In this study nearly all students gave positive feedback about the overall experience. Most students were positively influenced personally and professionally, and said they were willing to repeat the experience. The biggest difficulties reported are a lack of resources for the practice of the medical activities, and problems with communication. Apparently, as observed by Mutchnick et al. , ‘living in alternative social environments creates an educational experience unmatched in any textbook or classroom exercise’. Professionally, students declare that they have returned home with a greater sense of empathy towards patients, an augmented confidence in their clinical skills, and a better appreciation of the importance of issues such as health inequalities. The experience also seems to influence the orientation of the students’ careers, increasing the interest in public service. The students also report an increased awareness of problems concerning the use of resources. Similar results have been found in other studies [17, 26–31].
Jeffrey et al. , carried out a literature review examining the potential role of international health electives in improving students’ professional growth and career choices. Key findings from the review suggest that a medical elective experience gives opportunities for medical students to strengthen self-confidence in medical practices, increase knowledge of tropical diseases, gain a better awareness of environmental health and public health actions. In addition, medical electives seem to influence the career choices of medical students. The results of Jeffrey et al., are in line with the results of the present study, where the vast majority of students declare that the experience has had a positive impact on a personal level, and that the experience led them to reflect more deeply on future choices at post-graduated level.
The number of students doing a medical elective in a LMICs has progressively increased over the years . It is also confirmed by the present study. In the first 5 years of the project (2005–2009) there was each year an average of 52 applications. This increased to 142 in the last 5 years of the project (2014–2018). During the course of the project there was a corresponding increase in the number of departures, from an average of 15 over the first five years to 33 over the final five years. It should be noted that increase occurred despite the fact that travel and accommodation costs are incurred directly by students and that the recognition of experience with credits does not seem to be widespread in many universities.
Although educational and other potential benefits offered by elective periods in LMICs are recognised, the experience presents a number of challenges. For instance, electives may falsely raise student expectations, and put strain on local human resources. As observed by Ackerman , ‘on-site supervisors, the back-bone of most electives, are only possible with a reciprocal, long-term relationship either through a local university and medical school, a Nongovernmental Organization (NGO), or an International Nongovernmental Organization (INGO) working in the area. The educators must ensure that the host organization is appropriately integrated into the community and that community goals are at the forefront’. Willott et al. , highlights that, ‘even if sending institutions oblige that students pre-prepare objectives and receive guidance about what is expected of them during elective, effective monitoring of students’ activities on the ground is nearly impossible’. In addition, he observed that, ‘students frequently want to be able to decide for themselves where they go and how they spend their electives, but this may not be what is best for hosting institutions, nor for global health more generally’. As pointed out by Edwards and colleagues , a major concern regarding medical electives is that students may practice, ‘beyond their competence, to their own and their patients’ detriment. This may be more common in developing countries where supervision is scant and students may assume that limited health care resources justify their adopting roles or performing procedures which would be restricted to fully trained staff at home’.
These reflections highlight the benefits of an experience like the WP, which is organised and implemented by an NGO with long-term working relationships with the African populations and is well integrated into the community. The project is carried out in health facilities where DwA staff have been working for many years. Having well-known locations for electives reduces the potential risks connected with this type of experience, and better ensures a satisfactory level of supervision, the lack of which being a serious problem in many similar experiences .
The project described herein was possible thanks to the initiative and collaboration of an NGO and a medical students’ organisation, without any direct support form a university. To the best of our knowledge, only a small number of Italian universities facilitate pre-graduate medical elective experiences in LMICs. The WP has enabled pre-graduate medical elective experiences to students from 30 different Italian universities (there are 43 faculties of medicine in Italy). The WP therefore, seems to be making up for the lack of international experience in LMICs offered by universities. The situation is different in other countries. For example, in Australia electives are a compulsory component of all medical curricula. They usually last 2 to 8 weeks, either in Australia or overseas, including LMICs . In the UK approximately 90% of medical students undertake medical electives, with 44% of them doing so in LMICs . A study from Germany (Munchen University) found that 17% of pre-graduate medical students undertake medical electives in LMICs . However, at post-graduate level the situation seems better structured. A number of initiatives appear to be going in the right direction, including agreements between DwA and some Italian universities, concerning collaboration on global health and medical experience and operational research in Africa .
We should note that before medical schools allocate substantial resources for international medical education, more rigorous evaluation of the effectiveness of medical elective experience is needed to demonstrate whether they add value to medical training , and what impact they may have on the communities and institutions involved . Long-term follow-ups of elective participants after medical school in relation to their career choices (e.g., type of medical practice, career developed in public or private sectors) can provide more convincing arguments to medical schools that investing in medical electives will pay dividends in the long run .