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Medical electives for international health

Electives are vehicles to change health care in the developing world, argues Amitava Banerjee

Medecins Sans Frontieres sponsored a medical student to work in Malawi

Health inequities between developed and developing countries have widened despite globalisation, and the lack of health workers in many poor countries is a threat to international health. Why not have greater coordination between medical school electives and health programmes in developing countries? This could be a simple, cost effective intervention that uses existing resources to help to tackle the global shortage of health workers.

The World Health Organization’s World Health Report 2006 stated, “A shortage of human resources has replaced financial issues as the most serious obstacle to implementing national HIV treatment plans.”¹ A total of 1.3 billion people worldwide lack access to basic health care, often because of a lack of health workers. Fifty seven countries, most of them in Africa and Asia, have severe shortages in health workforce. The report estimates that 4.3 million health workers, including doctors, nurses, and technicians, but also management and support personnel, are needed to fill the gap.¹ The huge inequities in numbers of health workers between developed and developing countries and within countries are directly associated with poor health outcomes.¹

Why should we care?

The world’s population continues to increase, and more than a billion people live on less than $1 (£0.68; €0.76) a day. More than 800 million people are malnourished. And more than 2.5 billion people lack access to adequate sanitation.²

Such inequities have many complex contributory factors and so collaborative efforts between richer and poorer countries across disciplines are needed to tackle them. Questions arise about how to tackle the brain drain, how to train and recruit health workers, and how much responsibility should be shouldered by developing countries. Health professionals have often been vehicles of social change, often in spheres far beyond health, and these human resource inequities provide an opportunity for action.^{3 4}

International health has played a growing role in undergraduate and postgraduate medical education in rich and poor countries, and the medical student elective gives most doctors their first exposure to international health.^{5 6 7} Although idealistic aims might attract students to medical school, several studies show that these ideals fade as medical students and doctors progress through their training.^{8 9} Therefore, medical students, with their enthusiasm for international health, are well placed to contribute to the formulation of solutions for the global health workforce crisis, perhaps through their electives.

The status quo

International organisations, such as WHO; governments; non-governmental organisations; and medical journals recognise the scale of the problem.^{10 11 12} In the United Kingdom Nigel Crisp, former chief executive of the National Health Service, was commissioned to write a report about what the UK’s contribution should be to health in developing countries. He recognises the need for global health partnerships and supports the role of health professionals in helping to tackle current and future challenges in international health.¹³ The Global Health Workforce Alliance was formed in 2006 by WHO to rapidly train health workers and to ensure ethical recruitment of health workers and better health workforce planning worldwide.¹² Coordinated efforts in recruitment, training, and investment in Malawi have led to a 40% rise in the number of doctors compared

Student on elective working in southern India

with 2003, but such efforts need to be sustained and applied elsewhere.¹¹

Medical students on elective represent a sizeable population of potential health workers who are not being considered in this debate. As an example, there are 33 UK medical schools and about 6000 medical students a year. In 2004 it was estimated that 40% of UK students spend their 6-12 week elective in developing countries,¹⁴ most commonly for the reasons given in the box. Many links exist between medical schools in developed countries and hospitals and clinics in poorer countries, and the lead has been taken by medical students themselves, with the rise of social networking websites and websites such as the Elective Network (www.electives.net).

Electives occur towards the end of undergraduate training and so students have the medical knowledge required to start practising as a doctor. In the UK several medical schools have final examinations before the elective period, which means that although those students may not be provisionally registered with the UK General Medical Council, they have the knowledge needed to practise medicine. At present Western medical schools take most of the responsibility for students on elective, but at least some of that responsibility is shared by the host university or medical institution. The student is expected to follow the same guidelines for good practice as they would at home. If students are properly prepared and act within the limits of their comfort, knowledge, and competency, neither they nor their patients’ safety will be compromised.

Two perspectives

No consensus has been reached on guidelines even though electives have been part of the undergraduate curriculum in the UK and other Western countries since the 1970s.^{14 15 16} There is limited literature about the ethical role of Western medical students when they are working abroad even though they are governed by many guidelines when they practise at home. Two perspectives exist on the role of an elective. The conservative camp thinks that an elective student’s role is to observe and not to practise medicine on poor people. The utilitarian view is that some help is better than none and that medical students have knowledge and skills that place them under a moral obligation to help people in need. Most doctors and medical educators fall in the grey area between, where elective students should do what they would be expected to do in their home country within the boundaries of their own and their patients’ safety.^{15 16} Medical schools are increasingly dissuading students from taking electives in countries with a high prevalence of HIV/AIDS and not allowing students to carry out procedures that are prone to exposure in such settings.

The current model for electives is centred on Western students and doctors and their training, and the needs of the developing country’s health system are not the primary consideration. The only commitment that the medical student has to fulfil is to get medical school forms signed by the host institution and to write an elective report.¹⁴

Help on elective

Medical students who pursue electives in developing countries can improve the situation by selecting projects that will contribute to health and development in the host setting; selecting projects that are part of an ongoing programme so that continuous care is possible; considering the effects of their elective on the host institution; and collaborating with the host institution to consider how elective students can be most constructive.

Although medical students are already part of the human resource, no national or international coordination exists in this area. If even 10% of the pool of UK students were acting as health workers on elective in developing countries, practising skills in which they were competent in organised programmes, this would represent 600 medical students a year to supplement local healthcare personnel. This would have a particular impact in rural settings. Sufficient overlap exists between the timing of electives in each medical school, such that a programme could be staffed all year round. If programmes are developed so that there is overlap and continuity between cohorts of students of at least one week, there should be capacity for handover. In addition, local health workers should be involved in supervision of the programme and ensure that services are provided throughout the year. A four week preparatory module on international health before the elective period has been shown to have positive outcomes.¹⁴ A similar module could ensure adequate preparation for students on the proposed programmes.

Liabilities and responsibilities

Senior medical students would be competent to act as health workers, in areas such as secondary prevention services for cardiovascular disease, including blood pressure and diabetes monitoring, and sex education. Programmes that emphasise primary care, health promotion, and prevention would benefit most from medical students acting within their competencies, and their liabilities and responsibilities would be the same as at present.

For most students the elective is an opportunity to leave the rigid schedule of the medical course, and planning your elective is part of the experience. Students would not be coerced into programmes that they do not want to attend; many medical students already choose to spend their elective in rural areas of developing countries at their own cost. Positive student experiences can shape future medical careers and styles of practice and are more likely when students are practically involved in teaching and clinical placements.^{17 18} As a Lancet editorial noted, “No other part of the course transforms students so rapidly and profoundly, and both they and their teachers argue strongly that the overseas elective should find a secure place in any new medical curriculum.”¹⁵

Healthcare workers, particularly medical students, can be catalysts for social change, and such a scheme has potentially far reaching consequences for health and development.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

See “Electives and international health: a student’s view” (Student BMJ 2009;17:68, http://student.bmj.com/issues/09/01/careers/68.php).

Amitava Banerjee clinical research fellow Stroke Prevention Research Unit, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU
amitava.banerjee@clneuro.ox.ac.uk
Student BMJ 2009;17:58-59 | February

1. See “Students whose behaviour causes concern: case history” (BMJ 2008;337:a2874, www.bmj.com/cgi/content/full/337/dec29_1/a2874).World Health Organization. World health report 2006. Geneva: WHO, 2006.
2. Global Poverty Report. Okinawa Summit. July 2000. www.worldbank.org/html/extdr/extme/G8_poverty2000.pdf
3. Jareg P, Kaseje DCO. Growth of civil society in developing countries: implications for health. Lancet 1998;351:819-22.
4. Jotkowitz AB, Glick S, Porath A. A physician charter on medical professionalism: a challenge for medical education. Eur J Intern Med 2004;15:5-9.
5. Educating doctors for world health [editorial]. Lancet 2001;358:1471.
6. Yudkin JS, Bayley O, Elnour S, Willott C, Miranda JJ. Introducing medical students to global health issues: a bachelor of science degree in international health. Lancet 2003;362:822-4.
7. Fox GJ, Thompson JE, Bourke VC, Moloney G. Medical students, medical schools and international health. Med J Aust 2007;187:536-9.
8. Crandall SJ, Volk RJ, Loemker V. Medical students’ attitudes toward providing care for the underserved: are we training socially responsible physicians? JAMA 1993;269:2519-23.
9. Smith JK, Weaver DB. Capturing medical students’ idealism. Ann Fam Med 2006;4(suppl 1):s32-7 and discussion s58-60.
10. McColl K. International action on migration of health workers. BMJ 2008;337:2065.
11. Roberts O. Tackling global shortages in health workers. BMJ 2008;337:1971.
12. Rehwagen C. WHO alliance aims to tackle the world’s lack of health workers. BMJ 2006;332:1294.
13. Crisp N. Global health partnerships: the UK contribution to health in developing countries. London: Department of Health, 2007.
14. Miranda JJ, Yudkin JS, Willott C. International health electives: four years of experience. Travel Med Infect Dis 2005;3:133-41.
15. The overseas elective: purpose or picnic [editorial]? Lancet 1993;342:753-4.
16. Banatvala N, Doyal L. Knowing when to say “no” on the student elective: students going on electives abroad need clinical guidelines. BMJ 1998;316:1404-5.
17. Mihalynuk T, Leung G, Fraser J, Bates J, Snadden D. Free choice and career choice: clerkship electives in medical education. Med Educ 2006;40:1065-71.
18. Cate OT. A teaching rotation and a student teaching qualification for senior medical students. Med Teach 2007:1-6.

       

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