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Medical electives have long been part of the undergraduate curriculum, and many students choose to undertake a placement in a developing country. In countries where healthcare provision is hugely underresourced, students have found themselves under pressure to exceed their role. They have been expected to diagnose and treat patients without direct supervision from a qualified doctor. Some have found themselves running clinics and wards; others have found themselves to be the most qualified person available.1,2
The British Medical Journal believes students should not take on the role of a qualified doctor, “irrespective of any encouragement which students may receive from members of the host organisations to which they are attached”.3 This includes not diagnosing, prescribing, or treating any patient without strict clinical supervision. They feel that students fail to appreciate the dangers of treatment, particularly where familiar medical problems are complicated by unfamiliar poverty. Their deontological view is saying that students should treat their work in the developing world exactly the same as they would in their home countries. It is unethical to “practise” on the local population because it has the misfortune to be poor.
Others have advocated a utilitarian view; that some help is better than none at all, and that medical students are in possession of knowledge and capabilities that place them under a moral obligation to use their skills for those in need.2,4
While we in the developed world agonise about the levels of responsibility during electives, what do native healthcare staff, those actually living and working in the developing world, think? Surprisingly, there are no published studies in this area.
METHODS AND RESULTS
A questionnaire was administered to all healthcare staff at one hospital in a developing country: Helena Goldie Hospital in the Solomon Islands. It asked whether they believed medical students should be allowed to diagnose, treat, and prescribe without direct supervision from a qualified doctor. Staff were also asked what they believed students were allowed to do in England without direct supervision. The response rate was 84.8% (39/46).
The majority of healthcare staff believe medical students should be allowed to diagnose (94.9%), treat with practical procedures (89.7%), and prescribe drugs (84.6%) without direct supervision during their elective. The majority of healthcare staff do not know that students are not allowed to perform similar roles in England without direct supervision (table 1).
The majority of healthcare staff believe medical students should diagnose, treat, and prescribe drugs without direct supervision in the Solomon Islands. Possibly this is because staff consider, through years of hosting elective students, unqualified medical students do possess certain skills that enable them to have this level of responsibility. Furthermore, staffing structures in the Solomon Islands differ from those in England. Nurses are allowed to prescribe drugs and many make diagnoses themselves. The staff may not think a doctor is necessary to supervise a medical student as there is invariably an experienced nurse around to oversee their actions. A big lifesaving intervention in the Solomon Islands is the use of antibiotic therapy. The prescription and dispensation of antibiotics by medically unqualified personnel, including medical students and nurses, surely does more good than harm in the prevention of considerable mortality and morbidity?
The results show that most staff do not perceive a difference between the role of a medical student in England and in the Solomon Islands. Thus it could be said that students are “practising on the poor” by exceeding their normal role without the host institution realising but with their full blessing. This appears to be due to lack of knowledge about medical education in developed countries. Most staff do not know that English medical students are not allowed to diagnose, treat, and prescribe without direct supervision from a qualified doctor in their home country.
All countries are unique so it is hard to generalise the results to other nations. However, healthcare staff worldwide should be made aware of the role of medical students in their home countries so they can make informed decisions about the level of responsibility to give these students during their elective placement. This would vary between universities as the elective period is undertaken at different stages of the medical course in different institutions. It would help alleviate the moral dilemma faced by students expected to exceed their normal role, while giving the host institution autonomy about whether students can “practise” on their patients.
My thanks to Dr Jayne Parry, Department of Public Health and Epidemiology (University of Birmingham) for her help with the statistics.
SJJR received a £500 bursary from the Institute of Medical Ethics towards this project.
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