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ss nucleus - spring 2007,  Electives - the world's your oyster!

Electives - the world's your oyster!

Peter Armon wants to send you packing...

What an awesome opportunity you have as medical students during your final years to visit another part of the world and experience medicine in a totally different environment. It can be the most rewarding experience of your student years and if you are able to go to a resource poor country, it might literally prove to be life changing for you as it has for many others.

Of course, not everyone is able to travel abroad. Personal or financial constraints may limit the options open to you. There are many things you can do within the UK. Think about what has really interested you and caught your imagination so far during your training – there may well be opportunities to explore these subjects further either in the UK or in another culture overseas. Whatever your options, do something and, if you can, go somewhere different to do it but don't waste the opportunity on offer to you.


My trip has made me excited about being a doctor… but even more importantly I have realised that I am also a messenger of the Good News with the eternally significant role of introducing people to the Great Physician, Jesus Christ, who can heal people's broken relationship with God.

John Greenall – writing about an elective to Mseleni Hospital in South Africa


Start planning early

This is not something that medical students are known for doing, but if you leave it to the last minute, then you may well find that all the best places have been booked up! Bear in mind that a response to your communication won't be high on the priority list of a busy, overworked administrator in an understaffed office, especially in a resource poor country and replies may take time. Internet connections overseas can be down for days (or weeks) at a time and if you have to rely on snail mail then it may take months to get a response.

You should be starting your preparations a good 18 months in advance, so if it's only that far away then don't procrastinate any longer - get on with it!

Where to find information

This article should be of value wherever you are thinking of going on your elective but I would urge you to visit a resource poor country and catch something of God's concerns for the poor, the oppressed and the underprivileged.[1] Why spend your time in a resource rich nation where you may see little more or different from what you will have seen and where you will probably get very little 'hands on' experience to boot?

The new edition of CMF's booklet, Preparing for your elective in a resource poor country, will give you plenty of food for thought and is well worth a read. You can get a free copy from the CMF office or download it in PDF from the overseas website at www.healthserve.org/electives/preparing/medical_elective. The student pages on the website are also packed full of useful information on places to go, contact addresses and reports from students who have been there.

There are many other websites and books on the subject but The medic's guide to work and electives is another excellent place to start and is packed full of ideas. There is an associated website at www.medicstravel.com, which is a fantastic source of ideas and information.



Why go to a resource poor country?

It will really blow your mind and stretch you to the limit – physically, emotionally and spiritually – but it's then that you will really learn what you are capable of. You will also realise that the God and Father of our Lord Jesus Christ is a God who answers prayer and who can be relied on in time of need.[2] It's in such a place that you will find that God really speaks to you – and you will listen!


Phil Thompson writes about an elective in Zambia:

I learnt much about medicine in a third world country but moreover I learnt much about my relationship with God, or should I say his relationship with me. Never before have I been so sure that God is there alongside me at each step I take and that he will never leave me.


Medically, you may find yourself in situations where you have little more than your bare hands and brain to rely on. It's here that your clinical skills will be honed and developed in a way that will never happen when you have innumerable lab tests and machines to give you all the answers you need. You will see advanced pathology that you haven't even seen mentioned in your textbooks, but you will have those beside you with the knowledge to teach you and see you through. You are likely to be given much more responsibility and gain much greater hands-on experience than you will in the UK, which will boost your confidence for the foundation years.


Important tip

It would be wise to seek written confirmation that you will always be working under careful supervision and not left on your own.


If you are thinking that God might be calling you to work abroad at a later date – perhaps as a missionary - then there is no better way of 'testing the waters' than by doing your elective in such a country. It will certainly blow away all your romantic ideas of 'missionary life'. The opportunity to experience life firsthand in a resource poor country is priceless and you will gain a far better insight than by listening to missionary talks, watching presentations or surfing the net.


Charlotte Angel writes of lessons learned from an elective in Tanzania

The average life expectancy in the UK is 86 years; in Tanzania it is only 49... Death happens there often but life has to go on for those left behind. I returned from Africa with a renewed faith, a thankful heart for how lucky I was, and a desire to use my skills as a doctor as well as I could, especially for the benefit of those who most need it instead of just those who can pay for it. Having little money or material goods doesn't mean you are poor and every person on this planet is precious.


When to go

This will – for the most part – be decided for you, but the later in your training the better. Exams may be looming on the horizon but don't be put off. You will gain more if you know more before you go. What you have personally seen and done, you will never forget – which will be useful for exam purposes!

At the same time, do check out with your hosts what time of year is best – especially with the climate (you don't want to be knee deep in mud and cut off from the outside world). Likewise, make sure your teachers will be around and not on leave or that you arrive in the midst of a series of national holidays when everything is closed down.

Where to go?

This will be determined by the sort of experience you want to gain and your own background. A Spanish speaker might prefer to go to South or Central America while a French speaker might want to try one of the West African countries. You may want to experience a mission hospital set-up or alternatively prefer to work in a secular context. Some prefer the large academic institutions where they can specialise; others may prefer a place where they have to deal with all that comes their way; yet others may just want to be dealing with HIV/AIDS or palliative care etc.

What about the money?

Obviously, cost will be affected by a number of factors – not least the destination. As a rule of thumb, the total cost of your elective is likely to be in the region of twice the cost of the airfare. It is usually cheaper to live in a resource poor country but that will also entail some 'lifestyle' adjustments as well – being prepared to eat what is put before you and sleep wherever! Don't forget to include costs of visas, airport taxes, immunisations, HIV and malaria prophylaxis, in your budget.

You will find some information about sources of funding on the student elective pages on the Healthserve site: www.healthserve.org

Be creative and prayerful in your approach. Raising the funds is just a part of the challenge. God will have something to teach you in this area as much as in any other. Many have proved that God really does supply all our needs as we move out in obedience to his call on our lives; his grace is truly amazing.[3]


Think

Do you really need to be wearing an expensive watch or jewellery etc? You will be setting yourself apart from the crowd and tempting the thief.


Did you know?

The commonest cause of morbidity and mortality amongst expats working in a resource poor country is not disease but road accidents.


Personal safety

This will be a worry to your medical school authorities and your parents, and this may hold you back. Things are not always what the world's press paint them to be but you would be wise to check things out on the UK government website at www.fco.gov.uk or contact someone who lives in the locality (the overseas desk at CMF may be able to put you in touch).

Also bear in mind that life is not easy for a single girl in an Islamic environment. Many restrictions are likely to be placed on your movements and it may well prove to be culturally unacceptable for you to travel alone. You may prefer to go with a friend. It's good to have a shoulder to cry on anyway but remember that living in close quarters with someone – even some one you think you know well – can turn out to be quite stressful at times.

In the clinical realm, there will be the problem of AIDS that you will have to face up to and you will need to take precautions. You may even decide to avoid undertaking some surgical or obstetric procedures. Don't feel under pressure about this. You need to be wise and sure in your own mind as to what you will or won't do. The matter is discussed at CMF Elective Days and there is advice in the Preparing for your medical elective. No doubt your student health service will advise you. They are however, likely to be understandably ultracautious on your behalf.

Other health and safety concerns

Advice on immunisations can be found on the WHO website at www.who.int/ith. An excellent site that contains a wealth of other advice on health matters, such as the contents of a personal medical kit etc, is at: whqlibdoc.who.int/publications/2005/9241580364_chap1.pdf

InterHealth is a Christian organisation, connected with CMF, which would be happy to hear from you and to give advice. Contact them via info@interhealth.org.uk.

Do remember to take a plentiful supply of any personal medications you are taking on a regular basis. If you wear glasses or contact lenses, it would useful to take spares and a copy of your prescription. Be careful what you drink (eg always see the bottle opened) and what you eat (eg make sure things are well cooked and only eat peeled fruits).

Don't be afraid to ask the local people about local hazards, eg is there bilharzia or are there crocodiles in the local lake? Keep yourself well covered at dusk and beware of travelling after dusk.

Other practicalities

Do find out as much as you can about the country you are visiting. It will be very much appreciated by the local community and gain you great kudos, if they can see that you have taken the time to learn how to greet them in their own language and to learn a little about their customs and culture.

Do check out what dress is acceptable and how formal or otherwise you need to be when attending ward rounds. Do you need to take a white coat? What sort of weather can you expect? What sort of accommodation is provided or will you have to find your own – if so are there any contact addresses?

Bear in mind that as a westerner, you will be regarded as exceedingly rich and knowledgeable. Humility will be needed and an understanding of your own limitations.

Things to take

Find out if there are any things that your hosts or host institution need that you might be able to carry out for them. It might involve you in raising funds to purchase such items for them – but a sponsored half marathon or two might do wonders for your health and fitness!

Teaching material can be very useful. CMF produces a very useful (and free) Developing Health CD-ROM, which you would find helpful to peruse and then pass on to your hosts. Teaching Aids at Low Cost (TALC) also produces free teaching CDs and other materials that you can acquire and take with you - visit www.talcuk.org. It's always helpful to have a BNF on hand and to take one of the Oxford Handbooks of Medicine and/or Tropical Medicine.

CMF will also provide you with a free copy of their booklet Elective Life Support, a collection of daily readings and meditations running over eight weeks. Steve Fouch writes in the introduction:

For many students their experience overseas truly puts their faith to the test, challenges their cultural assumptions and forces a re-evaluation of their relationship with God. While for most this is ultimately a positive and enriching experience, for the majority (if not all) it is also a struggle! This book is a response to that need, providing daily Bible reading and meditations written specifically to help students focus on the realities of being healthcare workers in cross cultural situations.

Small gifts for your hosts and those that you meet should not be forgotten. Again children often lack school supplies and pencils, rubbers etc are like gold dust. Don't forget spare batteries for your camera and other appliances.

Travel tips

Make sure your passport has at least six months to run and that you have the visas you might need. Scan a copy into your computer and email it to yourself so you have a copy in case of loss or theft. Carry some spare passport photos with you. Make sure you have the address and telephone number of the local consulate or embassy. Such details can be found at www.fco.gov.uk.

Keep small personal items and any cash hidden on your person. It's probably best to take a rucksack or case that you can carry yourself. There will be no shortage of willing helpers at your destination but they may disappear with all your belongings! Don't let things out of your sight. Don't keep all your valuables, cash or documents in one place.

Consider travel and health insurance. The BMA offers a good student insurance package: www.bma.org.uk/ap.nsf/Content/jointheBMAstudentmembership.

All work and no play?

Do plan some time for recreational activities into your elective programme. Not something one has to remind students about; it's more likely to be the other way around! Bear in mind however that your behaviour or 'misbehaviour' may well muddy the waters for future students.

Expectations

It is very important to sit down right at the beginning of your preparations and write down your hopes and dreams, aims and objectives for the trip and what you expect to gain from it. You then need to check these against what your host institution and your own medical school are expecting of you. It may take some discussion and a little give and take to come to an agreement about these things but if you don't do so there will be endless frustration and disappointment – on both sides. It's worth repeating the exercise soon after your arrival on site to ensure the situation hasn't changed in the interim.

You will find that healthcare systems in a resource poor, poverty stricken country operate in a very different fashion to what you are used to. The money available to spend on drugs, equipment and staff salaries is almost non-existent. Patients will often have to pay for their treatment and may have to make very difficult decisions as to how to spend the little money they have. As a result, late presentation for treatment is more likely to be the rule than the exception and there may be little that can be done to salvage the situation.


did you know?

In the UK some £1,500 per person per annum is spent on healthcare. In many resource poor countries that figure is nearer £2 per person.


This will be just one of the reasons why attitudes to disease, death and dying are very different to those you will have previously experienced. You are likely to be overwhelmed by the unfairness of it all – children dying unnecessarily for lack of adequate nutrition, immunisation or drugs that you know are freely available at home. You will find yourself on an emotional roller coaster – try to prepare yourself for that or ask yourself how you will cope.

In the light of the poverty all around you, the lifestyle of the local expatriates – be they missionary or otherwise – may trouble you, but ask yourself how you would cope with living in their situation, perhaps with a young family to look after and educate?

Ask questions – but sensitively. Try not to be judgmental. Take time to find out why things are as they are, why local attitudes and beliefs are so different, why medicine is practised so differently, before you make any judgments. The way you are used to doing things might not work where you now find yourselves or it may not be appropriate to do things in the way you are used to. Go with a servant heart and a teachable spirit.[4]

Just before you set off

  • Make sure you have reconfirmed your arrival time and place with your hosts.
  • Make sure you know whether, where and when you will be met.
  • Do you have a contact telephone number for use in emergencies?
  • Go through the final checklist in Preparing for your medical elective.

There is nothing more scary than arriving in a foreign airport, knowing no-one, not being able read the signboards and not knowing how to get to your final destination - made worse by arriving in the middle of the night and finding the information centre closed and that you don't have a contact number!

When it's all over and you arrive home again

  • Continue to take your anti-malarial medication for the recommended time.
  • Take time out to reflect on what you have learnt – perhaps go on a mini retreat.
  • Expect to experience 'reverse culture shock'. You will have changed. Your outlook on life will have changed but back home things just seem to go on as normal.
  • Expect an emotional roller coaster – deep feelings of anger that things are as you have seen them to be and 'no one seems to care', the unfairness of the 'system', guilt - at being able to come back and leave the poverty behind, of not having been able to do a great deal to change things and feelings of frustration and depression about it all. These are all quite normal feelings and are not unusual but they do need to be expressed and worked through. Perhaps they will form part of God's continuing challenge to you to get involved in the longer term and to be part of his answer to the situation.
  • Take time out with a trusted friend or counsellor, someone you know is a good listener and with whom you can talk through such issues – both negative and positive.
  • Don't forget to contact your hosts and others who have helped you and say thank you.
  • Keep any promises you might have made - to your hosts, friends and yourself.
  • Send a copy of any report or research project you write up to your host hospital/mentor.
  • Continue to pray for the friends, hospital and country you have left behind.
  • Don't forget the things you have seen and heard and all that God has said to you; keep any promises you might have made to him.
  • Continue to follow through on what God might have called you to do in terms of a commitment to serve him overseas after you have qualified.

Andrew Fearnley writes of some of the situations he witnessed:

It all just seemed so totally unfair. That's one of the biggest problems I had when I was working in Lesotho. So many things just seemed so ridiculously unfair to me. So many of the patients that I saw lived lives that are so immeasurably more difficult than mine it made me feel ashamed. I felt ashamed that I am part of a world that allows this to happen, that my privileged existence must in some way be responsible for the staggering inequality that stands before me each day.


A final thought

As you seek to fulfill God's plan for your life, go on your elective with the certainty of his love and peace surrounding you, with his joy in your heart. You will experience the power of his presence in all that you do.

Your elective is a tremendous privilege and an opportunity to experience both the joy and the sorrow of God over his broken world, to serve the poor and to contribute something to enabling his kingdom to come and be established on the earth.


Resources mentioned in the text

websites for elective information

website for funding

website for country details

contacts for travel health information

Teaching Aids at Low Cost

website for student elective insurance

books and booklets worth reading

  • Preparing for your medical elective - available from CMF on electives@cmf.org.uk
  • Wilson M. The medic's guide to work and electives. London: Arnold, 2003
References
  1. Pr 31:8,9
  2. Heb 13:5,6 (best read in Amplified Version)
  3. Phil 4:11-13,19
  4. Phil 2:5-11
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