Education without borders: medical students abroad

In advance of a conference on ‘education without borders’, Anthony Redmond considers the ethical issues around sending medical students on elective courses in low-income countries

October 10, 2015
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There are dangers as well as opportunities for British medical students who do part of their training abroad

Many students from the UK will spend some of their time in far-off lands.

Backpacking during a gap year and holidaying during the vacation are only indirectly related to their university experience; it’s the time and freedom that are the factors. But there are direct overseas educational links with many courses that allow students to take part of their course in another university and immerse themselves in another culture. The educational and personal developments that follow are well recognised and, when part of an equal exchange of costs and benefits, can truly enrich the university experience.

But what if the costs and benefits are not shared equally? What if students from rich countries study in poor countries, without a reciprocal arrangement and without paying their way as they would at home?

The medical student elective is a useful example. This used to be largely an opportunity to study a chosen area of medicine in depth. Now, for many, it is a de rigueur term-time trip to a far-off land, sheltered from close scrutiny and, for those who can afford it, professionally organised by an external agency. Yet the original light-touch approach that so liberated it from the necessary, but potentially stifling, constraints of a tightly controlled medical curriculum has allowed part of the course to escape the quality assurance and close scrutiny over safety and ethics that is such a feature of modern medical training.

My own experience reveals that, while some students still pursue a specialist area in the UK, many are either in a similarly highly developed country seeing patients with the same conditions as here, or in a poorly resourced country seeing patients with conditions that they’ve never seen before – and without the support mechanisms in place to protect them and their patients from their inexperience. Neither of these will be particularly educationally enriching, although they may have other benefits and attractions.

Don’t get me wrong; experiencing medicine in a different cultural context is, in my view, an essential part of becoming a well-rounded doctor. But there is a cost. The funding that accompanies an individual medical student to the institutions where they are placed in the UK does not accompany them during their elective. So unless the student pays themselves, it’s a freebie.

This may be acceptable if they go to work at a well-funded institution with a global health philanthropic agenda, but it is unacceptable for the cost to be borne by an under-resourced centre in a poor country.

So what are the benefits? Just seeing the progress of diseases outside the safety net of the NHS will hopefully fortify their support for a system that can only come under increasing threat as their career unfolds. Students will also encounter diseases rarely to be found in the UK and, in the context of knowledgeable supervision, this will be of broader educational benefit and may even allow them to make the diagnosis at some point in their future practice.

But, given the vulnerability of healthcare provision in some of the countries they go to, this supervision will not always be present. Rather than learning they will be teaching; and rather than seeing they will be doing. In fact, I hear that students value certain overseas electives precisely because they can work unsupervised and carry out procedures that they would not be allowed to do alone or even supervised in the UK. This is in spite of the constraints they know they must adhere to in the UK. After all, they don’t yet have a licence to practise medicine, and if it’s unethical or even illegal for them to do something in the UK at this stage of their career, then taking advantage of more porous ethical and legal regulations in vulnerable countries is surely something to be avoided.

At its worst, medical students can find themselves in the ethical dilemma of facing an overwhelming demand with their limited skills. The temptation to do something may prove irresistible; but they, and their patients (if they are lucky), will have to live with the consequences.

The concept of “any help is better than no help” is widely held among doctors and patients alike. This may be understandable, but it can allow inappropriate medical intervention by inexperienced practitioners on an uncritical and needy population. This can be seen in responses to disasters in poorer countries, with well-documented cases of inappropriate surgical interventions inflicted upon some of the most vulnerable. This issue of inappropriate, inexperienced responses to sudden disasters is now being addressed at an international level (often with efforts focused on capacity building). We should do the same for education.

Education without borders should mean just that; free movement backwards and forwards and not just a one-way street. The true costs, financial and cultural, must be acknowledged and met, and the benefits therefore made available to all. We have as much to learn from other countries as they have from us and, with regard to healthcare, for example, perhaps more to learn from some in the management of limited resources.

Anthony Redmond is professor of international emergency medicine at the University of Manchester, where he co-founded the Humanitarian and Conflict Response Institute. He is one of the lead speakers at the Education without Borders: Students and staff overseas in a high-risk world conference, to be held at the Bridgewater Hall in Manchester on 21 October.

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