Electives in Developing Countries

James Loan / FY2 Academic Critical Care / NHS Grampian

Donald Waters / FY2 Academic Paediatrics / Oxford University Hospitals NHS Trust

It is the start of a new medical year and, for many students nearing final year, time to start thinking about planning their electives. Foundation Doctors Jamie and Donald explain why they feel going to the developing world is a brilliant way to get the most out of your experience. They also guide us past some of the pitfalls of an overseas medical elective in a low-middle income country, coloured by their own experiences in Nepal, Vietnam and West Africa.

Organising your medical elective can be a stressful experience. For many students, it is the first major opportunity to shape your own medical training – the first chance to formally assert your individuality and take a step towards the sort of doctor that you want to be.

There are hundreds of overlapping factors that you have to take into account when choosing an elective, but of these one of the most important has to be location. Everything else will come from this decision, from the type of hospital you are working in to the specialties that are available to study under, from what you are able to do in your free time to what opportunities there are for undertaking extracurricular projects. We hope that a lot of you might be considering undertaking part or all of your elective in a low- or middle-income country. Indeed, we plan to argue through this article that doing so would be a brilliant and highly worthwhile decision which will benefit not only you, and your career, but also the place that you visit and the people that you meet there.

The Big Picture

We live in exciting and tumultuous times. In the richest nations of the world health continues to improve – with genetic technology and other advances promising further health gains; while in poorer nations life expectancy is stagnating or even going backwards. Poor people die young and avoidably. Of the 6.6 million children under 5 who die every year, 99% do so in low- or middle-income countries (LMICs), predominantly from preventable causes. Overall, most measures of global inequality are increasing: the rich are becoming richer whilst more than 30% of the world’s population continue to live on less than $2 a day.

Indeed, while some low-income countries may show signs of economic development, these are often driven by the gains of the already-rich and are offset by an increase in overall inequality, driving the majority of the global populace further into spirals of poverty and ill health. The healthcare needs of these countries are huge, but generally not reflected in the provision of healthcare workers: 25% of the global burden of disease is cared for by just 1.3% of the global health workforce. The poor people of our world desperately require medical assistance that, sadly, in many cases is not coming or not coming fast enough.

These data starkly highlight what many of us are already aware of and what we may see on the news each evening. Whilst shocking, we do not present them here to daunt you. Rather we want to highlight how important the healthcare needs of those in low-middle income countries are, and argue that in addition to the personal and career benefits outlined below, conducting your elective in a low-resource setting will enable you to get close to these issues, understand these individual human stories as more than just a set of numbers, and ultimately do something beneficial – either now or in the future.

“Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less”, Marie Curie.

Marie Curie’s famous quote encapsulates well how we can challenge feelings of distress and helplessness when confronted by the gigantic issues involved in global health. Maybe you aren’t going to be able to provide the assistance a qualified doctor could, maybe it will be a more difficult experience than an elective in a richer country. However, if you walk in to your elective with a smile, an open mind and good intentions then you will leave behind new seeds of possibility for improving the lives of patients where material and organisation resources may be scarce. Furthermore you will take away a deep personal understanding life and health in low-resource settings and hopefully be inspired to use this knowledge to tackle inequalities. And believe it or not, we promise you you’ll walk away with a lot more than just that.

So why should I?

Firstly, you will get direct involvement with a completely different type of medicine that you simply can’t appreciate without getting on a plane. Many of you are undoubtedly aware of the global issues outlined above and may plan to try to provide some assistance by working in a low-resource setting at some point in your career: any experience you can gain now will be invaluable.

You will all be familiar with the sense of discomfort that a first clinical placement causes, even at home. You must learn a whole new culture and interact with colleagues and patients in an unfamiliar manner. You become exposed to sicknesses and diseases, often masked or hidden from the public eye. This culture shock begets a steep but ultimately beneficial learning curve and is similar to what you will experience stepping into a wholly unfamiliar hospital environment overseas.

You may see unprecedented numbers of patients presenting with unusual diseases – or diseases progressed far beyond what we might expect to see in Europe and the US. An awareness of healthcare issues specific to the country gifts you the opportunity to start to address it: many excellent student-led charities and initiatives have sprung from elective experiences in developing countries and your potential to make a significant impact in this manner should not be underestimated. Students are able to take a step back from the clinical milieu and see how simple, achievable interventions can translate into patient benefit. Your contacts in your host country and access to a motivated student body will allow you to start effectively flying the flag for underrepresented issues back home.

Make an impact

There are other ways of making a real, immediate positive impact during your elective that you shouldn’t miss out on. Get in touch with your host unit and ask them if there is anything that you can help with. Perhaps there are specific surgical instruments that they are in dire need of, or medical textbooks or even expert advice on publishing their research in a high impact journal. Having found out their specific needs you can set about thinking how your elective can help: charities such as MedAID can help source old or unwanted equipment from the NHS to deliver overseas, perhaps you can organise a used textbook drive at your medical school, or meet up with a professor to discuss how to assist in their research? With a little initiative it is possible to make a valuable contribution to unit and people that you are visiting.

Teaching

The doctor:patient ratio may be much greater than you are used to (compare Africa’s startling 2.3 health workers per 1000 members of the population with America’s 24.8). Whilst, if you are unfortunate, this can result in less teaching, less supervision and subsequently fewer learning opportunities, it can also be to your advantage. Finding an enthusiastic teacher: the ability to smile, say hello to doctors and patients in their native tongue and to persevere until someone welcomes you are essential here. They will almost always be happy for the helping hand that a senior medical student can lend and, ensuring that you make clear the limits of your competence to them, you will gain a great chance to hone your practical and consultation skills.

You will also benefit from observing conditions being managed in a very different manner from our familiar evidence and guideline-based medicine, which is usually based on data derived from US or European populations only. The experience that you gain handling such unfamiliar cases will hugely benefit your work back home: your ability to listen to the patient and their family’s understanding of illness will be enhanced along with your ability to determine the best way for you to help the patient at hand. By gaining exposure to diseases, such as tuberculosis, AIDS and other infectious disease – as well as unusual presentations of more familiar conditions – you will widen your clinical acumen tremendously.  With the advent of cheaper air travel these diseases are no longer focused purely in any one area of the world, and you never know when a case of leishmaniasis or cysticercosis may present to the busy UK A&E department you are working in.

Research

Electives in low-middle income countries can also be rich in untapped opportunity to conduct research.  Having conducted (or attempted!) research in a low-middle income country demonstrates that you are a cut above the many other junior researchers and also provides you with an opportunity to give something back to the country that has hosted you. The key for students interested in this is to track down an effective supervisor – preferably one with experience in conducting research overseas – who will be able to support you in countless ways.  Of importance, they can assist you in selecting a project that is meaningful and manageable for the time you have available and help you in finding funding and ensuring that the research is conducted in a responsible and ethical manner. Whilst this might sound a daunting prospect, with sufficient time, planning and enthusiasm it is possible and highly rewarding.

Other skills

Moving onto those “generic professional skills” which we’re sure your medical education departments have been emphasising with all their hearts; conducting a successful elective in a low-middle income country demonstrates great initiative and organisational skills, important for any future job application and also future adventure planning! Choosing to do your elective in a low-middle income country is by no means easy and demonstrates that you are able to effectively organise things from a distance, working in an unfamiliar system, and then make it work on the ground once you are there, interacting with a wealth of new peoples and cultures. This experience should be of particular interest and value to all medics interested in working overseas but also any planning in collaborating in either a clinical or research capacity, an increasing part of any UK consultant role.

New friends

Lastly, as medicine is a social subject and medics usually social people, the one thing that you can guarantee on any placement overseas is that you will meet interesting people and make friends. This is brilliant, as not only will you make valuable contacts with whom you may be able to organise clinical and research overseas work in later years, but by having friends overseas you may gain a safe harbour in a storm – or a bed during a holiday – and you will begin to see your life and work as a part of a bigger picture. While this is also true of conducting an elective in Australia, you can easily go there on holiday next year with your wonderful Foundation wages and having friends in low-middle income countries gives you an invaluable new perspective on the world that could change your life in a way that Fosters on the beach just can’t quite match.

Pitfalls and naysayers

In this section we are going to try and anticipate some of the possible reasons that you may have, or may have heard of, for not travelling to a low-middle country for part of your elective. These are important to consider so that any potential problems can be identified and minimised or circumnavigated before you hit the ground! However, none of them are insurmountable and in many ways challenges can only add to the fun, here goes:

“What if I am thrown in too deep?”

This is a natural and important concern. Medical education may be less strictly regulated and there may be instances where you are expected to do something that you are not trained or competent to undertake. In these instances it is important to be able to politely and firmly explain that you cannot do it. People are usually understanding that the UK system requires that medical students are not pushed beyond their competence level whilst on elective.

You may see practices that you disagree with and again it is important not to feel pressured into participating. Take a step back, remember that visiting students should not be not be essential to service provision and be prepared to question practices, whilst keeping an open mind that best practice at home likely differs significantly from at your host country. When planning your trip it is advisable to seek out students that have visited there previously and listen to their experiences. In severely deprived countries where severe staffing or resource shortages are likely, you are at increased chance of being asked to provide care that you are not qualified to. There is also often an increased risk of crime and poor road safety. If you are worried that you are going to be overly pressured into providing care or that your own safety is at risk, then be ready at an early planning stage to reconsider and look for an alternative placement.

“I’m not interested in poverty tourism”

Good – and nor should you be. However, it is highly valuable to learn how medical services adapt when resources and funding are lacking or spent elsewhere. Observing and assisting the process of formulating a diagnosis and providing treatment without the wealth of technology available in your normal NHS setting will encourage you to think laterally about problems back in the UK. By seeing what we may consider to be best-practice at home being ignored in favour of procedures with less evidence you will learn how culturally rooted healthcare can be and how difficult it is to generalise the results of research conducted in the US or Europe to other countries with different population demographics. This will help you to see how fragile much of the dogma that you learn at medical school is and will improve your patient focus.

“Electives are difficult to organise in developing countries”

This is often the first stumbling block – finding a reliable contact to organise your elective with in your destination country can be difficult; especially when access to the internet, telephones and postal services may be limited. It is important to start trying to get in touch as far in advance as possible: 18 months would be ideal, although this is not always practical. Ask doctors working in your medical school or specialty of interest if they know of interesting places to go or have contacts, check the Adventure Medic Resources Section and be prepared to wait longer than usual for a response to your queries. It is important to state clearly from the outset what you need from your destination hospital in terms paperwork – will an email saying “you’re welcome to come” suffice, or do you need a letter on headed paper? Get it out of the way.

Another essential aspect to consider is whether the country you are looking at is safe to go to. Any medical school is unlikely to let a student travel to a country with a bad rep from the Foreign Office so their Travel Advisory page is a good place to start. You might also want to try to get in contact with doctors or other students who are already in the region as they will be able to provide you with an accurate local picture of what things are like on the ground.

“But would it look better on my CV to have visited a US/European centre of excellence?”

Having visited a prestigious institution can look very impressive, but this doesn’t always correlate with an excellent learning experience. Sure, it demonstrates that you beat the competition to secure a place there, but because of this popularity it is possible that learning opportunities will be diluted by a high number of students/junior doctors or institutional complacency. Furthermore, if you have already trained in a highly ‘Western’ hospital, it is likely that the differences between where you are visiting and what you have already experienced will be slight.

The cost of applying to well-known institutions can also be a significant problem, especially as many places will not refund you if they reject your application. Many low- and middle-income country placements will not charge you a placement fee and we would argue you are likely to have a more valuable learning opportunity travelling further afield. (Also do you want to be the guy/gal in the pub who has been to the same place on elective as everyone else?)

Medical employers recognise that what is important is not where you go, but what you learn, and often due to the wealth of new experiences on offer in low resource settings you will pick up skills and experience you simply couldn’t in a more traditional setting. Try to speak to someone who has visited where you are thinking of going before to ensure that there are ample learning opportunities, you could even consider attempting to organise a small research project that you could do on the ground.

What did we do?

James Loan / As a wannabe neurosurgeon, I travelled first to the small Annapurna Neurological Institute (ANI) in Kathmandu, Nepal before moving on to Cho Ray Hospital in Ho Chi Minh City, Vietnam – one of the worlds busiest neurosurgical centres.

Donald Waters / With a vague idea of a possible career in ophthalmology but a definite intention of working as a doctor in developing countries in the future I undertook my elective in Hôpital St. André de Tinré, Benin. This is the biggest specialist eye unit in West Africa but only has two consultants and to date only one elective student!

The pictures at the top of the article are from these expeditions.

Conclusions

We hope we have gone some way to convincing you that undertaking your elective in a low-middle income country would be a fantastic decision for many different reasons, both personal and professional. There is so much to gain and we wish you all the very best of luck in wherever your first medical adventure takes you. If you have any questions at all please get in touch with us (donaldwaters@hotmail.co.uk / jjloan90@gmail.com) and we will be more than happy to assist. Bon voyage!

Keen to start organising your elective? Have a look at the Adventure Medic Resources Section for some ideas.