Knowing when to say “no” on the student elective
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7142.1404 (Published 09 May 1998) Cite this as: BMJ 1998;316:1404
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Whilst I accept much of what Banatlava and Doyle say in their editorial on student electives I feel that their advice will come across as pompous and detached rather than of practical value.
No-one disputes that medical students should not pretend to be qualified and "practising on the natives" is unacceptable. However it is inevitable that the degree of supervision of students in developing countries will bear no comparison to the UK. For some students this will mean following around a qualified doctor and merely observing what goes on. Many students however will be more than capable of assessing and treating illness if given adequate initial supervision and advice. What would be the consequence of a blanket "no" from the student? Patients would eventually be seen by someone qualified in most circumstances but inevitably overpressed doctors cut corners and it is certainly possible that this places the patient at a similar risk to being treated by a student.
Of course circumstances never arise where qualified doctors in the third world have to give treatments without previous training or exposure to the condition. Or is the experience of Veeken more typical? 1 This is a slightly different argument but would Veeken be acting unethically if he were a student reading Maurice King's textbook by torchlight? I think not.
Universities should make students aware of these issues but the final judgement must be made by the local medical host, the student and the patients they see.
Dr Stewart Pringle
Specialist Registrar
Dept of Obstetrics & Gynaecology
Southern General Hospital
Glasgow G51 4TF
1 Veeken H. Sudan: in through the back door. BMJ 1998;316:1446-7
Competing interests: No competing interests
I did my elective in India in 1992. I went to assist a British GP in a village clinic which was set up to improve local health and also to do longitudinal studies into health problems in the area. When I arrived, I was informed that the good news was that the GP was staying for 2 weeks to show me the ropes, and after that I was on my own for 3 months as Action Health 2000 couldn't provide another doctor.
I was terrified to start with - I was alone, 150 km from the city and civilisation, no one to talk to apart from the paramedic who spoke English, in a mud hut village with intermittent electricity, having to share a room with 3 Indian men, and having to run a clinic and see problems I'd never heard of, let alone knew how to treat. I had 60 different drugs to use, could do basic tests to diagnose anaemia, malaria, TB, UTI's and do ESR's, and a large supply of text books. I also used my weekends to visit hospitals in the city to attend clinics and learn various physical signs and treatments so I could further help the villagers.
Only 1 person died while I was there (not my fault but I felt very guilty for some time), and I made many people better or improved their quality of life. Sometimes I didn't know what to do - but is that any different from now? The only difference being that I had no one to ask.
If I had said "no, I won't do this because I'm not qualified", I would have missed out on the most amazing experience of my life. I learnt how to take responsibility, and how to make a decision, even if it turned out to be wrong and then to deal with the consequences. I learnt where to look up information and how to use it appropriately. I improved the lives of people who had no other medical care available. And I grew up a lot. These are all things which are important to being a doctor, but which sadly most people learn when they are already HO's. On my return, I felt that I was much better equipped for dealing with patients and the wards, and was also able to behave in a more mature and desicive manner.
Ethically, I think it is very difficult to say that it is okay for a medical student to take on responsibilty of that sort, when they are not fully trained. But morally, can you justify the closure of a populations only local healthcare centre for 3 months just because the only person available hasn't got his/her final degree? Why should they have to suffer without care of any description? Surely some care is better than none at all.
Competing interests: No competing interests
Medical elective studies in developing countries should be considered an important part of clinical education and not be thought as a holiday. It allows students from developed nations not only to see, feel and value the importance of being a 'medic' but also gives them an insight into rural and tropical medicine.
Therefore time spent on elective should reflect that, this can only occur if a student is allowed to assist, make clinical diagnosis and suggest treatment where possible, if he or she is able to do so.
To date no harm and no legal action has been taken against any medical students and for this reason one should not list conditions for those going on electives.
Competing interests: No competing interests
Towards development of a structured elective programme
We agree with the suggestion of Banatvala and Doyal for a structured elective.
If the medical universities do see an educational purpose in the electives abroad, then there should be a coordinated "Medical Students' Elective Programme" (MEDISTEP as we may call it). I propose that the student bodies, university medical schools' consortia, and professional bodies such as British Medical Association, with the help of Overseas Devlopmental Agencies should develop the programme and guidelines on the role of the students.
The MEDISTEP programme consists of an registry ( ideally electronic these days). This registry maintains an active list of overseas medical colleges and faculty, who formally express a firm interest to provide some sort of supervision. This programme should also store information on the host city, location, travel, accommodation, languages, local cultures etc. In United Kingdom and elsewhere, the overseas doctors from developing countries are an important resource. All students registered for an elective and the proposed host institution should receive current guidelines emphasizing the students' role.
Ideally medical students should complete their electives abroad in hospitals and health centres attached to medical colleges. This step would eliminate many drawbacks mentioned in the editorial by Banatvala and Doyal.
An important step is to devise a mechanism to pair the visiting medical student and the host (institution) medical student. The host institution can designate a faculty member to oversee the student's curricular requirements and rotations. This move would help the visiting medical students to develop a source of contact and enhance acclimatization on their arrival.
The visiting students can see and assess a variety of clinical cases and participate in the academic sessions at the teaching hospitals. Besides these, they would have many other opportunities to participate in the health needs assessment, immunization programmes, health education sessions and outpatient clinics at the primary health care centres.
The visiting medical students can exchange with their counterparts information on curricula, clinical practices, methods of education and research. This way electives help to develop better understanding, overcome any barriers, and foster international partnership. The students can also gain insights into problems related to health infrastructure and health care delivery.
On return home, the students should register their experiences on the process and outcome of their electives in a database and this information would be very valuable in the evolution of the MEDISTEP programme.
Competing interests: No competing interests