quality international experience, systematic preparation,including identification of suitable sites and clear objectivesis essential.³ ⁵ Some sites have developed guidelines on howto handle international elective students. Sites that receivestudents infrequently may not have such guidelines. Sendinginstitutions should therefore consider selecting sites withexperience in handling international electives.

Most students arrive with introductory letters that state thepurpose and objectives of the placements. Some of these areexplicit, but others are not and may not state the competenciesof the students. It is important to have briefing sessions whenstudents arrive to discuss expectations and debriefing sessionsat the end. The level of responsibility of clinical decisionmaking and care should be defined at the outset. Students shouldget permission from the site supervisor to diagnose, prescribe,and perform procedures—and if necessary these should besupervised. If the level of responsibility is exceeded, fellowstudents should have the mandate to communicate this to thesupervisor. Some sites hold regular feedback sessions with students,and this helps provide the confidence, support, and guidancestudents may need.

Most patients cannot tell the difference between qualified doctorsand students. Nametags may help, but only if the patient canread. A verbal introduction through an interpreter is most practical.The ethical standards of seeking consent in its most practicalform should be upheld by all elective students wherever theymay be. Whenever possible, students should be in pairs (as theleast number at a site).Warnings about violation of ethicalnorms should be defined in the briefing session. Any violationsshould be handled as soon as they happen.

Ethical oversight

In the case described the authors owed it to the patients toensure that the unethical behaviour is satisfactorily handled—andthey tried to make this happen. The issue should ideally havebeen handled by an ethics committee at the host site—evenan ad hoc one if one did not already exist. As well as takingany immediate action to protect patients and educate the student,the host site should also report back to the sending institution.

Students are helpful when they go to work in poor areas, butboth the sending institutions and the host sites need to makeclear the ethical rules under which they should behave. Andhosting sites should have procedures for handling unethicalbehaviour.

Competing interests: None declared.

Cite this as: BMJ 2009;338:a2875

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