LINKS case study competition

Medicine in Malawi - Enhanced Electives in Developing Countries
Neil Merrylees, Jon Dowell (Staff) Rebecca Acquah (Student) Dundee Medical School, UK
Dan Namarika Director of Medicine, Kamuzu Central Hospital, Lilongwe, Malawi
Introduction
Medical student electives are a memorable learning experience and approximately 40% are spent in a developing country. With around 8000 students a year from the UK alone participating in medical electives this equates with 500 years of student time annually. Students often have laudable motivation but are rarely helped to learn or contribute most effectively whilst away.
We have sought to create an ethical trade elective experience specifically to challenge the existing ‘health tourism’ norm. Academic publication is pending and we are now seeking publicity for the concept to encourage dissemination. Start up funding from the Scottish Government International Development Fund and NHS Education for Scotland has been secured along with support from Dundee Medical School.
Methodology
We have established a program of placements for senior medical students in Lilongwe through a twinning arrangement with Dundee University, Malawi College of Medicine (COM) and Kamuzu Central Hospital, Lilongwe (KCH). The normal six week elective has been extended to four months for selected students at Dundee Medical School. Students must demonstrate suitability through participation in an international health module (or significant previous developing country experience), a sound academic and health record, appropriate understanding of the programme aims, participation in tropical medicine training, cultural/safety briefings and fundraising for KCH (£500 each).
The aim is to provide an exceptional learning opportunity for students but, crucially, also clear benefits for their Malawian counterparts and host hospital. Overall the approach aims to be sustainable as a form of ‘educational trade’. Hence:
• Student contribution to patient care is improved by arranging extended placements, throughout the year, based in one clinical area.
• Learning and supervision is coordinated by a senior clinical tutor for both elective and local health care students together.
• Practical support with educational resources and medical equipment is provided by project/student fundraising.
There is scope for a number of other health service connections to expand as a result of this project, especially the high profile of student fundraising activities and prospect of ‘twinning’ of an NHS trust with a specific hospital overseas. This could be replicated at many centres.
Activities
The first cohort of students is currently in Malawi, something which has been three years in the planning. To date we have:
• Secured £60 000 start up funding (NHS Education Scotland and the Scottish Government International Development Fund)
• Established formal support (via a memorandum of understanding) with KCH, Dundee Medical School and Malawi College of Medicine (CoM)
• Selected and prepared the first two Dundee student cohorts. (7 in first, 8 in second)
• Benefited from two pairs of Malawian students visiting Dundee for 6 week electives.
• Supported anaesthetic Clinical Officer training in KCH via financial support for courses, books and equipment.
• Funded a visit by two medical physics technicians to KCH
• Sent 2008/9 cohort of students to KCH. These students are now established participants in providing care and promoting educational meetings for staff in the medical wards. Typically our students:
o Share responsibility for a bay of 4 patients with local junior clinical staff.
o Learn about conditions they rarely encounter, do procedures and take responsibility rarely available in the UK.
o Encourage (by their presence, provision of equipment and attitude) an enhanced program of clinical meetings at which both they and local staff (clinical officers and interns) benefit from training provided by local consultant staff.
• Agreed how the first years support funding (£5000) will be spent to provide enhanced basic equipment for the ward area.
• We are considering how start up funds can best be used to support a planned expansion of CoM via the creation of a new campus in KCH. This will enable support increased medical training in Malawi.
Outcomes
The first year of this scheme will transfer approximately £10 000 of resource to KCH and students will spend a further £12 000 in Malawi. Dundee Medical School benefits from a course offering innovative and exceptional opportunities (Program is heavily oversubscribed). Specific achievements of the program to date are:
1) Motivation for both staff and students in Malawi and UK.
2) Equipment has been provided (projector and laptop for continuing medical education) and will shortly be ordered locally for medical department (e.g. Patient trolleys, sphygmomanometers, oxygen concentrators etc.).
3) First audit in KCH looking at outcomes of admissions of patients on HAART (HIV treatment)
6) Change of attitude and sense of accountability in patient management imparted to Clinical Officer (CO) Students
7) CO students learnt how to use powerpoint and lead case presentations
8) Bedside teaching: Dundee students teach local students on examinations, procedures, and specific western diseases like stroke. They receive specialist HIV and tropical disease training, for instance, managing acutely toxic patients with sepsis or malaria.
9) Exchange students report increased awareness of health care provision in a different country and many new clinical experiences.
Challenges
To establish a sustainable trade we must prove there is sufficient educational benefit to persuade those funding medical education that resources should follow students to centres overseas which demonstrate an enthusiasm and ability to provide excellent clinical education for UK students.
To make a significant difference this process requires publicity. There is a clear demand from UK students for more ‘ethical electives’. An alternative model may well help this process.
There are associated risks. Forming partnerships requires time, effort and some resources. Culture shock causes distress and problems with excessive responsibility, culturally inappropriate behaviours, and personal risks (HIV, RTA) can arise. Unrealistic expectations may be created.
Conclusions
In summary, although electives are a popular and successful aspect of undergraduate medical courses we suggest they can be improved and negative effects minimised using a fair trade ethos within a formal institutional link. Though currently small scale we believe this concept has great potential and is now ready for increased publicity.