Knowing when to say “no” on the student elective

The elective can be one of the most exciting components of a medical student’s training. When done abroad, it sometimes offers the opportunity to experience health care in a different cultural and organisational setting and to see diseases that are rarely, if ever, encountered in Great Britain. Other benefits include the maturity that comes from medico-social understanding, self-reliance, and resourcefulness that the elective experience can provide.¹ Several reports describing activities on electives provide further insight into their opportunities, challenges, and benefits.^2–6

The increasingly focused medical curriculum in the UK is a key reason to promote the elective. Yet despite its advantages, some concerns remain. The author of a report of his elective alludes to the discomfort felt about suddenly being expected to “see patients” (p 1466).⁶ Such concerns are often no different from anxieties experienced by medical students in Great Britain. However, when students travel overseas a well structured and supervised attachment is essential. Poor supervision can place students in positions which are ethically, and perhaps legally, invidious. Pitched into the often frenetic atmosphere of health care in a poor country, students may assume that limited resources and huge health needs justify taking on some of the roles of qualified doctors. This is unacceptable—irrespective of any encouragement which students may receive from members of the host healthcare organisations to which they are attached.

Medical students are not professionally qualified. This is the same in Great Britain as it is elsewhere. Most countries, if not all, will have legal requirements for the registration of medical practitioners analogous to those of Great Britain’s General Medical Council. Any student studying in such countries who is unregistered but who pretends to be a doctor does so both unethically and illegally. Whatever their national origin, patients have the right to know that they are being cared for by students who cannot and must not assume responsibility for their diagnosis and treatment. Indeed, such patients also have the right not to participate in the education of students at all.

When in countries where healthcare provision is extremely scarce, students must recognise that there may be pressures to exceed their role. They must not diagnose illness, prescribe, or administer treatment without strict clinical supervision—however “unprofessional” this may feel. Students may not appreciate the dangers of treatment, particularly in countries where familiar medical problems are complicated by unfamiliar levels of poverty. In such circumstances, even with the best of intentions, inadequately supervised students risk doing more harm than good.

One of the elective’s great virtues is that sometimes students may be able to undertake more procedures than back home. Provided that these are well supervised—even from a distance—and patients agree to be attended by students, there is no problem. A more difficult issue arises when considering what constitutes acceptable supervision. Before beginning their elective, students should be prepared by their medical schools in Britain to know when to ask for help and what to do when it is not forthcoming.

It might be argued that the dire health needs of some patients encountered on the elective warrants bending the rules. The assumption is that surely some help is better than no help. Is this an acceptable argument? We think not—unless patients require immediate care to save their lives. Here students would be expected to act as good citizens and do their best, but not under the pretence of being “qualified doctors”. The dangers of doing so were recently outlined by the Lancet, which condemned the few unprofessional aid agencies that have employed medical students for relief activities—even in the face of urgent need.⁷

We are not suggesting a naive approach to the predicaments of poorly resourced countries and that students should go expecting to be treated as if back in their home country. The question is one of moral boundaries—of knowing where to draw the line between those activities which are and are not clinically appropriate. At present, there is little advice published, and related discussions with students only occur on an ad hoc basis. This situation must improve. Medical schools should take the lead in the formulation of clear guidelines and medical students should insist on them before beginning electives where they may be morally and legally compromised.

Students should be taught how to recognise their limitations so that they are adequately informed to know when it is appropriate to say “no” wherever they happen to be learning medicine.

Personal view p 1466