‘Saving lives on holiday?’ or ‘What is a medical elective?’

The seven weeks in Khartoum will be my medical elective, part of my final year at medical school.  Such placements have been part of medical curricula in the UK since the 1970s. But what are they like?

Should an elective be a chance to have a bit of a holiday and save a few lives for fun? Or a courageous, single-handed slog against all odds for the good of mankind? I rather suspect (and hope) that it’ll turn out to be neither of these. So in that case, again, what exactly is an elective? And what’s the point of it?

If you were to ask me, I’d say that an elective is probably a little like a cross between a gap year and a regular medical placement: A short clinical attachment (i.e. 2 months based in a hospital) abroad or in the UK, which is normally self-selected and self-organised.

Like any of the modular placements which make up training for medical students (e.g. paediatrics or cardiology), an elective provides some important educational opportunities. Various authors have identified several of these medicinally-based benefits, including the improvement of knowledge, skills and confidence, the accumulation of resource- ‘awareness’, and the development of some insight into future career choices*. Overall, in this clinical vein, you could see an elective as a chance to enrich your academic soul through exposure to favourite medical specialties, different teaching or supervision, and new therapeutic experiences.

But like a gap year, it’s also supposed (I think) to be a bit fun! Depending on your destination, your elective is your ticket to leave behind the familiar scenes of the past five years and immerse yourself for a couple of months in a new place, culture, language, and health system. If you play your cards right, you can spend those weeks somewhere you’ve always wanted to visit – whether that’s for reasons of history, culture, family connections, or simply because it’s five minutes away from the world’s best beach! Put this way, wouldn’t it be good if most career paths included an elective period?!

But hang on a minute, is that all there is to it? Education + Enjoyment = Electives? If that was really the whole equation, couldn’t we just substitute in a couple of lectures, a few ward sessions and a holiday for the elective? Be a lot easier to organise wouldn’t it? There must be something more to it, and sticking with the E’s, I’m going to suggest the last component might be called ‘Edge’.

Shouldn’t an elective occasionally push you out of your comfort zone, turfing you out of the cosy certainties of medical school into the precipitous unknowns of the real world? Unlike medical school, where responsibility always lies with someone higher, electives students’ decision ‘to act, or not to act’ may actually mean something. This is where a hint of controversy touches the topic. How far should you as a student go? Where exactly is the edge here?

Whilst on elective, many factors may come into play to increase students’ autonomy. These might include a low staff to patient ratio, limited student supervision with unrealistic expectations of their performance, and a high value attached to clinical decisions (due for example to limited availability of lab tests or specialist opinion). Simultaneously, students may be more frequently exposed to situations and demands closer to the limits of their competence than ever before. Overall, it may occasionally appear as though they wield a new and giddy power over their patients.

Conceivably, an elective student’s decisions may concern whether to attempt a solo-appendicectomy (the answer is no!), which drug to use to treat cutaneous leishmaniasis, whether to act as lead assistant in an emergency caesarean section, or just simply whether to admit someone for observation. The difficulty is in knowing where the edge is, and which path to take in order to avoid pushing both your patient and yourself over it.

A major factor in these situations is presumably your attitude – how you see yourself and your role. I think it can be very difficult, with reasons both plausible and implausible stacking-up to justify you in pushing the boundaries. Isn’t your help better than no help? The chance of life better than the prospect of death? Isn’t it in fact a duty to bring painstakingly-acquired knowledge and skills to bear upon deprived patients and depleted medical systems?

However, whilst such propositions may be beguiling, aren’t they in fact little more than excuses for exercising this new-found power? Surely a more searching question to ask yourself is exactly what help your knowledge and skills would give to a patient’s chances of life?

I would guess that the best solution might begin with trying to keep any surging adrenaline at bay and then, placing your patient’s interests uppermost, quickly consider your capacities and limits. Remember that you’re a medical student! I’m not suggesting that students should never do anything new – they’d never get anywhere, let alone qualify – just that they should be doing things for the right reasons. The acid test is probably ‘if this patient was a member of your own family, would you make the same decision’?

Or is that all too simplistic and short-sighted? Should there in fact be different standards for different settings? If patients live under different realities and have different expectations of health care, then do Western standards just hold things back? Ultimately, I doubt that there’ll ever be a great deal of regulation or evaluation of all this. Different authors have commented on the scarcity of real data or studies of such situations. Until there is more, I guess it remains down to each individual student to evolve their own sense of professionalism, to decide where their own edge is.

After all of that, what will I be hoping to get out of my own elective? Perhaps a little of each of those three E’s! Some opportunities, lots of fun and some chances to learn more about medicine and where I fit into it. I would also like to get to know Khartoum and its people a little whilst I’m there. And why Khartoum in the first place? Well that’ll hopefully be for my next blog…

Will write again soon!

Pete

* If you’re interested then read Dowell, J., Merrylees, N. (2009) Electives: isn’t it time for a change? Medical Education. (43) 121-6

Also some interesting thoughts in the following letter, comment piece and article respectively.

–          Banerjee, A., Banatvala, N., Handa, A. (2011) Medical student electives: potential for global health? The Lancet (377) 555

–          Graham, N. (2010) Elective Ethics. Student BMJ (18) 65-67

–          Edwards, R., Piachaud, J., Rowson, M., Miranda, J. (2004) Understanding global health issues: are international medical electives the answer? Medical Education. (38) 688-90