Do we need an elective for our medical education?
Medical electives have been part of the medical school curriculum since the 1970s in the United Kingdom. They are typically 4-8 week medical placements organised by the student in a field they are interested in. Electives are an extended period to increase understanding of global health, improve our clinical skills and deepen understanding of a speciality. They are the only part of the course in which students have autonomy over their learning. Unfortunately, I am part of the cohort of medical students who will be losing this opportunity due to the devastating Covid-19 global pandemic.
Medical electives have been recognised as an opportunity to learn about global health including principles of public health, health equity, and international healthcare systems. Understanding this is becoming increasingly important as healthcare becomes globalised, and countries become more inter-connected (1). The General Medical Council (GMC) recognises this, stating that students should be able to discuss from a global perspective the determinants of health and disease and variations in health care delivery and medical practice. Experience of these objectives may be obtained by students going abroad. Indeed, 80% of students do so (1) with 40% of students going to low income countries (2). There is no other time in the course to go to another country, and is a practical way to learn about global health.
Furthermore, electives are also regarded as an opportunity for professional and personal development. Whilst working and living in another country, students can broaden their mind, appreciate cultural sensitivities, compare healthcare systems and consider social issues they had not previously. The best way to consolidate these experiences is after the elective itself, with active reflection on the different skills developed such as better communication skills and ability to work with people from diverse backgrounds (3).
The elective also provides students more time in a speciality of their choosing, which is exceptionally useful if they have not yet had a placement in it (4). This awards students many benefits such as deciding if the speciality is for them, developing a better understanding and observing its practice in a hospital with a different context. The experience will also put them in good stead for applications for speciality training. This time period can also be a chance to undergo a project, adding to their curriculum vitae (CV). In addition, students can go to world-renowned hospitals and network with doctors in the specialty of interest for future opportunities.
With this in mind, although the elective can have a significant role in medical education there is no structure for ensuring it, due to the great variability in experiences. Electives are the least structured part of the curriculum and do not follow the same rigorous educational objectives as other components (2) . This, and the fact it is student organised, is part of the reason they can often be regarded as a period of medical tourism rather than one for real learning. On the other hand, one could argue the additional challenges elective provides, should the student seek them, is excellent for their education (4). Nonetheless, much of the benefits are ascribed to an international elective but to insist students have to go abroad penalises medical students who are less affluent. These students tend to stay in the UK for their elective but will graduate to become equally competent doctors. Therefore the contribution of the elective to medical education is inconsistent, but its potential is great.
Therefore, the crucial question is whether we can replace what one would learn from a medical elective in a different format. Regarding global health, teaching with lectures and seminars have been happening throughout medical school, and continued during the pandemic. These have included topics such as effect of environment, socioeconomics, resources and climate change on health. This format standardises the knowledge for all medical students, and therefore can attempt to meet the GMC’s guidelines. However, the lack of first-hand experience means further efforts should be made. We could have additional online lectures from international institutions, and their personal experiences of practicing medicine in their country. Leaders in global health can give excellent insights into the different facets of improving health for all, and this could be arranged in an online conference format. Doctors of different specialities from around the world could give talks on how they practise to inform students on their favourite specialities. To partially replace the patient experience, one could explore the possibility of medical students joining online consultations, with the patient’s permission, in the speciality of their choosing. Research wise, medical schools could use established connections to bring together students and international doctors and set up a research programme, in the effort to offset the cancelled projects. Systematic reviews and review articles can be conducted and electronic patient data can be accessed remotely. Therefore, students may be able to achieve publications from home and improve their CV. Of course, co-ordinating all of this is no mean feat, but may be possible if medical schools recognise the significant educational loss of the elective.
In conclusion, the learning points the elective is claimed to deliver are not always met due to the diversity of experiences. A student’s personal involvement in another institution and country is irreplaceable, but the key points essential for professional development may be achieved without going outside the UK. Medical schools must teach the global health aspect of the GMC outcomes with lectures and seminars, independent of the elective completely. The experiences of students on electives vary hugely and to centre global health education around them is unrealistic. In addition, issues specific to developing countries need to be emphasised as students will not have a first-hand perspective. Opportunities to learn about different specialities and undergo research can be facilitated by online video calling. Therefore, my cohort missing out on a medical elective is an unfortunate consequence of the global pandemic, but our medical education does not have to be compromised.
1. Hastings A, Dowell J, Eliasz MK. Medical student electives and learning outcomes for global health: a commentary on behalf of the UK Medical Schools Elective Council. Med Teach. 2014;36(4):355-7.
2. Miranda JJ, Yudkin JS, Willott C. International Health Electives: Four years of experience. Travel Med Infect Dis. 2005;3(3):133-41.
3. Lumb A, Murdoch-Eaton D. Electives in undergraduate medical education: AMEE Guide No. 88. Med Teach. 2014;36(7):557-72.
4. Kusurkar R, Croiset G. Electives support autonomy and autonomous motivation in undergraduate medical education. Med Teach. 2014;36(10):915-6.