Re: International Electives

[Firsttimer]

Lol, House is an fictitious example. It's a little difficult to get into a discussion on modernity and modernity with regard to medicine, so I tried to use a convenient example. If you want better real-life examples of the exclusion of the patient, consult the Holmesburg prison trials or Tuskegee syphilis experiments for more dramatic examples. Or read any literature on the subject–I'm sure a simple google search will bring up a lot. Yes, talking to patients has been important for a long time, but the nature of the questions have changed throughout history. Modern medical praxis shifts questions from "how do you feel?" to "tell me where it hurts." Disease is the focus of attention with modern medical doctors, not the patient. This is why House is such a great example–in fact, it is obvious the writers are well-versed in discourse on the matter.

 

"How much medicine have you practiced?" LOL.

[A-Stark]

You're coming perilously close to making me invoke Godwin's Law. Attempting to define "modern medicine" by inhumane experimentation is laughable and absurd. House depicts medicine so far removed from reality that the diagnoses don't even make any sense (to say nothing of the curious lack of nurses, specialists of any kind, or general plausibility).

[Firsttimer]

Lol, yep, dramatic examples and I avoided the Nazi experiments for the sake of Godwin (though they and the doctor's that could not wait to get their hands on the 'data' are also excellent examples). However, they are excellent. They do depict the utter removal of the patient from the patient-doctor experience. You could also talk to any one of your older professors and ask them how the practice of medicine has changed (with regard to the patient) since they started practicing medicine. Again, you could just read literature on the matter. It is a common fact that modern medicine situates the patient as secondary to disease.

 

Unfortunately, our debate has strayed very far away from international medical electives, and since I've now achieved Godwin's Law, I think my part of the discussion has come to an abrupt end

[Firsttimer]

Can't help myself

 

Here's a list to start with if anyone is interested (I even found one on House, just for you A-Stark ):

 

The Afterbirth of the Clinic: a Foucauldian perspective on “House M.D.” and American medicine in the 21st century;

 

Witnessing and the Medical Gaze: How Medical Students Learn to See at a Free Clinic for the Homeless;

 

Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry;

 

William J. Donnelly, "The Language of Medical Case Histories " Annals of Internal Medicine 127, no. 11 (December 1997);

 

Andrew Goliszek, In the Name of Science: A History of Secret Programs, Medical Research, and Human Experimentation;

 

Allen M. Hornblum, Acres of Skin: Human Experiments at Holmesburg Prison, a True Story of Abuse and Exploitation in the Name of Medical Science;

 

James H. Jones, Bad Blood: The Tuskegee Syphilis Experiment, New and expanded ed. (Toronto: Maxwell Macmillan Canada, 1993);

 

Beckman HB, Frankel RM. The effect of physician behaviour on the collection of data. Ann Intern Mcd 1984;

 

"Why we need a new clinical method," Ian R. McWhinney....

[Mamie]

Well, condescension suits you well Firsttimer. You should consider a career in academics.... and I don't mean academic Medicine.

 

I guess that no one told you that assuming gets you no where. If you ever hope to enter and practice medicine you'd better remember that. Just FYI I'm not a science undergraduate student (and I do practice clinical medicine) but I'm sure lots of science undergrads are not nearly as poorly versed as you assume they are.

[Firsttimer]

Wow Mamie, I was hoping to be the complete opposite of condescending, especially given the attitude in your "check your facts" speech. I am only trying to carry on a discussion on a topic that I am passionate about. I am truly sorry if I have offended you, it was not my intention. I actually considered your comments to be a positive contribution to the discussion...

[A-Stark]

Lol, yep, dramatic examples and I avoided the Nazi experiments for the sake of Godwin (though they and the doctor's that could not wait to get their hands on the 'data' are also excellent examples). However, they are excellent. They do depict the utter removal of the patient from the patient-doctor experience. You could also talk to any one of your older professors and ask them how the practice of medicine has changed (with regard to the patient) since they started practicing medicine. Again, you could just read literature on the matter. It is a common fact that modern medicine situates the patient as secondary to disease.

 

Unfortunately, our debate has strayed very far away from international medical electives, and since I've now achieved Godwin's Law, I think my part of the discussion has come to an abrupt end

 

A common fact? And your references include papers by "critical theorists" who are probably very good at reading about medicine, but have no experience in medical practice (or education!). Osler would not approve; in fact, if you want some real insight into medical training and the sorts of approaches that have been in vogue for the last 80 years or so, a good Osler biography or similar text would probably be a lot more useful. Connecting this to the aforementioned experimentation, however, was an excellent way of destroying any remaining goodwill you were enjoying in this thread.

[Satsuma]

I think that Firsttimer brings up some good points about global health electives needing some improvements. Certainly, it is valuable experience to go abroad and participate and observe how medicine is practiced in a developping country. But many of these electives are not well structured. I think when they are formalized and part of an actual university, then maybe these are stronger electives.

 

I did an elective in Africa. While setting it up, one of my preceptors had asked why I wanted to do it. I told him many reasons, one of which included the possibility of being able to do things I would not have the opportunity to do here in Canada. And he replied...well you are just going to Africa then, the practice on black people. I think this is an interesting perspective. And it is true in a sense.

 

I did go to Africa, and not to my initial choice location. Instead in a much smaller place than I had planned. I was very much unsupervised as a 4th year student. And while this is surely unethical, I began to see that they were getting some better care with me than they would otherwise. On the flipside, I also missed diagnoses, and surely mismanaged some because of my lack of skill, and lack of knowledge regarding tropical diseases and even non-tropical diseases etc. And without internet access to look things up, well, hard to improve your knowledge base. Also, the way you are taught to manage something here, might not be the best way to manage something there, based on living conditions etc.

 

So, maybe some pts got better care than what they would have been getting if I wasn`t there. But it is fair to say that most got care that was substandard to what we would expect in Canada. In Canada, people seen by medical students expect to subsequently be seen by a certified physician or at least have the case reviewed with one. When we go abroad and practice medicine should we not be accountable and provide care of the same standards we would expect here? (excluding limitations as a result of resources, like medicines, and various lab tests...but more, not practicing outside your scope).

 

This thought really hit home for me, when people that worked in the clinic I was at, would bring me their relatives....specifically to me, asking me to take care of their sick loved one. Somehow, just because I was white, they trusted me. That is the complete opposite of anything that happens here. Nobody here trusts the foreigner. But where I was, they did. And people would come to the clinic, that wouldn`t normally, because they heard a "white doctor" was there. And I tried to figure out why that would be. And I asked alot about this. One person said, if you have bothered to spend all this money, and come all this way, then you must care.

 

When people give you this much trust, I really feel we owe it to them, to deliver quality care. I argue that unsupervised medical students (and it seems even premeds) don`t offer this. And I don't buy the argument that they would be getting better care then they would otherwise. It still isn`t really ethical in my mind.

 

I think international electives are valuable. And I dont think they necessarily have to contribute anything specific to the host country. I mean, I think as a student it is ok to do things for your own learning. But I do think that there should be a certain standard of care that is adhered to and a certain accountability.

[Jochi1543]

Thanks for the great post, Satsuma.

[Firsttimer]

A common fact? And your references include papers by "critical theorists" who are probably very good at reading about medicine, but have no experience in medical practice (or education!). Osler would not approve; in fact, if you want some real insight into medical training and the sorts of approaches that have been in vogue for the last 80 years or so, a good Osler biography or similar text would probably be a lot more useful. Connecting this to the aforementioned experimentation, however, was an excellent way of destroying any remaining goodwill you were enjoying in this thread.

 

Some of the authors are indeed critical theorists, and some are journalists (hardly credible, though still interesting to read and with a lot of interesting points), but some are also clinicians.

 

So the only expert on medicine is the doctor? I ask again, what about the patient? What about the recent report outlining how physicians and medicine are not meeting the needs of Canadians? Why do you think that is?? I also was careful to say that the human experimentation examples are indeed dramatic examples of the follies of modern medical practice. Another is saying that only doctors have anything valuable to say concerning medical ethics. It's completely arrogant. There is value beyond the world of medicine, and often, outsiders have excellent critiques of disciplines.

[A-Stark]

I agree generally with all of that, and I think the lack of adequate supervision and ability to do things you can't at home are problematic. However, at least part of the value of an international elective is to be exposed to different standards of care. Low-income countries lack resources for equipment, supplies, and simply for adequate numbers of health professionals. It is not unethical to provide care that is "substandard" when you are fundamentally limited by the resources of your location. The lack of supervision is problematic, but only to the extent that you are practicing with a degree of autonomy that is not commensurate with your level of training in Canada. Would a medical student with an equivalent amount of training from the host country be granted the same autonomy? If the answer is no, then there is a real problem, but if the answer is yes, then it really would depend on your own assessment of your skills. What seems clear enough, at least, is departing with the "right" reasons.

[Firsttimer]

Satsuma, thank you for the breath of fresh air!

 

I wanted to bring up exactly that perception of white Western doctors that you speak about in some of my earlier posts, but decided to avoid it. I was earlier accused of suggesting that there is coercion involved in the international electives. While I avoided before, I will discuss it now. Something that white Westerners cannot understand, unless they do some real work WITH people (not FOR), is that there very presence is coercion. Some residents (not all!!) of some countries have this perception that white doctors (especially white male doctors) are all-knowing and can solve any medical issue they might have. This is where the coercive factor comes into play. One's 'whiteness' causes the coercion.

 

"Race" is a very important part of what you are talking about in your post and that is a very important part of what I am trying to get across.

 

I agree that the benefit should not necessarily be to a country, however, I do think that it is possible to set up a system that does allow for greater benefit to individual communities and simply to individuals.

[A-Stark]

Some of the authors are indeed critical theorists, and some are journalists (hardly credible, though still interesting to read and with a lot of interesting points), but some are also clinicians.

 

So the only expert on medicine is the doctor? I ask again, what about the patient? What about the recent report outlining how physicians and medicine are not meeting the needs of Canadians? Why do you think that is?? I also was careful to say that the human experimentation examples are indeed dramatic examples of the follies of modern medical practice. Another is saying that only doctors have anything valuable to say concerning medical ethics. It's completely arrogant. There is value beyond the world of medicine, and often, outsiders have excellent critiques of disciplines.

 

Was that the report by Nick Busing and the AFMC? Having read most of your "Foucauldian perspective" article, it strikes me that you have erred in failing to present clear arguments (like Satsuma) and so continue to bring up overwritten, overtheorized, and jargon-laden pieces that, while solid exercises in critical theory, contribute little to nothing of value to Real World experience.

[Nobodycirclesthewagons]

 

I did an elective in Africa. While setting it up, one of my preceptors had asked why I wanted to do it. I told him many reasons, one of which included the possibility of being able to do things I would not have the opportunity to do here in Canada. And he replied...well you are just going to Africa then, the practice on black people. I think this is an interesting perspective. And it is true in a sense.

 

Do you mean he was saying "Just practice on black people here, instead of going to Africa?". What kind of point was he trying to make? Blacks in Canada compared to blacks in an African country are totally different. Well, more importantly, the culture/ideas are very different, so what was he trying to get at?

[GenericStudentDocName]

The heart of this matter is this.

 

Post-Modern Medical Standards would cite a certain level of ethical standards should be applied to decisions (whether treatments, research etc) involving human subjects.

 

These standards include proper procedures so that there is not exploitation and that there is a high-level of proof that certain treatments work - not just anecdotal evidence.

 

In the case of international medical electives - we have very little evidence as to what our exact impact is (whether good or bad) and whether what we are doing is positive. In fact, our level of evidence for our impact on the health of native populations is lower than the experiential evidence that is cited often by (sarcastic gasp) naturopathic physicians.

 

The common argument for doing these electives is that the student gets an experience.

 

Now, if I were to give you a hypothetical situation in which a doctor is providing treatment for which there is little evidence as to the impact; on patients that do not have a codified standard to protect their own rights (i.e. proper consent and education as to the treatment) - with his justification being that he needs to do it for his own experience of providing it (i.e. research results, proving himself right) - you would say that this would be unethical.

 

This is the biggest issue with international medical electives. You are providing care without proper consent (not to say that native people can't make decisions but I would argue the information and system with which they base their decisions to seek care isn't close to what it should be and is certainly not close to the protocols that we have in Canada) and without knowing its impact on patients and justifying it by citing one's own experience. This is very similar to the unethical research that was mentioned before and is the basis for the allegation of exploitation.

 

Just to further mention standard for proper consent. There are hundreds of companies running medical tourism and there is no single watch-dog that educates patients as to which ones are good and which ones aren't. Additionally, do the companies you work for get consent based on properpatient education that you are not even a medical professional? Can you in good consicence tell me that everyone you have treated understood your level of training and could properly consent to you specifically giving them care?

 

Addtionally, legally in Canada a family physician who preforms a colon resection and performs it poorly is put up to the standards not of other family physicians who perform colon resections but to the gold standard general surgeons. As such, a 4th year student providing primary care for patients - should be ethically compared to a family physician in Canada not to other 4th-year students and not the local population. (This may hold up for comparison studies on the impact of students' provsion of care but not for a physican's ethical duty of care). To take hyperbolous look, if a 4th year student were to perfrom surgery in Zambia - he should be ethically compared to a Canadian surgeon not a family physician who also performs surgeries in Zambia.

 

How bout the 4th-year student who was practicing tropical medicine without proper education? Would you ever put in a stent in someone without the proper training? I just seems that our lack of respect for life is troubling.

 

Now an argument may say that this could provide for better Canadian physicians if everyone did this (my only guess as to how this could be backed so wholly and blindly by medical schools (mine included)) but where is the evience for this? There isn't any good evidence (besides this isn't a good justification - exploitation for a better health care in Canada) As well, I would argue that any studies that did look at this would have major baises based on accurate outcomes.

 

So my question to A-Stark is how do you justify providing care to human beings without a standardized system for patient consent (amongst all of these tourism companies and even within the ones you have worked), evidence as to its impacts and then justify by saying its a good experience (i.e. I got something out of it so its justified)?

[blaaaax]

First off, I love this discussion.

 

Secondly, I see your point GenericStudentDocName but counter with this: do we really have such a system of consent in place here? Honestly? We tell ourselves we do, but when we approach a patient and tell them we are a first year medical student, they still place an inordinate amount of trust in us. I have never seen someone go out of their way to tell them how little we actually know.

 

I think the analogy is more apt than most people would like to admit - put simply whether we are in developing or developed nations we still practice on those who are not fully informed.

[Jochi1543]

 

I think the analogy is more apt than most people would like to admit - put simply whether we are in developing or developed nations we still practice on those who are not fully informed.

 

But is there any way to fix this? What should we do, carry around a syllabus of our courses year-by-year complete with the educational objectives and a printout of our exam marks? And also be prepared to read it outloud in case our patient is not literate? And have it printed in 80 languages in case our pt's first language is not English or French?

[blaaaax]

I'm not saying there is, that's the dirty secret of our training system. But what I mean is that while there are more checks and balances here to ensure that med students are not operating beyond their level of training, the patient is still not very informed. Therefore in my opinion when you go abroad on international elective it comes down to the integrity of the student, you and you alone are there to make sure you are not extending yourself beyond what you are capable of.

 

I know personally of situations where someone has gone abroad and exceeded those boundaries, and that is egregious. However, knowing how international electives can affect your training and indeed your entire career trajectory I personally find it hard to condemn them based on the unethical actions of (what is hopefully) a few.

[GenericStudentDocName]

How many clinical situations were you in here as a 1st year medical student in which you were providing direct patient care?

 

During the whole medical school process none of our decisions are ever final and at the very least when you introduce youself as a 1st-year student they know that you aren't a physician.

 

Though miscommunications that you mentioned may happen here to an extent; the problem is amplified in international medical electives to the point where comparison is difficult.

 

However, I understand the diversity of clinical settings, and , realisticaly, I am not even supposing that every person that comes in needs to be informed of you in every language - but standaradization of these companies (i.e. license) with protocals of what should be allowed for every level of student I think would be a good first step to protect patient rights. Obviously, people would go above this system but at least its a step in the correct direction.

 

This is what we should be advocating at this stage. That companies require licensure from the CMA to do overseas clinical work. Then at least there is a modicum of patient protection rather than the free-for-all currently in place.

[blaaaax]

The problem is most people don't go overseas with a company (at least in my circle). What do you propose if you are organizing one-on-one with a small hospital or an NGO?

[Firsttimer]

I would recommend the following (in abbreviated form):

 

At the level of the University:

 

1. Set up a formal and permanent professional/academic relationship/commitment with a university in a country that has one of Canada's official languages as one of its own official languages. Ensure that students speak French if it is a French-speaking country or English, if the alternative.

 

2. Set up professional exchanges at said university whereby a Canadian teaching doc(s) can go to immerse themselves in the cultural/medical/professional/etc. context of that particular country. On the flip side set up a reciprocal exchange for docs from the partner university to come and do the same in Canada. The long-term commitment by the docs will provide a bit of an ethical safety net.

 

3. From the long-term experience gained from the docs, create a core curriculum for global health (GH) at the university within the context of the particular country/university/region that is chosen and have a class(es) that highlight the cultural context of that region as well as the context of medical and health (social determinants) education in that country. Same goes for both universities. The class(es) would doubly serve the purpose of preparing the students in the way that the pre-departure training is supposed to.

 

4. Host electives in each country with the GH doc(s) acting as a facilitator(s) throughout the process. The docs would ideally have a daily briefing/debriefing session to help students work through the complexity that is global health.

 

One-on-one electives should be avoided to avoid the ethical conundrum spoken about above unless the med student is partnered with a doc from their own university that has been through 2-4 in that country.

 

I am aware that there are those that disagree that there is an ethical conundrum to begin with, but in any case...

 

Sorry, I'm in the middle of cooking supper and I've been too brief, but those are a few things I could think of.

[blaaaax]

I applaud your detail, I think something along these lines would be fantastic to implement. The pragmatist in me says we are a long way off however, as most schools are only now starting to integrate global health into the formal curriculum. In the mean time, I still believe in the power of international electives, and hope that students embarking on them educate themselves, reflect hard on what they are trying to accomplish, and hold themselves to the highest degree of integrity while on elective. Perhaps it is these students that will one day be in a position to establish a program as ambitious as the one you have laid out here.

[future_doc]

hey guys, if you are against plagiarism, I encourage you to report the ^ above poster who is selling term papers.