How to avoid Voluntourism - an ethical elective. TEN Award ~ Sarah Fishwick - Highly Commended

by Ruth Price on 23 Sep 2016

The General Medical Council defines an elective as ‘a period of clinical experience that is chosen by the student and is often taken outside the UK’ (1). When planning an elective, the world is the student’s proverbial oyster. There are few restrictions on the destination or area of medicine that medical students can choose.

As many as 40% of UK medical students choose to travel to Low and Middle Income Countries (LMICs) during their elective (2). Former Chief Executive of NHS England, Nigel Crisp, stated that:

‘medical, nursing and healthcare schools should work with others to ensure work experience and training placements in developing countries are beneficial to the receiving country’(3).

Despite plentiful literature on the benefits for medical students of undertaking electives abroad (4-7), there is a relative paucity of literature on the effects on patients and their communities in LMICs (7).

‘Voluntourism’ is the amalgamation of charity work with a holiday. Voluntourism has been criticised for selling the opportunity to observe injustice, without providing any sustainable relief to the community (8). Medical electives can easily fall into this description. Furthermore, visiting students can pose harm to the host community, for example through increasing the drain on local resources(9, 10), placing greater demands the clinical staff’s time(10), and detracting opportunities away from local medical students(9, 11). Students might be presented with opportunities to carry out procedures they ordinarily would not be permitted to do, risking patient safety (10), a situation that more common in resource poor settings where supervision is limited (12).

Medical students therefore have the challenge, and responsibility, to plan their elective for the benefit of the receiving community and to avoid the risks mentioned above.

How then can this be done?

1.Prepare adequately

Several studies found that hosts in LMICs can perceive students as being ill-prepared, to the detriment of patient care and the relationships with supervisors (9, 11). Some have argued that electives will only be beneficial to host communities if they are delivered as part of a comprehensive teaching programme on international health (2, 12).

During preparation, students should aim to discover move about the country’s prevalent conditions, the social and environmental determinants of health and difficulties faced by the health care system (4, 9, 10). Pre-departure preparation should include cover health and safety, as well as communication and basic language skills and ethical and cultural issues that may be encountered (4, 9-11, 13). E-learning could be useful to such ends, for example participating in the Open Online Courses such as the ‘Preparing for an International Health Elective: Training in Global Health, Ethics and Safety’ course on learning platform Future Learn (14).

Elective preparation should closely involve the host where possible (9, 10, 15). This could involve establishing the aims of the placement with the host prior to the visit, allowing students to commit to work within the host’s needs in a way that is culturally appropriate (15).

2.Know and communicate your level of competency

Students on electives can perceive themselves as under pressure to perform tasks beyond their capabilities, which can be compounded by hosts believing students to be more competent than reality (10). It has been suggested that students assume that working in an environment with limited resources justifies adopting roles beyond their training by adopting an ‘if not me, then who?’ attitude (12).

Risking the safety of patients by working beyond the limits of one’s skills and training would not be tolerated in the UK setting (1). If students are to apply the same standards to patients abroad it is vital that students are aware of their limits and can communicate these to their hosts effectively.

This process can begin during elective preparation. Students could communicate their level of training through developing a ‘competency passport’ by working with a tutor at their own medical school to draw up a list of skills and procedures they are confident in performing. This agreed list could be sent ahead to the host, and carried with the student during the placement.

3.Go as part of a long-term link to that area

Where possible, students should plan their elective to fit in with a sustainable link to that community. The literature recommends establishing formal partnerships between sending medical schools and receiving institutions as a way to developing the reciprocal benefits of electives.

These partnerships allow for continuity and a more regular flow of students (9, 10, 16, 17), can facilitate pre-departure training (9, 16) and allow hosts to plan how to use the incoming students’ skills (4, 11). Partnerships can involve the distribution of expertise and financial resources (11, 18). Medical schools in resource poor settings can also benefit through an association with a well-known institution (19). Furthermore, partnerships can allow for bidirectional student exchanges to take place whereby students the opportunity to experience healthcare in each other’s home environment (13). This represents the ultimate reciprocal elective experience.

In conclusion, medical students choosing to go to LMICs should carefully consider the impact of their elective, and should be challenged on how to plan their elective to be of benefit, rather than harm, to the receiving community. Preparing well, communicating with the host prior to the elective and being involved in a sustainable partnership are key to achieving this.

A personal reflection

My intercalated degree in international health has provided me with time to consider my elective carefully.

Building on the principles outlined in this essay, I have chosen to ask a prison GP with long term links to an NGO working in the Philippines to be my elective supervisor. I have kept in touch with my supervisor in the year leading up to my elective and this has allowed me to learn about the ongoing work in the prisons in the Philippines. I have the opportunity to get involved in planning a project that is useful to local needs. My supervisor knows me well, and so I am confident I won’t feel pressured to act beyond my competency.

Unfortunately not been able to join a bilateral exchange, but have used my BSc research project to seek recommendations on how to improve future partnerships.

References

1. General Medical Council. Tomorrow’s Doctors, Outcomes and Standards for Undergraduate Medical Education. Manchester: General Medical Council, 2009.

2. Miranda, J.J., Yudkin, J.S., Wilcott, C. International Health Electives: Four years of experience. Travel Medicine and Infectious Disease. 2005;3:133-41.

3. Crisp, N. Global Health Partnerships. The UK contribution to health in developing countries. 2007.

4. Dowell, J., Merrylees, N. Electives: isn’t it time for a change? Medical Education. 2009;43:121-6.

5. Mutchnick, I.S, Moyer, C.A, Stern, D. T,. Expanding the Boundaries of Medical Education: Evidence for Cross-Cultural Exchanges. Academic Medicine. 2003;78(10):S1-S5.

6. Jeffrey, J., Dumont, R., Kim, G., Kuo, T. Effects of International Health Electives on Medical Student Learning and Career Choice: Results of a Systematic Literature Review. Family Medicine. 2011;45(1):21-8.

7. Thompson, M.J, Huntington, M.K., Hunt, D., Pinsky, L.E., Brodie, J.J. Educational Effects of International Health Electives on U.S. and Canadian Medical Students and Residents: A Literature Review. Academic Medicine. 2003;78(3):342-7.

8. St George's University and Kings Colledge London. Voluntourism. 2016 [June 2016]. Available from: https://www.futurelearn.com/courses/health-electives/1/steps/81598.

9. Bozinoff, N., Dorman, K.P., Kerr, D., Roebbelen, E., Rogers, E., Hunter, A., et al. Toward reciprocity: host supervisor perspectives on international medical electives. Medical education. 2014;48(4):397-404.

10. Lumb, A., Murdoch-Eaton, D. Electives in undergraduate medical education: AMEE Guide No. 88. Medical Teacher. 2014;36:557-72.

11. Kumwenda, B., Daniels, K., Merrylees, N.. Medical electives in sub-Saharan Africa: a host perspective. Medical Education. 2015;49:623-33.

12. Edwards,R., Piachaud, J., Rowson, M., Miranda, J. Understanding global health issues: are international medical electives the answer? Medical Education. 2004;38:688-90.

13. Crump, J., Sugarman, J., Working Group on Ethics Guidelenes for Global Health for Global Health Training. Global Health Training Ethics and Best Practice Guidelines for Training Experiences in Global Health. American Journal of Tropical Medicine and Hygiene. 2010;83(6):1178-82.

14. Future Learn. Preparing for an International Health Elective: Training in Global Health, Ethics and Safety. 2016. [June 2016]. Available from: https://www.futurelearn.com/courses/health-electives.

15. Kraeker, C., Chandler, C. “We Learn From Them, They Learn From Us”: Global Health Experiences and Host Perceptions of Visiting Health Care Professionals. Academic Medicine. 2013;88(4):483-7.

16. Balandin, S., Lincoln, M., Sen, R., Wilkins, D., Trembath, D. Twelve tips for effective international clinical placements. Medical Teacher. 2007;29(9-10):872-7.

17. Hays, R., Gupta, T.S., Worthington, R. The Role of Clinical Electives. The Clinical Teacher. 2013;10:199-201.

18. Dowell, J., Blacklock, C., Liao, C., Merrylees, N. Boost or Burden? Issues posed by short placements in resource-poor settings. British Journal of General Practice. 2014:272-73.

19. Kanter, S.L. International Collaborations Between Medical Schools: What are the Benefits and Risks? Academic Medicine. 2010;85(10):1547-8.

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