Intended for healthcare professionals

Letters

Medical students' electives abroad

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7171.1528 (Published 28 November 1998) Cite this as: BMJ 1998;317:1528

Students need extensive advice on planning electives

  1. Jane Zuckerman, Elective tutor.
  1. Royal Free Hospital School of Medicine, London NW3 2PF
  2. Medway Hospital, Gillingham, Kent ME7 5NY
  3. Chogoria Hospital, Chogoria, Kenya, Africa

    EDITOR—Banatvala and Doyal's editorial on student electives abroad raised several issues.1 As the elective tutor at the Royal Free Hospital School of Medicine I am responsible for ensuring the wellbeing of each student going on an elective both in the United Kingdom and abroad. Time has to be spent with each student, discussing every aspect of their plans and identifying potential problems. This includes considering their academic suitability, the occupational risks and, importantly, travel related hazards.

    Students choose to gain medical experience in various settings. Some wish to experience health care in a rural setting, others in a university teaching hospital. Students must be aware of the differences in setting and learning experience. Some may be shocked to find few medical resources and may be expected to act as a fully qualified medical practitioner. Others may be disappointed to find that they gain little “hands on” experience other than shadowing the duty doctor. The experience that a student hopes to gain from the elective must be discussed to highlight any potential difficulties.

    The possibility of culture shock, language difficulties, and loneliness are among other subjects that need to be addressed. Advice should be given on immunisations, antimalarial prophylaxis, and other general methods of prevention of illness. The necessity of comprehensive travel and health insurance must be emphasised.

    Students are encouraged to write a report on their experiences during the elective, which is subsequently read by fellow students. It is hoped that in this way students will have an appreciable overview of what to expect, not only from the place but also from the clinical experience and teaching. The interaction with other students and the social activities available are also an important consideration.

    Medical students need to receive comprehensive and appropriate advice about their elective placement. An “electives evening” is held annually for the students at this medical school. A comprehensive publication on electives in collaboration with the Medical Defence Union is also available.2

    A series of articles on how to plan your elective was published in the studentBMJ.3 This initiative started with an editorial followed by a series of articles focusing on all aspects of the elective in several countries accompanied by an article written by a medical student reporting their own experiences there.4

    I hope that the above mentioned will encourage medical students to seek advice that should be readily available in their own medical schools, thus ensuring that each student enjoys the experience of the elective.

    References

    Some care is better than none at all

    1. Heather Harris, Senior house officer, surgical rotation.
    1. Royal Free Hospital School of Medicine, London NW3 2PF
    2. Medway Hospital, Gillingham, Kent ME7 5NY
    3. Chogoria Hospital, Chogoria, Kenya, Africa

      EDITOR—Banatvala and Doyal's article1 reminded me of my experiences while on elective in India in 1992. I assisted a British general practitioner in a village clinic set up to improve local health and do longitudinal studies into health problems in the area. On arrival I was informed that the doctor was staying for two weeks to show me the ropes. After that I was on my own for three months as Action Health 2000 couldn't provide another doctor.

      I was terrified initially—I was 150 km from civilisation, had no one to talk to apart from the paramedic who spoke English, was living in a mud hut village with intermittent electricity, having to share a room with three Indian men, and had to deal with problems I'd never heard of, nor knew how to treat. I had 60 different drugs to use, could do basic tests to diagnose anaemia, malaria, tuberculosis, infections of the urinary tract, could measure erythrocyte sedimentation rates, and had a large supply of textbooks. At weekends I visited hospitals in the city to attend clinics to learn various physical signs and treatments so I could further help the villagers.

      One person died while I was there (not my fault but I felt 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 was that I had no one to ask.

      Had I refused to take this on I would have missed the most amazing experience of my life. I learnt how to take responsibility and make decisions—even if they turned out to be wrong—and deal with the consequences. I learnt where to find information and how to use it. I improved the lives of people who had no other medical care available. I grew up a lot. All these things are important to being a doctor, but most people learn them when they are already house officers. On my return, I was better at dealing with patients, and able to behave in a more mature and decisive manner.

      Ethically, it is difficult to say that it is OK for medical students to take on such responsibilities when they are not fully trained. Morally, however, can you justify the closure of a population's only local healthcare centre for three months just because the only person available hasn't got his or her final degree? Why should people have to suffer without care of any description? Surely some care is better than none at all?

      References

      Those who are qualified to help should help

      1. James K Torrens, Physician.
      1. Royal Free Hospital School of Medicine, London NW3 2PF
      2. Medway Hospital, Gillingham, Kent ME7 5NY
      3. Chogoria Hospital, Chogoria, Kenya, Africa

        EDITOR—I work in a rural hospital in a developing country and was interested to read Molloy's account of his student elective in India,1 with the accompanying editorial advocating the drawing up of clinical guidelines for similar periods of overseas elective experience.2 Banatvala and Doyal challenge the legitimacy of the assumption that “some help is better than no help” and suggest that if a life saving intervention is needed, the medical student should act simply as a good citizen and do his or her best. In the following week's BMJ, I was fascinated to read the discussion surrounding a doctor who, having had an alcoholic drink, intervened in the care of a patient with a possible neck injury.3 Presumably Cressey attended the sporting event primarily as an “ordinary citizen,” but found himself unable to avoid the ethical obligation laid on him as a doctor, despite the less than ideal circumstances. In the accompanying commentaries Walsh says that doctors can never renounce their duty to help should the need arise; and Rigter and de Beaufort say that drawing up guidelines on alcohol use for doctors off duty (or for their subsequent actions) would be virtually impossible.

        Although medical students are not doctors, they nevertheless find themselves in situations such as Molloy's where, even if viewed as ordinary citizens, they are in possession of knowledge and capabilities that surely place them under a moral obligation to use their skills to help those in need. In addition, if it is perceived as difficult to draw up guidelines on alcohol use for doctors off duty, then I believe that it will be doubly difficult to draw up meaningful and enforceable clinical guidelines for medical students working in developing countries. Adequate supervision seems to be a minimum requirement, but the sheer number of patients, the extreme nature of their illnesses, and the often unpredictable variations in hospital staffing levels are just a few of the factors militating against the reliable implementation of practical guidelines.

        I realise that part of the ethicist's task is to advise on standards that all of us should strive to achieve; but when faced with a situation where there is an obvious need, and there is someone available who can address that need (whether a slightly inebriated doctor, an inexperienced medical student, or a conscientious citizen) then, as thousands could surely testify, some help—if it's truly help—is indeed better than no help.

        References