“Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one's lifetime.”
Mark Twain, The Innocents Abroad / Roughing It
For many medical students the elective is the highlight of their undergraduate education. Commonly undertaken abroad, it is often a source of fond life-long memories. There are, however, various issues that may hamper the elective plans of even the most organized student. Here, I will discuss issues that I myself have come across and those that I have identified in the literature.
Publish or Perish
Research and the publication of papers in peer-reviewed journals are an increasingly valued part of career progression for medical students and doctors. Publications even garner points in the scoring system for foundation programmes. Medical students are acutely aware of this “publish or perish” mentality.(1) There is, therefore, pressure on medical students to produce papers before graduation. Depending on its timing, the elective may provide a coherent period of time in which to work towards a much-coveted publication.
This opportunity also offers a challenge, however: should this time be used to gain academic lauds in lieu of clinical experience? Is it possible to achieve both in the time allowed for electives? The exact proportions will vary between medical school but there is certainly a number of students who forego direct clinical experience during their electives. Deciding on the very nature of the elective, and balancing time between clinical and academic content presents a challenge in of itself.
Vora et al’s examination of essays written by medical students about their experience on electives in foreign countries identified language barriers as a common problem.(2) Kumwenda et al’s 2014 qualitative study of English-speaking medical students showed that even in places where English was spoken as a second language by the locals students struggled more to contribute to patient care.(3) Concurrently, the presence of a language barrier has been identified as having the potentially to negatively impact patient care.(4)
It is therefore important that in planning their electives that students are mindful to arrange to work in a place where they can communicate and best contribute to patient care at an appropriate level. They risk having a detrimental impact on patients if they are too heavily impeded by a language barrier.(4) This is only one of many examples where elective students must carefully consider the ethical context in which they are practicing.
Do No Harm
Many students undertake their electives in developing countries. Indeed, an estimated 350 years of “elective time” is spent in developing countries by UK students alone every year.(5) Though this experience is invaluable and electives should be sought to broaden a students’ understanding of how healthcare is delivered in under-resourced settings it also presents an ethical conundrum. A combination of limited supervision and limited resources may precipitate a situation where students feel they are forced to act beyond their competency.(6,7)
This is a worrying situation, as the same ethical rules apply abroad as at home. To carry out a procedure or assume responsibility beyond one’s competence has the potential to cause harm to patients and is no more ethically acceptable in a developing country than a developed one. Conversely, it has been posed that the clinical culture of each healthcare system is different and it would be inappropriate for students’ home institutions to impose their own standards upon host institutions where medical students may be able to provide a valuable contribution. These arguments have been conceptualized as conflicting deontological and utilitarian views, respectively.(6)
Students are torn between the immediate need of the healthcare system in front of them and the strict ethical framework in which they are compelled to work. Indeed, students are reminded that it is unethical and in fact illegal to assume the role of a doctor “irrespective of any encouragement they may receive from the host organizations to which they are attached”.(8)
Another aspect of elective planning therefore involves ensuring that the placement is well supervised and not likely to put students in a position where they must compromise ethical standards.
Foreign electives can boast hefty price-tags. Coming as they do at the end of at least five or six years of steady accumulation of student debt, the financial constraints associated with electives are a major consideration for students. Flights, visas, essential medical investigations and immunizations, accommodation and fees for elective courses themselves are common costs. For many these can actually dictate where they chose to visit on their elective.(3)
There are various grants available to support students but for many the cost may be the main barrier to their dream elective.
I myself have encountered each of the above problems in the course of planning my own elective. I considered devoting the time to an academic project but eventually decided on a clinical placement. Only being able to speak English I myself was limited to going to a country where English is spoken as a first or second language. The planning process has also involved specifically ensuring that I will have adequate supervision and that my role on my elective will be well-defined- something which has worried me. The cost of some destinations has also been prohibitive.
To discuss all of the challenges faced by students organizing medical electives would be beyond the scope of this essay but here I have aimed to provide a broad overview using my own experience as a template. Clearly there are many obstacles to planning a medical elective but it is important, as Mark Twain quipped, to overcome these and not to “vegetate in one little corner of the earth all one’s lifetime”.
1. Griffin MF, Hindocha S. Publication practices of medical students at British medical schools: experience, attitudes and barriers to publish. Med Teach. 2011;33(1):e1-8.
2. Vora N, Chang M, Pandya H, Hasham A, Lazarus C. A student-initiated and student-facilitated international health elective for preclinical medical students. Med Educ Online. 2010 15;15.
3. Kumwenda B, Royan D, Ringsell P, Dowell J. Western medical students' experiences on clinical electives in sub-Saharan Africa. Med Educ. 2014 48(6):593-603.
4. Bozinoff N, Dorman KP, Kerr D, Roebbelen E, Rogers E, Hunter A, O'Shea T, Kraeker C. Toward reciprocity: host supervisor perspectives on international medical electives. Med Educ. 2014 48(4):397-404.
5. Dowell J, Merrylees N. Electives: isn't it time for a change? Med Educ. 2009 43(2):121-6.
6. S Radstone. Practising on the poor? Healthcare workers' beliefs about the role of medical students during their elective. J Med Ethics. 2005 31(2): 109–110.
7. Edwards R, Piachaud J, Rowson M, Miranda J. Understanding global health issues: are international medical electives the answer? Med Educ. 2004 38(7):688-90.
8. Banatvala N. Knowing when to say “no” on the student elective Students going on electives abroad need clinical guidelines. BMJ 1998 9; 316(7142): 1404–1405.