Sunday, September 28, 2008

Medical students abroad: a risk for resource-poor countries?

Something that I have been noticing lately is an increasing numbers of American university students -- both graduate and undergraduate -- doing research or a clinical elective abroad. The push for students to 'go global' is being strongly encouraged by our university and is reflected in the creation of new institutions and initiatives. As university IRB co-chair, I am seeing more more and more proposals of student-led studies to be conducted in Ghana, Haiti, Namibia or Indonesia. Sending students out to do research or gain practical experience in developing countries is part of a general trend in the United States and Europe. Note that, in this context, 'global' often boils down to students of (relative) affluence furthering their education by engaging with the foreign poor.

This phenomenon has a lot of positive aspects. It is obviously good that students have the opportunity to broaden their perspectives and gain experience by working or doing research abroad. It at least goes some small way in countering the medical 'brain drain', i.e. physicians from developing countries seeking greener pastures in better-off countries. But as Suneel Bhat argues in the September 27th issue of The Lancet (subscription required, goddammit), we should be concerned about the potential risks posed to patients when young doctors-in-training work abroad as part of their educational programs. The primary concern, according to Bhat, is that the doctors-in-training may be in a position where local institutions or patients expect or demand that they render medical services that they are not yet qualified to deliver. There are, however, many unknowns in this area: we don't know how much developing countries actually benefit from the presence of budding first-world physicians, in relation to the benefits reaped by patients in the developed world whose physican has (so to speak) cut his or her teeth on patients in resource-poor countries. We also don't know the incidence of malpractice and medical error committed by doctors-in-training working abroad. Maybe the incidence is not very high; maybe it is significantly high, but there may be no mechanism for reporting, or perhaps local medical institutions profit by being hosts of foreign medical students and therefore don't raise a fuss. It is hard to say.

Probably the most controversial part of the paper is where Bhat raises the spectre of ethical review. Given at least the potential risks, Bhat asks, might the activities of foreign medical students be subject to something like the ethical review of research? Unfortunately, Bhat does not say how that would actually work when you are talking not about researchers, but clinicians-in-training. How could their clinical activities be subject to something like ethical review abroad, when such activities are not under similar scrutiny at home? What is lacking with medical student activities abroad (and also student research abroad) is often lack of direct and authoritative mentorship -- the worst case being when a student is sent to some village to fend for him/herself. If the competence of the student is still limited, the villagers have serious and complicated health problems, and local health care resources are scarce, then the risk of 'adverse events' increases, possibly traumatic for both the budding physician and patient.

Hat tip: Lilian's Muli Bwanji blog. Lilian, an ex-student of mine, is currently in Lilongwe (Malawi) working on her PhD in Epidemiology.

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Blogger Jim Sabin said...

Hi Stuart -

Thanks for the tip about Lillian's excellent blog. In one of her postings she spoke about students from the UK who come to Malawi to get clinical experience they are not allowed to get at home. That's a real worry. I've been much more sanguine about international study because the students I see at Harvard Medical School who do placements in developing countries are largely interested in global health equity type issues rather than in buffing up their clinical skills. In the Lancet article Suneel Bhat notes the relative absence of studies of the impact of these placements. This is important research to do. I'm going to keep an eye out for students who might want to do this kind of work on international placements as their own placement project!

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