Medical electives—not necessarily unethical and full of opportunity
First do no harm; everything else is a bonus—few of us have much confidence when we first start out. Indeed, when on medical elective there is not much students can offer in terms of self directed and useful clinical practice, and so equally little they can do to detract from the work of the host institution. This is in part why electives are not only ethically justified, but also constitute an intrinsic rite of passage, because they can offer a great opportunity for personal development, not only clinically but also socially and culturally.
I am about to embark on a 10 week elective—provided I pass finals—and, having already undertaken a two week placement in obstetrics and gynaecology in Mahamodara Hospital, Sri Lanka, I have a better idea of what to pack (fewer gloves), and what to expect from a foreign healthcare system. However, this practical awareness is of far less consequence than the unexpected insight I gained into the differences between the United Kingdom’s health system and the one I encountered in Sri Lanka—particularly in what it means to be satisfied by healthcare.
It seemed to me that the gentler expectations of Sri Lankan patients resulted in greater patient—and clinician—satisfaction than we have in the UK. I say this because, in spite of the heat, the lack of privacy, and the lack of basic provisions (episiotomies are often performed without local anaesthetic), the patients were so grateful to have delivered safely in a hospital that the discomfort and difficulty were a minor concern. In contrast, I have witnessed births in the UK where if all goes well there is lukewarm politeness (“Well of course it was going to be fine, everyone was just doing their job”), but if something goes wrong—such as in notoriously fraught instrumental deliveries—blame and dissatisfaction often follow, regardless of whether there is fault.
I accept that I am making generalisations from limited experience, but this observation made me consider that patient satisfaction might be about more than simple mortality and morbidity figures. As we strive for medical and technological advancement, we might have strayed from the path of being able to be content. Better mortality statistics have contributed, somewhat paradoxically, towards greater unhappiness because they make us expect more. How to deal with this is complex: we must realign expectation with provision; not lowering the former, but by changing what satisfies us—perhaps by putting more focus on values such as dignity and compassion. I now have a broadened understanding and a new perspective on the nature of patient satisfaction—things that I would not have gained had I not experienced healthcare from within a different culture.
Aside from the clinical growth an elective can provide, the experience of other cultures and healthcare systems is especially important in a global profession such as medicine, given the cultural variance in practice, illness behaviour, and attitude to management. In Sri Lanka, typically patients would not present—because of the cost—until their illness was far advanced, and they were quietly accepting of a poor prognosis. This is so different from the situation in the UK where people may present for trivial reasons, and it is not uncommon to see patients anxious for treatment to improve longevity even if it will not improve quality of life. Appreciating the differences in cultural attitudes, which are so relevant to our practice in our multicultural society, was a key benefit of my elective.
In Sri Lanka I was able also to offer the students and staff an insight into the UK’s healthcare system, as well as help them make foreign contacts. Surprisingly, I also seemed to contribute a semi-useful pair of hands clinically, particularly in the delivery suite with the high rate of births, and in chaotic gynaecological clinics where speculum examinations occurred on an almost “revolving door” basis. When I’ve met foreign students on rotation in my hospital in the UK, they offer a similar contribution; there is usefulness and a reciprocal function to elective students, however minimal it might seem to some.
The ethical questions—such as whether foreign students are a burden to the host country; and whether the host country has anything to gain when offering electives—are often used to counter the benefits of medical electives. However, hospitals often require a fee for hosting students, preventing financial disadvantage, and are not required to accept students should they not want to. Additionally, there is much that medical schools can do to ensure that electives are ethical, by informing their students about acceptable practice, preparing them clinically and culturally, and supporting them while abroad.
My experience was everything that I hoped for from a medical placement in another country. I would argue, however, that it is the possibility of an unexpected change of mindset—which I think will shape my future practice—that underscores the importance of electives in different healthcare settings.Verity Blackburn, , final year medical student,
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
Cite this as: Student BMJ 2013;21:f7132