All eight medical students in SSMEE agreed to participate in the research. However, the two students from the University of Rwanda had not undertaken their elective within the intended time frame due to delayed student selection by the university and restrictions as to when their elective could take place within the academic calendar. As such, data from six of the eight students is presented, each identified by a letter from A-F. The six students undertook an elective in Malawi, Rwanda or South Africa, however, the elective destination is not specified as this could breach student confidentiality.
Value of the Elective
Interview data highlighted the perceived value for students, which has been grouped into four categories: clinical knowledge and skills, personal and professional development, attitudes and global perspectives. Although the data was independently analysed, the same themes emerged as presented in Figure 1(5-8) hence the same themes were used.
Clinical knowledge and skills
All six students described the elective as providing opportunities to apply and develop their clinical knowledge and skills, such as: history taking and examination skills, communication skills, diagnostic capabilities, and practical procedure skills. Sometimes this was by exposure to diseases, such as schistosomiasis and malaria not encountered in their own hospital setting and in other cases it was the application of previous learning. Some students felt more independent in patient management, such as examination of the neurological system, auscultation of cardiac murmurs and placing central lines, chest drains, using sonography for trauma assessment and use of a defibrillator, not readily available in their own institution. An example of this type of learning is:
“I was able to see and interpret MRI images something I hadn’t had adequate opportunity to do at my college…..picked up some techniques they used while operating….improve my capabilities in taking a focused history and what to look for as we examine patients depending on the working diagnosis” (A)
This elective also led some to reflect on differences between their elective experience and how things were done in their home institution as well as the application of their learning:
“I realised that patients were being explained everything and being involved in every step of the way including them to write in the file what they had understood and sign against it. I found this very striking since back home, we mostly talk to rather than talking with the patients. I am going to practice this and share it with my colleagues” (B)
“I had a patient with a severe head injury [in home country], and I used the principles that I had been practising in [elective country]” (F)
All students felt their learning was applicable to their home context.
Personal and Professional Development
The elective resulted in students’ personal and professional development in areas such as vocational drive, meeting their own goals and improving confidence:
“In terms of myself, it reaffirmed me that I was in the right profession and that I was becoming the competent doctor I've always wanted to be... Before the elective, I didn't think I'd be comparable with a student in a different institution but now I know I can be and there's no excuse for not dreaming big.” (F)
Personal attitudes were challenged resulting in a desire to change, e.g. be kinder to patients or less wasteful of resources.
“I am advantaged compared to my peers to know some more but I also share with them the ideas and knowledge.” (A)
Students experienced different languages, cultures, healthcare systems, beliefs/values and diet allowing them to reflect how this impacts local populations and look at their own background and healthcare system from another perspective.
“The culture had a toll on health-seeking behaviour. Most of the patients believe in traditional medicine and therefore would visit traditional healers and only come to hospital when everything failed, therefore they would present late to hospital!” (A)
Students recognised that teaching methods vary between countries and highlighted their positive experiences of elective-based teaching:
“I observed that the professors and lecturers (at least the ones that taught me) are not intimidating and always want to teach students. It is somehow different to [home country] where sometimes you feel intimidated.” (E)
The feasibility of SSMEE was explored by considering student's perceptions of an IME in another African country and the challenges they anticipated or encountered.
Students described their feelings about IME in another African country. Initial attitudes among the six students varied, with some changing over time. Students A and B were happy to have the opportunity to go anywhere. Students D and E initially preferred to go out of Africa. With hindsight, however, student E recognised the elective undertaken provided him/her the opportunity to see something different, as s/he had desired, and student D is now motivated to visit more African countries rather than leave Africa because “there is a lot more to learn especially in Africa with regards to resource constraints and the burden of disease.” Student C, also favoured the elective within Africa:
- “The disease burden within Africa is similar, …, by staying here you are learning similar things just in a different way and different place.
- From my understanding, African countries have more hands-on learning opportunities because medical students are more hands-on.
- Charity begins at home, so why travel across an entire ocean for something you can achieve in your own backyard.
- Africans should build and support other Africans, and this is a good way to do that.”
Student F initially associated ‘elective’ with leaving Africa, however, had “such an amazing experience…can't imagine having the experience I had in an outside [of Africa] country”
Challenges Anticipated or Encountered
In the pre-elective questionnaire, five of the six students identified potential concerns such as: getting lost, communication, cultural awareness, the potential for culture shock, insufficient personal knowledge and skills, safety and money shortages or non-functional bank cards. Actual challenges encountered were discussed in post-elective interviews:
Each student received a 1000USD bursary towards elective expenses. Students were asked how much their elective cost and five of the six students provided figures. Costs ranged from 900USD to 1600USD. At least four out of six students required further funding. Four of the six students supplemented the bursary with their own finance obtained via family or friends. Only two students had additional costs covered by their own University. For those covering their own additional costs, limitations of funds had a considerable impact:
“I mainly faced a shortage of funds. I had no stipend to cater for meals especially in the last week. Most of the money for upkeep I got from home and it was not really enough.” (A)
Student D described few opportunities to pay by bank card in their elective country resulting in high bank charges to withdraw money which could have been avoided had they known to expect this.
The language barrier was a concern expressed by students prior to their elective. Two students revisited the language barrier during post elective interviews. One student mentioned that discussions took place in English and the [local] language was easy to learn. Student D however found:
“It was quite challenging to talk to patients and examine because of the language barrier. I had to learn some [local language] words to ease the consultation. I also asked for help from one of the doctors or nurses to translate” (D)
Student D declared s/he would increase efforts to learn different languages used in his/her country to improve communication with patients.
A range of practical issues were encountered by students. South African students wanted to travel to Rwanda however were unable to due to political reasons. Another student encountered visa problems because the allowed time was inadvertently overstayed.
Student E encountered logistical challenges because the accommodation was not as close to the hospital as expected, incurring transport costs. Other unexpected issues arose in terms of electricity supply and supervision:
“I was not aware about the electricity cuts. I would have been better prepared for them.”(D)
Concerns over safety and theft had been expressed pre-elective by student E although neither was experienced by any of the students. Student C shared that s/he had been concerned about the possibility of xenophobia, however, this was not encountered and instead experienced positive social interactions.