Interest in international clinical electives is growing rapidly in the United States and Canada, especially among first-year medical students who often have time for extended travel the summer before their second year. While these students are rarely qualified to provide much in the way of direct care, they often get their first exposure to health care in a less-developed country through international electives. When they are well-designed and well-structured, international electives can be a powerful catalyst for a career of public service to underserved populations at home and abroad. In this commentary, however, we offer some words of caution.
Student interest in international electives stems from laudable motives. Most students are aware, in theory, of the vast disparities in health care around the world and wish to make a positive contribution through volunteer work. Many may even be anticipating careers in which international work is central. The question of who is helped most by these experiences is nonetheless a valid one. Students typically spend a few weeks or a month in a variety of settings in a country in which the culture, language, clinical practices and common illnesses are unfamiliar. While students may provide helpful assistance, their knowledge, skills and goals may not always be congruent with the needs of the host community, resulting in opportunities for misunderstanding and sometimes risks to students or patients. Four areas of concern have to do with the necessity of cultural competence, students' impact on the clinical environment, risks to patient and student safety, and medical student tourism.
First, medical students tend to focus their attention on medical conditions independent of economic, political, cultural and contextual factors. The structure of the elective can impact how they understand the role of these nonclinical factors in health and disease. For example, students housed in hotels with access to Western food and many conveniences of home will probably have a more difficult time understanding the lives of clinic patients who are a part of the local culture. While concerns about student safety and comfort are important, students’ understanding of health and illness in the local environment is enhanced when disparities between their living conditions and those of the people they are serving are minimized. Equally important is the need for student sensitivity to local cultures and social expectations. Sometimes it is hard to contain reactions when circumstances are both unexpected and unsettling, but blunders can have lasting consequences for students, patients and future electives. Students who have some preparation for the complexities of cross-cultural interaction prior to leaving the U.S. may have a better understanding of how to react to new and different circumstances, what to expect of their environment and how to avoid giving offense. The value of this preparation cannot be overstated.
Impact on the Clinical Environment
Second, the mere presence of students can impact a clinic or hospital setting, even when the student does little more than shadow local clinicians. Students would do well to consider what it is like for a patient to be observed by a comparatively wealthy young foreigner, often of a different race or gender. For some patients, the presence of a student signifies interest and is appreciated. For others, an observer inhibits full disclosure. If, as is natural and appropriate at home, the student wishes to ask questions, it is hard to know how this will be interpreted by the patient. Does the question show concern, or does it distract the physician, taking time and attention from the patient? Does the question increase the patient’s anxiety? In crowded hospital wards, in the interests of privacy, physicians often speak very quietly, and only those who are close can see and hear. Again, how might the presence of foreign observers affect communication, caregiving or the learning opportunities of local students by taking up limited space? In short, it is important for students to recognize that their physical presence can be helpful and, at the same time, potentially disruptive for the people with whom they interact.
Risks to Patients and Students
Third, medical students are often eager for the clinical experiences which international electives promise to provide. Depending on the setting, however, circumstances may be such that students find themselves expected to act in situations for which they are unprepared and unqualified. Sometimes these circumstances jeopardize both patient and student safety. But when the choice for a patient is a student’s care or no care, what should the student do? When regulations are lacking, when medical needs are great and a student's knowledge exceeds that of alternative care providers, what constraints should apply, especially if a local physician asks him or her to act? How should students balance the needs of the moment with the fact that they represent their medical school, their country, perhaps their race and religion, and future medical missions? If a patient is harmed, the repercussions may last for years. Needless to say, these concerns are compounded in the occasional cases of students who view international electives as an opportunity to practice procedures they aren’t allowed to do at home. Not only is this attitude highly unethical, it poses potential liability risks to the sponsoring medical school.
“Medical Student Tourists”
Finally, some students may be interested in international electives chiefly as a way to travel for academic credit. Medical student tourists are easily spotted—they spend minimal time in the clinics, instead using the elective as a jumping-off point for recreational activities. Host personnel recognize this and have little respect for such students. Yet, arguably, curiosity and a spirit of adventure are assets for any physician. How ought students to balance these wishes with a clear commitment to learning and medical service? How much recreational time is acceptable when students are abroad?
This review of some of the problems that commonly arise in international electives is offered as a caution, not a deterrent to such electives. Experience in a less-developed country can be an extraordinary opportunity for students to learn and contribute to underserved populations. For electives to be successful for both the students and host community, however, thorough preparation and planning are essential. Ideally, preceptors from the sponsoring institution who are familiar with the host setting, personnel and medical needs of the community will establish how many students can be accommodated at one time and where the students will live and will ensure that the specific tasks the students perform are appropriate to their skill level and adequately supervised.
Students should study the history and culture of the region where they will be working, know something about the health care needs in the area and be prepared for the kinds of work they will be doing. They should be encouraged to immerse themselves in the communities, to learn as much as they can about the living and working conditions of the people they are serving and to reflect on what they see and experience. But most importantly, only students who sincerely want to care for the underserved, whether at home or abroad, and who are genuinely curious about the myriad factors that impact their patients’ lives and health should aspire to participate in these electives. While credit-bearing electives imply a focus on education, international clinical electives must locate learning in the context of genuine service and respect. Asking the question, who are we helping? before, during and after engaging in international electives, may help to ensure that such experiences are successful for both students and their hosts.