Written By: Thomas Stubley
Birmingham Medical School
The international elective is a well-established aspect of the undergraduate medical curriculum in the United Kingdom, with a large proportion of today’s practising doctors having undertaken one whilst students. I spoke to Kanhai Dalal, a medical student at Leeds University who wrote his thesis as part of his intercalated masters focusing on some of the potential issues that arise from international medical electives. He very kindly summarised his work, as well as providing some brief advice for the future.
Could you give us a brief overview of the work you did last year?
For my master’s thesis, I researched undergraduate international medical electives (IME), focusing on those undertaken in the Global South. I conducted a literature review of the current research and a critical discourse analysis of the biggest organiser of IMEs in the UK, Work the World (WtW). Surprisingly, most of the research surrounding medical electives focuses on the educational outcomes and health of the medical students, ignoring the impact that these students are having on their host hospitals. There is a significant volume of literature surrounding the ethical issues of ‘voluntourism’, which may take a similar format to IMEs, however electives seem to have been largely ignored in academic research. I was drawn to this research topic because of anecdotal evidence of student and doctors working in a role that superseded their training in the UK. This is also evident from published case reports.
What do you think are the main issues with IMEs and these companies?
I think it is important to highlight that the primary aim of electives is the education of medical students and not about helping underserved populations. However, an analysis of post-elective student blogs on the WtW website and the surrounding literature shows that many students choose their electives in order to ‘make a difference’ or ‘give back’. Underpinning this admirable desire, however, is the belief that some care is better than none. On the face of it, this logic may seem sound, though it can undermine the development of the hosting healthcare systems. This is often because healthcare projects set up by foreign charities are not integrated into the healthcare system of that country and may therefore weaken public health efforts.
Putting the issue of helping vs learning to one side, is it not possible to view electives simply as a fair business transaction? You are paying for an educational experience and a hospital is providing that service, much like medical school. The main issue with this is the financial structure of companies such as WtW. For example, a student may pay £1300-2000 to a company for them to organise your elective and most of that money ends up as profit in London, with only a small amount of it going to the healthcare workers and hospitals that are hosting your elective. In addition, instead of paying the hosting hospital a fee for their services, WtW pay the hospital a ‘donation’. This plays into a harmful and false narrative of the Global North giving aid to a passive Global South.
What are the benefits and harms of student electives and should they still be running? Is there a potential solution for the future?
Student electives represent one of the most exciting experiences of medical school and I don’t think they need to stop running. There is plenty of research showing that the elective is a highly useful educational tool for students, leading to students acquiring new knowledge and skills as well as gaining in maturity from undertaking them.
However, in their current form, I do believe that they can be unethical and often perpetuate, rather than reduce, global power dynamics and inequalities. The COVID-19 pandemic has presented an opportunity to re-think the structure of the elective as the 2019 and 2020 cohorts of UK medical students have been forced to conduct their electives within the U.K. A potential solution for the future may lie in reciprocal exchange electives or long-standing partnerships between institutions. Reciprocal exchanges would be beneficial for both sets of students and promote global partnership; however this would take significant time and commitment to organise.
Long-standing partnerships between UK universities and hosting hospitals would allow students to have a regulated role and receive sufficient amount of supervision whilst the hosting hospitals would be able to receive appropriate payment for their work. This could be more simply established, however would require medical schools to become more actively involved in the process of organising electives. Currently the General Medical Council do not require medical schools to regulate electives despite their strict standards for placements that occur in the UK . It may be unethical for electives to be a compulsory part of medical education yet left unregulated.
What can students do to avoid these ethical issues?
In terms of what students can do to undertake an ethical elective, I would strongly encourage utilising student groups, for example Students for Global Health, to facilitate partnerships with hospitals so that future students can return to established placements. In addition, there are generally fewer ethical issues with undertaking electives in environments that are not resource scarce. If you want to undertake your elective in a low-resource setting, be mindful of the burden that you may represent and to whom your money is really going.
Some students will decide to plan their elective using a company such as WtW. From the briefer analysis I conducted of other companies, WtW does in fact seem to be one of the most ethical companies on the market, though, as mentioned above, they do have significant ethical hurdles to overcome. I believe that at the most basic level, you should ensure that you are not going to be expected to work in a capacity outside that exceeds your level of training provided in the UK.
References
Friedrich, J. (2019) ‘"Your presence is enough to make a huge difference ”: constructions of agency in voluntourism discourse’, The Elpinstone Reveiw, 5(May), pp. 1–16.
Green, T. et al. (2009) ‘Perceptions of short-term medical volunteer work: A qualitative study in Guatemala’, Globalization and Health, 5, pp. 1–13. doi: 10.1186/1744-8603-5-4.
Huish, R. (2012) ‘The Ethical Conundrum of International Health Electives in Medical Education’, Journal of Global Citizenship and Equity Education, 2(1), pp. 1–12.
Lawrence, E. R. et al. (2020) ‘Embedding international medical student electives within a 30-year partnership: the Ghana-Michigan collaboration’, BMC Medical Education. BMC Medical Education, 20(1), pp. 1–7. doi: 10.1186/s12909-020-02093-6.
McLennan, S. (2014) ‘Medical voluntourism in Honduras: “Helping” the poor?’, Progress in Development Studies, 14(2), pp. 163–179. doi: 10.1177/1464993413517789.
Niemantsverdriet, S. et al. (2004) ‘“I found myself to be a down to earth Dutch girl”: A qualitative study into learning outcomes from international traineeships’, Medical Education, 38(7), pp. 749–757. doi: 10.1111/j.1365-2929.2004.01843.x.