Literature selection results
The results of the advanced search of databases is shown in the PRISMA diagram Figure 1. The searches yielded 1413 studies. Following removal of duplicates and studies not meeting inclusion criteria, 37 papers were included in the scoping review. Final papers included in the review are listed in supplementary Table S1.
Overview of the selected studies
Travel destinations were mostly based in Sub-Saharan Africa (including Malawi [17,18], Zimbabwe [17], Zambia [18], Uganda [2,19,20] Tanzania [18,20], Botswana [21,22], Ghana [23,24], Benin [25], Kenya [17,26] and South Africa [19,26,27]), but also included other LMICs such as Solomon Islands [8,28,29] and India [2,17,22,26]. Students described in the studies mostly came from the USA (including Michigan [24] and Pennsylvania [21]), the UK (including London [17], Oxford [30], and Birmingham [31]), and Canada [2,22,26,32].
There were a variety of types of papers, including interviews with students and clinicians, descriptions and evaluations of existing teaching and exchange programs, as well as editorials, literature reviews and a letter to the editor. For the purpose of this analysis, rather than being grouped by the type of journal article, the papers were grouped by the “perspective” on which they were based. The first group was publications based on interviews and reflections of students returning from electives (14 papers) [8,17-20,22,24,26,27,29,31-34]. The second group consisted of publications written by members of host institutions in LMICs, or based on interviews with them (5 papers) [2,25,28,35,36]. The third group was publications which were produced by neither of these groups, consisting primarily of editorials, systematic reviews, and guidelines written by universities (18 papers) [5-7,9-14,21,23,30,37-42].
Summary of main results
Papers were analysed with respect to the five focus themes and the number of papers addressing each of these themes is illustrated in Figure 2A. Many papers mentioned more than one theme. To see which ethical dilemmas were predominantly explored by travelling medical students and which by host institutions, these data were further broken down to show the number of student and host papers addressing each theme, as shown in Figure 2B. Of note, there were fewer host-perspective than student-perspective publications.
Exceeding clinical competence
As seen in Figure 2A, exceeding clinical competence was the most commonly mentioned of the pre-defined themes. In interviews with UK medical students who travelled to Solomon Islands for a 4-week elective, a key finding was that students reported being asked to carry out tasks which they would not be asked to perform in the UK [8]. The attitudes towards whether or not it is ethical to act outside of one’s scope of competence were also mixed. In a study by Wiskin and colleagues, 379 students returning from electives were interviewed and 49% respondents said it is “more acceptable to work outside of the UK parameters” in LMICs [31]. In some studies, respondents reported that they “chose to go on an IHE because they anticipated having more opportunities to practise clinical skills” [26]. By contrast, in other studies students expressed difficulty assessing whether they were competent to carry out a procedure, especially in an unfamiliar setting, which made them reluctant to carry out tasks [8,25].
One-sided benefits in partnership
Some papers discussed the need for establishing bidirectional travel programmes as opposed to unilateral ones [2,24], and identified administrative, financial and language barriers which can prevent students from LMICs from travelling to a HIC) [38]. The importance of exchange of teaching and ideas between the institutions was also discussed [21,30,42]. One report of an elective partnership between UPenn and a hospital in Botswana suggested that this can be done through including the host institution in research, abstracts, and posters [21], while another paper focused on use of peer-to-peer teaching [42]. Some papers found that the lack of benefit to the host institution from accepting visiting students is largely due to inadequate preparation of visiting students prior to embarking on their elective placement, and the short duration of placement [30]. Borah and colleagues evaluated a year-long elective partnership between Loyola University Chicago Stritch School of Medicine and a clinic in Bolivia, and found that the longer length of stay mitigated many ethical challenges associated with travel to LMICs, as it allowed the students to “become integral and accountable members of a full-functioning healthcare team” and “long-term responsibilities may decrease the potential burden that they could otherwise impose upon their host site” [11].
Respect for patients and local culture
A common point discussed within the theme of “respect for patients and local culture” was the idea of consent. In a paper based on interviews with students after electives, a student reported that she wished to obtain consent from a patient before examining her abdomen but did not do so because she felt “constrained within the local medical hierarchy”, while another respondent discussed the ethics of “the idea that privacy seemed not to exist” [26]. In a series of interviews with members of host institutions, many respondents reported that “students had higher standards than expected” and one respondent explained that students “sought informed consent before practising procedures such as injections or physical examinations” which was not routinely done in their institution [25]. Willott and colleagues explained that this discrepancy between expectations in obtaining consent can stem from practical limitations, as “contact time with patients is sometimes so limited that there is no opportunity for discussion or any meaningful choice other than to forgo treatment, as typically happens in public hospitals in India” [23].
Use of limited local resources
Although overall in this review, there were more student papers than host, more host papers than student papers mentioned this particular theme. One paper detailed a “Responsible Elective” programme set up by Dundee Medical School which aimed to promote an ethical partnership with a centre in Malawi, with the expectation that students will fundraise for the centre. The aim was for students to recognise “that these experiences, particularly in LICs, can consume already limited resources at host hospitals with limited benefits for them” [23]. In another study, clinicians from host institutions said that financial support from partner institutions could help offset some of the costs of hosting elective students, such as hiring translators [35]. In addition to financial resources, some papers recognised the use of other resources. Several papers identified that elective students use the supervising clinician’s time [2,11,26], and that presence of elective students increases clinician workload [25].
Collaboration with local community and colleagues
Analysis of “collaboration with local community and colleagues” revealed the importance of elective students being educated about ethics and following local laws. In an overview of the ethical and legal frameworks of short term experiences in global health, Rowthorn and colleagues stressed the importance of working together with local community leaders and that “university leaders and advisors must educate their students about ethical engagement with communities” [12]. In another paper, the role of students’ pre-departure briefings and guided reflections was raised as a way to ensure ethical behaviour is promoted and students are seeking genuine collaboration with the local community [5]. It also addressed the notion that policies around professional standards during electives should be developed and “these policies should be created in collaboration with host institutions” [5]. In a series of interviews with members of host institutions, the importance of long-term collaboration was highlighted, whereby elective students could establish networks within the local community, and return after graduating as researchers or teachers [36].
Inductive themes emerging from the papers: Negative impacts on local students and patients
The first theme which emerged during our review was “negative impact on local students”. In a multicentre study by Kumwenda and colleagues, based in 7 elective sites in sub-Saharan Africa, there were reports of difficulty making schedules for elective students which would not interfere with ongoing teaching, and problems emerging “when clinical staff assigned to supervise visiting students were also expected to teach local students” [35]. Another paper by Willott and colleagues reported that “clinicians and others in LMIC settings can devote disproportionate amounts of their time teaching and concerning themselves with the visiting HIC medical students on elective to the possible detriment to their own students” [23]. This idea was also discussed by Elit and colleagues, who in a series of interviews with elective students found that “health care staff often focused on the needs of the Western medical students” [26]. Interestingly, the majority of papers written from host perspective mentioned the negative impact of electives on local students [2,35,36]. By contrast, in papers written from visiting student perspective, this theme was only addressed in one [26].
The second theme which emerged was “negative impact on patient care”. When looking at the papers addressing limited local resources, it was found that 6 of them mentioned that visiting students may have a detrimental effect on patient care [2,9-11,25,26]. In a series of interviews with supervisors of elective students in 22 countries, Bozinoff and colleagues found that “host supervisors identified potential harms to patient care that might arise in the presence of visiting medical students, including harms associated with differing standards of care, longer wait times, lack of cultural competency, and language barriers between students, patients and staff” [2]. In addition to this, papers found that elective students can negatively impact care because “adequately supervising them diverts human resources from providing care” [10]. Interestingly, two host-perspective papers mentioned negative impact on patient care [2,25], while only one student-perspective paper did [26].