International medical electives undertaken by Australian medical students: current trends and future directions

In response to the increasing interest among medical students and junior doctors in studying and practising medicine abroad, the Medical Journal of Australia recently published A guide to working abroad for Australian medical students and junior doctors.1 It is in the context of increasing interest in global health2 and in the spirit of supporting young medical professionals that this study examines international medical electives (IMEs), specifically the number of Australian medical students undertaking them, and the support provided to those students by Australian medical schools.

Electives are a compulsory component of all medical curricula in . They are usually undertaken during senior clinical years over 2 to 8 weeks, either in or overseas, in both high- and low-resource settings. Consistent with increasing interest in global health, IME rates have been found to be high in the and increasing in the .2,3

Many benefits of IMEs have been described. Students report less dependence on technology; improved clinical, diagnostic and communication skills; better knowledge of tropical diseases and immigrant health; and better understanding of prevention, primary care and public health.2,4 Participation in IMEs influences students' career choices towards primary care specialties, graduate education in public health, and working with underserved populations.5,6 In contrast, the potential benefits to communities hosting students on medical electives have received little attention and are poorly understood.4

IMEs also present potential risks and harms to both the student and the host community. Risks to the student include transmission of disease, needlestick injuries, traffic accidents, crime-related injuries, and mental health problems.7 Potential harms to host communities, particularly in developing countries, emerge from a power imbalance between visiting students and host communities, and the potential for students focused on learning objectives to compromise patient care and community wellbeing.8 As a result, IMEs may falsely raise expectations, impose burdens on local human resources, and impede continuity of and access to care, ultimately compromising equity and sustainability.9

Predeparture training and post-elective debriefing can provide students with guidance and support to reduce potential harms and maximise the benefits of IMEs.10 Predeparture training prepares students with the tools to manage the ethical, cultural and logistical challenges they may encounter. Postelective debriefing provides a forum for students to discuss and explore any issues that arose, consolidate learning, and encourage the development of students as responsible doctors.

At present no study has evaluated the proportion of Australian medical students undertaking IMEs and the support offered by Australian medical schools. This study set out to remedy this evidence gap.

The Medical Schools Outcomes Database (MSOD) is a national initiative for longitudinal tracking of medical students through medical school and into prevocational and vocational training;11 it began collecting data nationally in 2006. In May 2012, we obtained data from the MSOD covering the period 1 January 2006 to to establish the number of students who undertook IMEs. Students consent to participate in the MSOD project in their first year of medical school, and are subsequently included in annual follow-ups. Therefore, the 2006 data only include Year 1 students, the 2007 data include students in Years 1 and 2, the 2008 data include students in Years 1, 2 and 3, and so on. As a result, four cohorts of students within the dataset had graduated and were used to estimate the total proportion of medical students who undertake at least one IME during their degree. Students who took more than one IME were counted once, and we estimated cohort size using the total number of students who were registered in the final year of their medical course.

We also conducted structured interviews with academic staff from 16 of the 19 Australian medical schools (those at the University of Notre Dame in Sydney and Fremantle have different curriculums and are considered as separate schools in this study). Data were collected from Australian medical schools between May and July 2012 and reflect the program status at that time.

We divided medical education programs into high-school entry (HSE) programs (5- or 6-year programs that admit students after they complete high school, although some students may have a prior degree) and graduate-entry (GE) programs (4- or 5-year programs that require students to have a prior undergraduate degree). Programs with a mid-year intake (ie, 4.5-year programs) were treated as 5-year programs.

We collected data on predeparture training and postelective debriefing independently from each medical school in . Data were collected in cooperation with the Australian Medical Students' Association (AMSA) and the AMSA Global Health (AGH) Committee, which comprises student representatives from every medical school in Australia. AGH Committee representatives were provided with letters of introduction, information sheets, consent forms, interview scripts, and response forms. Representatives were asked to gain consent and conduct an interview with the director of their medical program.

The income status of countries where students undertook electives was based on the World Bank Atlas Method. Lower- or middle-income countries included countries with a gross national income (GNI) per capita of less than US$12 275.12 For the purposes of this analysis, states that remain protectorates were placed in the same category as the protecting country.

Ethics approval for release of MSOD data was granted by the Medical Deans Australia and New Zealand Research and Scientific Advisory Committee (SA-2012-003). Ethics approval for data collection from medical schools was granted by the Social and Behavioural Research Ethics Committee at (Project N 5561).

Participation in the MSOD over our study period averaged 88% of students enrolled at Australian medical schools.11 The four cohorts in our study included the 5-year HSE program cohort that commenced in 2006, and three GE cohorts (the 4- and 5-year program cohorts that commenced in 2006, and the 4-year program cohort that commenced in 2007). Our findings on students in these cohorts who undertook IMEs are summarised in the Box.

Currently, 12 of the 16 Australian medical schools interviewed offer some form of predeparture training. However, in only six of these schools is predeparture training mandatory. The average duration of predeparture training is 4.7 (SD, 4.22) hours. By comparison, eight schools offer some form of postelective debriefing. However, in only three schools is this mandatory. The average duration of postelective debriefing is 1.2 (SD, 0.91) hours.

Our findings show that a significant proportion of Australian medical students undertake IMEs, and that more than half do so in developing countries.

Our estimates show that a greater proportion of Australian medical students undertake IMEs compared with US medical students. The estimated proportion of US medical students who undertook IMEs in 2007 was about 30%, and all of these were GE program students.13 By contrast, a study from the UK (where most medical schools offer HSE programs) estimates that 90% of medical students undertake IMEs, with 44% of them doing so in developing countries.3 While a much smaller proportion of Australian GE and HSE students undertake IMEs than UK students, a greater proportion of them do so in developing countries.

Considering that a significant proportion of Australian medical students undertook electives in developing countries, it is concerning that predeparture training and postelective debriefing are not offered to all students, and that what is offered is not always compulsory. However, improvement is achievable. In 2008, only 11 of the 17 Canadian medical schools offered predeparture training, and in only six of these was such training mandatory.14 By 2010, this had increased to 16 out of 17 schools offering predeparture training, with 11 making it mandatory.15 A similar transformation in is both necessary and possible.

Our study was limited by the lack of data for Year 6 HSE students, relatively small cohort sizes in senior years, and less than full participation in the MSOD program. Nonetheless, our data provide a foundation for further research into the content of predeparture training and postelective debriefing and financial support offered by Australian medical schools, as well as the benefits and acceptability of predeparture training and postelective debriefing programs to students. We encourage medical schools to scale up predeparture training and postelective debriefing that adequately prepare students to undertake safe and ethical electives. We also recommend that a similar study be repeated in 3 to 5 years to evaluate progress in predeparture training and postelective debriefing.