Year : 2014 | Volume
: 27 | Issue : 2 | Page : 143--147
Pre-departure training and the social accountability of International Medical Electives
Lauren J Wallace1, Allison Webb2,
1 Department of Anthropology, McMaster University, Hamilton, Ontario, Canada
2 Northern Ontario School of Medicine, Ontario, Canada
Lauren J Wallace
Department of Anthropology, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L9
Background: Due to widespread awareness of global inequities in health and development, participation and interest in International Medical Electives has grown. However, it has been suggested that the benefits of these electives for students and communities may not outweigh the harms. Pre-departure training (PDT) has been proposed as a route through which participants can adequately prepare for their elective experience. Methods: Through a review of the current literature, this article explores the ethics of international medical electives using a social accountability framework and assesses the success of PDT in mitigating harms for students and communities. Results: We find that the literature on PDT is limited. What is clear from completed studies is that the focus of PDT has often been centered on the clinical experience, while theories of development and health inequity remain minor topics. We argue that a greater benefit for students and communities could be gained from framing health inequity from a critical perspective, and integrating mandatory global health education into medical school curricula. Discussion: We suggest that attention to only PDT is not enough. In a socially accountable program, community partnerships must be bilateral and respect communities as primary stakeholders in the training of students and in program evaluation. Unfortunately, research to-date has focused on the student experience; further studies of the community perspective would help to elicit how PDT and partnership models can be strengthened, improving the experiences of both students and communities. Finally, individual medical schools and organizations that offer global health elective experiences must ensure that they take responsibility for monitoring PDT.
|How to cite this article:|
Wallace LJ, Webb A. Pre-departure training and the social accountability of International Medical Electives.Educ Health 2014;27:143-147
|How to cite this URL:|
Wallace LJ, Webb A. Pre-departure training and the social accountability of International Medical Electives. Educ Health [serial online] 2014 [cited 2019 Dec 6 ];27:143-147
Available from: http://www.educationforhealth.net/text.asp?2014/27/2/143/143745
The urgency of global health issues has come to the forefront of the public sphere in the last few decades. Through a rise in awareness of the suffering of others, particularly from preventable illness, an impetus for public action to reduce global health inequity has developed. As the public's awareness and interest in global health issues has burgeoned, so has the interest of medical students. Medical schools have begun to introduce avenues for student learning, leadership, and action on international health issues. ,,
One primary global health initiative that has been supported by medical schools is the International Medical Elective. These experiences provide students with the opportunity to practice and learn within global health settings, particularly in developing areas. Despite the growing popularity of International Medical Electives, many authors have expressed concern that there has been a considerable inattention by medical schools to the ethical dilemmas that may arise from these experiences. These authors have suggested that in some cases, the social benefits of electives for students and communities do not outweigh the harms. ,,,, To ensure that the benefits of International Medical Electives are greater than their costs, many authors have emphasized the importance of student pre-departure training (PDT). ,, Despite this suggestion, there has been little evaluation of the success of the implementation of PDT in reducing ethical challenges and increasing the benefits of International Electives for both communities and students. This paper explores the ethics of International Electives using a social accountability framework and evaluates the success of current PDT in making electives socially accountable. First, it is necessary to understand what exactly "social accountability" in medical education implies.
What is social accountability? "Social accountability" for medical schools was defined by the World Health Organization (WHO) in 1995 as: "The obligation to direct their education, research and service activities towards addressing the priority health concerns of the community region and/or nation they have a mandate to serve. The priority health concerns are to be defined jointly by governments, healthcare organizations, health professionals and the public". 
Since 1995, an international movement to make medical education more socially accountable has been occurring. As a result of the widespread interest in integrating social accountability into medical practice, many international communities of practice have developed. , One of the landmark initiatives responsible for developing a systematic approach to ensuring medical initiatives are socially informed is the Global Consensus for the Social Accountability of Medical Schools (GCSA), developed by the Global Health Education Consortium (GHEC). The consensus focuses on creating medical programs that will assist students to become lifelong community partners and gain a deeper understanding of the social determinants of health that affect their communities. This includes a focus on the competencies and cultural context specific to the population they serve, and collaborative partnerships in curricular development.  Although International Medical Electives are designed to reduce global health inequity, research suggests that these initiatives do not fully satisfy GCSA's principles.
The Social Accountability of International Medical Electives
Two main issues associated with International Medical Electives have been identified. First, it has been suggested that these electives tend to be a unilateral process focused primarily on providing benefits for students from wealthy countries.  Studies often advertise International Electives exclusively as opportunities for students to increase their personal and professional development. For example, authors describe how these experiences lead students to gain better language and clinical skills and cultural sensitivity, and increase student interest in working with underserved populations. ,,, Despite a focus on student benefits, there is much less specific mention or documentation of the tangible benefits of international electives for host institutions or patients. , Rather than benefiting host communities, studies suggest that these programs in fact can act as a drain on local staff time for patients in need, which places a burden on the local healthcare system. ,,
The focus on unilateral exchange in the literature suggests that International Electives are not fully socially accountable. Partnership, a key aspect of socially accountable medical practice and education, does not appear to be widely reflected in these initiatives. A focus on unilateral, rather than bilateral exchange between students and host communities is not only problematic because it places a burden on the health system but because it extends the historical legacy of paternalistic, unequal medical relationships between the global North and South. 
Second, authors suggest that the self-serving rationale behind International Medical Electives, which focuses on the importance of Western students gaining clinical skills, along with students' desire to help, is problematic in another sense. This is because these self-serving attitudes and altruistic desires can lead students to have inflated ideas about their skill as medical trainees. This may lead students to seek out tasks beyond their scope of practice, in a setting with limited medical supervision. ,, Alternatively, trainees can also be directly offered medical responsibilities beyond their capability by overburdened local staff who may see the presence of short-term trainees as an opportunity to take a break. ,
Research shows that opportunities for students to complete clinical tasks beyond their scope of practice can also arise from a local misunderstanding of their capabilities as a trainee.  As documented in several studies, situations where trainees practice beyond their capabilities represent a serious breach of ethical conduct and place local patients at risk of medical harm. ,,, The potential for medical harm is particularly significant in international electives because students trained in a Western medical context often lack the cultural and linguistic capabilities required to fully communicate about and understand health in resource-poor settings. ,
The documentation of medical students' completion of tasks beyond their scope of practice without adequate medical, social, linguistic, or cultural knowledge is entirely incompatible with the concept of social accountability. As emphasized by GHEC, socially accountable medical practice requires physicians and medical students to have the competencies required for providing medical care in the communities they serve, including medical, cultural, and ethical skills and knowledge.  The fact that International Medical Electives, initiatives that are designed to reduce global health inequity, are not fully socially accountable is problematic.
PDT has been promoted repeatedly as a mechanism to ensure students are adequately prepared to assist rather than harm the communities they work for. ,,, However, the literature on PDT and its ability to improve International Medical Electives is scant. Here, we review the existing studies on PDT and make recommendations for future research.
Studies on the issues associated with International Medical Electives have frequently called for formal ethics-focused PDT for students. Authors argue that adequate PDT will build trainee competence for global health work, which will allow students to better face ethical dilemmas in the field. PDT is also promoted as a way to ensure students better understand the social, cultural, political, and historical context of the communities where they work. This preparation is said to minimize potential harm to patients, research subjects, and communities. ,,,, These objectives are certainly in line with the promotion of social accountability, which emphasizes an understanding of and action to ameliorate local health issues.  However, the impact of PDT on the social accountability of International Electives appears merely anecdotal at this point.
Internationally, there are limited publications describing training for medical undergraduates. Anderson and colleagues, through their study of Canadian medical schools, provide one of the only comprehensive reports of global health PDT. They report that in Canada, 16 of 17 medical schools offer such training. However, of the schools that offer PDT, there are major differences in content, length and duration of the training, and students are responsible for organizing many PDT programs.  Although research on PDT has been completed in North America, , the literature on International Medical Electives outside of the region is limited.
Despite the lack of data available on PDT, what is clear from existing studies and reports is that training for International Medical Electives tends to be predominantly biomedical in focus. Topics such as the protection of personal health, specifically the prevention and management of infectious diseases, are commonly recommended for and found in global health training modules. ,, Where cultural and social issues are considered, their description is often accompanied by a lapse in structural analysis, specifically, an understanding of critical perspectives on development and the importance of imperialism and historically unequal power relationships in defining global health inequity. ,
To improve global health training, authors have argued for training that moves beyond the typically clinically defined model of biomedical education to a more critically placed pedagogical approach. Such an approach avoids the replication of the status quo to foster self-awareness, humility, and an ability to understand and challenge the deeper structural inequalities that underlie poor health. , Hansen and colleagues, for example, suggest a self-reflective, critical, and transformative pedagogy not located in the clinical domain that encourages students to question and challenge health inequity.  Similarly, Pinto and Upshur advocate for a critically oriented approach to global health education, one that is based on the principles of social justice, and incorporates understandings of development, and frameworks and theories that promote human rights. In addition to social justice, Pinto and Upshur argue that a critical approach to global health education should include the values of humility, introspection, and solidarity.  PDT that adopts such a critical perspective is necessary if International Electives are aimed at fostering a collaborative approach, and developing student competencies in global health. More research should be completed to analyze the frequency and form of critical pedagogies in PDT and their impact on students' ability to understand and ameliorate global health issues.
The limitations of PDT for International Medical Electives reflect a larger neglect of comprehensive global health education in the curriculum of medical schools.  In Canada, for example, some undergraduate medical education programs offer elective courses in global health, but there are few programs in Canada with mandatory curricular components in global health.  Researchers have called for more global health curriculum in medical schools in order to ensure that students are better prepared to work with different cultural groups, both at home and abroad. , From our perspective, the inclusion of global health in the medical curriculum is also important because issues of global health and health inequities are complex and require critical pedagogical techniques. As such, they require a longer-term commitment to learning than the typical timeframe provided by PDT.
Beyond Pre-Departure Training? Although PDT is an important component of a socially accountable elective, PDT must be embedded within a focus on the larger principles of social accountability. According to GCSA, a socially accountable medical institution will not only assist students in lifelong learning and skill acquisition to develop a competent medical workforce, but will also satisfy larger principles of social accountability. These include working in partnership with stakeholders in the design and implementation of service programs, including local communities, and supporting continuous evaluation and quality improvement. 
Partnerships between host institutions and agencies are essential specifically, for quality improvement, as well as the overall social accountability of PDT and International Medical Electives. To be truly socially accountable, students must gain knowledge in not only the larger, broad principles of global health, but also develop specific competencies consistent with the communities they serve.  Certainly, through their elective, students may automatically gain an understanding of the local issues that pertain to health. However, communities should also be engaged as primary stakeholders in the development of learning outcomes and curricula for the elective, including for PDT. Through community involvement, student training can focus on ensuring participants have an understanding of the specific ethical and cultural framework of the communities in which they work. In this way, the host community can become a partner in the educational and quality improvement process for electives.
Unfortunately, research has focused primarily on the student experience, rather than also eliciting the perspectives of local physicians, and community organizations and members on International Medical Electives. , As a result, the conditions supportive of a high quality partnership between communities and agencies are not well understood. Further research with community partners is essential to improving the quality of partnerships between medical schools, students, and local organizations. This research could involve completing case studies of specific successful projects to understand how successful partnerships have been developed, and their contribution to student learning and impact.
Aside from generating more research on effective partnerships and PDT, it is important for medical schools to take responsibility for ensuring that students are adequately prepared for their electives. The responsibility for overseeing International Medical Electives and PDT should be delegated to a specific faculty member, or committee. If resources allow, a coordinator with international medical experience should be hired to ensure that students have the support and mentorship they require. This individual should ensure that general medical curricula does not only broadly articulate the clinical diversity, ethical challenges, and difficulties in administering care in a cross-cultural setting, but that it also articulates the complex economic, political, and cultural forces and processes that lead to global health disparities. Organizations that offer global health experiences and International Medical Electives should work toward building global health competencies (such as partnering with local health experts, as advocated by GHEC). Such groups can work toward developing a PDT program that incorporates social justice and facilitates the development of a clear understanding of global health as well as the specific sociocultural and political context of a student's elective site.
International Medical Electives are presented by medical schools and international organizations as opportunities that provide students with the ability to understand and reduce global health inequities; yet, research on electives reveals that these experiences may not be fully socially accountable. We have explored the ethics of International Medical Electives using a social accountability framework and evaluated the success of current PDT in making global health electives more socially accountable. An examination of the current research reveals that although PDT is stated to minimize potential harms to patients and communities, evidence of the frequency and form of PDT, and the actual links between PDT and the social accountability of International Medical Electives is limited. Our exploration reveals that a critical pedagogical PDT, which offers education focused on the principles of social justice, may offer the best training for student clinical experiences in global health, and that this training should be embedded into the medical school curriculum.
However, we argue that attention to PDT and the development of general global health curriculum in medical schools should be accompanied by attention to the larger principles of social accountability. Perhaps the most important principle of social accountability is developing partnerships with the local communities in which International Medical Electives take place. Engaging communities as primary stakeholders in the development and evaluation of International Electives and associated PDT would ensure that high quality experiences for students and communities result. More research on the perspectives of the communities involved in International Medical Electives should be elicited to understand how students can be better prepared for their experiences in global health. Finally, individual medical schools and organizations that offer global health elective experiences must ensure that they take responsibility for monitoring PDT.
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