Introduction

The medical elective is a popular but under-researched and under-assessed area of undergraduate medical education. In the UK alone, 8000 medical students undertake medical electives annually. These electives may be domestic or international, clinical, or research-based. However, despite their popularity, there are no consensus guidelines on medical electives, with guidelines and assessments methods varying from institution to institution [1,2,3]. Such a state has led to a debate regarding whether medical electives are valuable learning experiences for medical students or simply a form of medical tourism, not dissimilar to voluntourism [4]. In order to combat this and to ensure medical students benefit from the elective experience, many medical schools have developed partnerships with other institutions in both developed and developing countries, whereby students undertake set elective modules at the host institutions with set objectives and outcomes [1, 4, 5]. However, this is not universal, with significant numbers of medical students having to organise their electives without institutional help and using websites such as The Electives Network [6]. Moreover, the situation regarding indemnity is ambiguous and is often left to the students to organise, with many host organisations not requiring evidence of indemnity and many students being advised to contact medical protection unions for advice and, potentially, indemnity [7,8,9]. Thus, given the vagueness of elective learning objectives and the potential for medical students to put both themselves and patients at risk, we sought to establish what clinical scenarios, procedural skills, and non-technical skills medical students commonly face during their electives. We enquired on whether they felt trained and competent to deal with these tasks and scenarios at the time of their elective and whether there were any adverse effects or events associated with any potential lack of competency and/or training. Once the knowledge and skills gaps were established in the fields above, we developed a simulation-based “medical elective suitcase” course, which was tailored to address these issues and better prepare medical students for their upcoming elective experiences.

Methods

Questionnaire design and distribution

A novel, fit for purpose, 20-item self-administered questionnaire was developed for the purposes of this study. It was developed in consultation with author SV (Consultant Vascular Surgeon and Foundation Programme Director), author VH (clinical skills and simulation lead), two clinical teaching fellows, and Foundation Year One doctors, at a District General Hospital, which hosts medical students from St George’s University London and King’s College London medical schools. It consisted of questions regarding elective experience, quantifying the clinical, procedural, and non-technical skills medical students encounter during medical electives. As well as establishing the above and baseline details including country of study, country of elective, duration, specialty, and setting of electives (i.e. rural vs urban), and it also explicitly asked whether or not the respondents had undertaken tasks, which they were not trained to manage and if any harm had come to patients being cared for in these situations. The ethical dimensions of this non-mandatory survey were explored, and no concerns were identified, with completion of this questionnaire was taken as implied consent to participate in this anonymous study. It was distributed to 436 students/doctors throughout the Republic of Ireland and UK via social media in the form of a SurveyMonkey link. It was not piloted.

Intervention—medical elective suitcase Course

Similar to the questionnaire, the course content was developed in consultation with authors SV, VH (clinical skills and simulation lead), two clinical teaching fellows, and Foundation Year One doctors, at the aforementioned District General Hospital. The course objectives decided upon were based on addressing the concerns of the survey results and can be found in Appendix Table 6. To meet these, the course combined workshops, small group practical skill sessions, and immersive simulation scenarios. Appendix Table 7 summarises each session. These were delivered to two separate groups of pre-elective medical students by the same faculty, on two separate afternoons—the first, a group of eight students in April 2016, and the second, a group of ten students in June 2016.

A pre-course survey was utilised to establish course participants’ prior experience with simulation-based teaching along with the clinical skills and scenarios to be addressed on the course. The pre-course survey also sought to establish the respondents’ confidence level with the above skills and scenarios, with respondents using a Likert scale to measure their perceived level of confidence with each skill and scenario. The course participants then filled in the same questionnaire after the course, as a post-course questionnaire, in order to establish any change in their level of confidence.

Data analysis—questionnaire

The results of the questionnaire were transferred to a spreadsheet (Microsoft, 2010, Washington, USA) for descriptive statistical analysis. Two-by-two contingency tables were analysed, and Fisher’s exact test was utilised to examine for statistically significant associations between respondent derived comfort levels and situations/procedures undertaken. A two-sided P value of < 0.05 was considered to be statistically significant.

Data analysis—medical elective suitcase

MINITAB 17 (Minitab Statistical Software, 2017) was used to conduct paired T tests on results of pre- and post-course data pertaining to course objectives set at the beginning of the course. A two-tailed P value of < 0.05 was considered to be statistically significant.

Results

Survey results

Respondent demographics

Table 1 contains a summary of cohort characteristics. One hundred ten individuals responded to the survey. Thirty-nine percent were house officers (FY1/interns), 19% were doctors more senior than house officer level, and the majority of respondents, 42%, were medical students. This represents a response rate of 25.2%. The majority of respondents (56%) attended medical school in the Republic of Ireland, followed by the UK (31%). Ninety-six percent of respondents undertook predominantly clinical electives, with 3% undertaking predominantly research electives. Sixty percent of respondents undertook their electives in the final year of their studies, followed by 35% who undertook them in their penultimate year of medical school.

Table 1 Survey respondent characteristics
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The majority of electives were undertaken in the ROI and North America (Fig. 1), lasted 4 (34%) or 6 weeks (22%), and were in an urban (81%) rather than rural setting. Medicine was the most popular elective specialty (35%) with psychiatry being the least popular.

Fig. 1
figure 1

Countries in which electives were undertaken

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Elective experiences

All respondents took part in either clinical or non-clinical activity, with 54% of respondents carrying out one or more clinical activity that they felt was out of their competence level.

A fifth of respondents reported that they were placed in situations they felt they were not trained to manage during their elective, with adverse effects/events occurring in 15% of these cases.

Overall, 26% of respondents agreed that a period of training prior to their elective would have better equipped them for the experience, when considering current students alone, this rose to 40%.

Clinical procedures

Wound suturing (22%), venepuncture (36%), and venous cannula insertion (32%) were the most commonly performed with 27, 17, and 19% of respondents, respectively, reporting that they were uncomfortable performing these prior to commencing their electives. There was no statistically significant association between the performance of these procedures and whether students self-reported comfort with these tasks, with P values of 0.54, 0.36, and 0.77, respectively. The setting up of IV infusions was performed by 16% of respondents; however, 20% of respondents were uncomfortable performing this activity prior to their elective.

Fracture reduction (30%), dislocation reduction (29%), and plaster casting (28%) were the leading practical procedures that respondents were uncomfortable performing prior to their electives. These were performed by 10, 8, and 14% of respondents, respectively. The likelihood of performing fracture reduction was statistically significantly associated with comfort level (p = 0.0129); however, this was not the case for dislocation reduction (P = 0.39) and plaster casting (P = 0.47).

Clinical scenarios

Management of sepsis (26%), oxygen management (26%), and airway management with basic adjuncts (19%) were the most commonly encountered clinical scenarios. Twenty percent of all respondents were uncomfortable with the management of sepsis at this stage in their training, with a further 17 and 18% admitting the same about oxygen management and airway management with basic adjuncts, respectively. The relationship between self-reported comfort and likelihood of performing these tasks were not statistically significant, with P values of 0.06, 0.73, and 0.70, respectively.

Neonatal CPR (34%), operation of neonatal resuscitaire (33%), and management of post-partum haemorrhage (31%) were the leading clinical scenarios respondents were uncomfortable dealing with prior to commencing their electives. This was closely followed by paediatric CPR (30%) and the management of acute haemorrhage (25%). The management of pre-eclampsia/eclampsia (24%), of a broken nose (24%), and of shock /hypovolaemia (18%) also accounted for a large proportion of these responses.

Other skills

Clinical communication skills were commonly used, with 19% of respondents “breaking bad news” at some point during their elective. A further 25 and 11% of respondents collected and statistically analysed data, respectively. In regard to these, 19% of respondents were uncomfortable with breaking bad news, and 11 and 13% reported the same with the collection and statistical analysis of data at this stage in their training.

Course results

Course participants

Table 2 summarises the characteristics of course participants with Table 3 summarising their prior experience. Eight medical students attended the April course whilst ten students attended the June course. All candidates were fourth/penultimate year students, with 13 attending St Georges University, London and five attending King’s College University, London. Ten of the course participants were male and eight were female. Most participants had completed rotations in Medicine, Surgery, Obstetrics and Gynaecology, Psychiatry, Paediatrics, and General Practice; however, only 39% had completed anaesthetics rotations. The majority of participants had previously attended simulation sessions, with only three not having attended any previous simulation sessions. Eleven participants had previously attended to acutely unwell patients, with the remaining seven having no such previous experience.

Table 2 Summary of course attendees
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Table 3 Summary of participant prior experience
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Course outcome

Course outcomes were based on self-reported confidence, in one’s ability to perform clinical and non-technical skills, in the context of a medical elective, i.e. specifically applied to a team of strangers, in a different country and healthcare system. Non-technical skill questions were based on the Anaesthetics Non-Technical Skills (ANTS) framework as they were considered the most universally applicable to foundation doctors. Appendixes Tables 8 and 9 describe the exact questions used in the pre- and post-course questionnaires.

Paired T tests were conducted to compare pre-course and post-course survey responses to questions regarding participants’ confidence with predefined non-technical and practical skills each section of the course was developed to improve.

Non-technical skills

With regard to non-technical skills (Table 4), there were statistically significant improvements in self-reported confidence in the ability to exhibit all elements of the ANTS non-technical skills.

Table 4 Summary of ANTS improvement
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Clinical scenarios

Improvements in clinical skill are summarised in Table 5. With regard to managing acutely unwell patients, there were significant improvements in self-reported confidence with the ability to initiate the management of acutely unwell patients (P = 0.02), lead a team in the management of acutely unwell patients (P < 0.01), and communicate effectively and efficiently in teams managing acutely unwell patients (P = 0.01). However, this was not the case with recognising acutely unwell patients (P = 0.07), assessing acutely unwell patients (P = 0.20), and calling for help when appropriate (P = 0.36).

Table 5 Summary of technical skill improvement
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With regard to clinical medicine, there were improvements in identifying sepsis (P < 0.001), knowing the components of the sepsis 6 (P = 0.01), and instituting the sepsis 6 (P < 0.01). Improvements were further noted with the management of epistaxis (P < 0.01) and in managing acute haemorrhage (P = 0.03).

Participants reported highly significant improvements in self-reported confidence with resuscitating a child (P < 0.01), resuscitating a neonate (P < 0.01), getting venous access, and taking blood from a child (P < 0.01), and operating a neonatal resuscitaire (P < 0.01).

Self-reported confidence in the ability to recognise and manage pre-eclampsia as well as post-partum haemorrhage both improved significantly (P < 0.01; P < 0.01), respectively).

Clinical procedures

Participants reported improvements in confidence with their ability to insert a male urinary catheter (P = 0.03), insert a female urinary catheter (P = 0.061), set up an IV Infusion (P = 0.01), and insert venous cannulas (P = 0.05). We did not identify improvement with venous blood sampling (P = 1).

There was increased confidence in the ability to hand and instrument tie knots (P < 0.01 and P < 0.01, respectively). Improvement was also identified in simple interrupted suturing (P < 0.01) but not continuous suturing (P = 0.07).

Discussion

Our data shows that a majority of medical students choose international medical elective experiences, with only 25% undertaking their electives in the British Isles. This is unsurprising as the benefits of cross-border medical electives are legion. For the students and their home health-care system, it has been shown that students returning from electives demonstrate improved diagnostic skills, decision-making skills, personal development, and awareness of social determinants of health [5].

For the host nations, particularly those in the developing world, medical students on elective can be important health workers, often providing a stop gap for the “brain drain” commonly encountered in many of these areas and helping to partly address the global shortage of health workers. Unsurprisingly, developing countries have been shown to host as many as 40% of UK elective students, who on average spend between 6 and 12 weeks on their medical electives [1].

With that said, it is important to consider the risk that medical students may pose to patient safety in these host countries. After all, as demonstrated in this present study, as many as 54% of medical students felt under pressure to carry out tasks, which they felt were out of the competence level during their medical elective. Nineteen percent of students felt that they were untrained to manage certain situations faced and these were at times associated with adverse events. The amount of harm caused is likely to be mitigated by the fact that many medical schools in the UK send their students to their electives after sitting their final examinations [1]; thus, it could be argued that although not officially registered with their respective medical councils yet, medical students at this point in their training should be able to display skills similar to those displayed by house officers/newly qualified interns. However, there is also extensive literature showing that newly qualified doctors and interns often lack adequate procedural skills and confidence, supporting the argument that medical students attending their electives potentially lack key skills required for ensuring maximal patient safety in a foreign environment—despite some of the identified skills, namely wound suturing, venepuncture, and IV Cannula insertion, being basic skills taught at the commencement of clinical rotations [10, 11].

The risk is however not only confined to the patients in the host countries; the students are also repeatedly putting themselves at risk. The fact that they are performing practical procedures such as venepuncture and venous cannulation whilst not being comfortable with the execution of such tasks is of particular concern, especially when considering the high prevalence of endemic blood borne viruses present in some of the areas in which these electives are undertaken. Unsurprisingly, studies have shown that significant numbers of students (8–25%) are exposed to blood borne viruses on elective, with a limited number of them (20%) taking post-exposure prophylaxis with them to their elective [12,13,14].

There are also the further medico-legal implications associated with performing practical procedures with low levels of confidence (as shown in this study), in that elective indemnity cover is subject to students not exceeding their level of qualification or competence [9]. This is highlighted by the fact that a fifth of survey respondents reported they were placed in situations they felt they were not trained to manage during their electives, with adverse events/effects occurring in 15% of these cases; a factor which may significantly contribute to personal stress and anxiety, especially when compounded by being in a foreign country.

The risks to patients and students do not solely revolve around the question of competence in performing clinical procedural skills. We also question whether medical students, at this stage in their training, simply lack the non-technical skills required to decline being placed in situations beyond their capabilities and comfort zones or, conversely, to handle the situations, which they are trained to manage efficiently. This is suggested by the lack of correlation between self-reported comfort and likelihood of performing certain tasks.

Non-technical skills are human factors defined as “general cognitive and social skills that allow (them) to … monitor the situation, make decisions, take a leadership role, communicate, and co-ordinate their actions within a team, in order to achieve high levels of safety and efficiency.” They are considered separate to the procedural and clinical skills applied in the evaluation and management of clinical problems [15], but just as important. Though the development non-technical skills (Appendix Table 7) has become a core part of post graduate training [15, 16], undergraduate medical education has yet to embrace them to the point of designing specific modules for all medical students. Indeed, whilst some programmes for training medical students prior to commencement of electives are focused on ethics and procedural skills [1, 5, 17], we were unable to find an example in the literature of one also focusing on non-technical skills. This represents a significant gap in pre-elective preparation as a certain level of clinical and non-technical skill may be expected in certain elective posts, not to mention when beginning foundation/intern training.

Although the importance of non-technical skills cannot be underestimated and there is a clear gap effectively training their students to master these skills, it is worth noting that our statement suggesting students lack non-technical skills based on the fact that we found no correlation between self-reported comfort and likelihood of performing certain tasks has its limitations. First of all, the comfort level reported is a self-assessment of each student’s skills prior to their elective commencing. This may represent a recall bias since many of these respondents were qualified doctors who at the time of questionnaire completion would have been confident in performing many of these tasks. Secondly, overestimation of each student’s skills can also have an effect on the type of response. Lastly, data around confidence levels and likelihood of task performance in this article was collected with the aim of researching the baseline relationships between comfort levels and the probability of tasks being carried out during one’s elective, with the hypothesis that by increasing each student’s skill level through a series of workshops prior to commencing an elective, student participation and task performance would improve. It was not collected to assess the level of non-technical skills demonstrated by the students.

We have, to this point, established that students run a high risk of putting themselves and patients at risk of harm by lacking the appropriate level of clinical and non-technical skills to manage certain clinical situations safely. This is very unfortunate considering that there is a wide range of literature suggesting that education, especially using simulation, can reduce the exposure to these risks. There are examples of simulation courses significantly improving medical students’ non-technical skills [15, 18] and improving safety with practical procedures [14]. This lack of education is further aggravated by the lack of good practice guidelines provided by medical schools. In fact, a 2008 survey of UK medical schools found that only 65% of schools provided specific pre-elective training [3], with an earlier study indicating that only one medical school had identified aims for medical students in the elective period, though all provided counselling/training with regard to health and safety issues prior to elective commencement [4].

In this study, we attempted to address the issues around a lack of pre-elective training by setting up the medical elective suitcase course. The aim was to demonstrate that a programme focused on improving medical students’ clinical and non-technical skills could better equip them to handle the challenges they will face working in foreign countries, environments, and health systems. This would ultimately lead to a more positive elective experience. A simulation-based model was used where possible; this is due to the overwhelming evidence highlighting the effectiveness of this mode of teaching in improving the management of acutely unwell patients by foundation doctors [19]. We also considered the fact that our medical students likely have a variety of learning styles, that is “preference for processing information in a particular way when carrying out a learning activity” or learning habits that allow individuals to benefit more from some experiences than others. These have been described by Honey and Mumford as four overlapping types—theorist, reflector, pragmatist, and activist, with Kolb describing a cycle of learning experiences composed of:

  1. 1.

    Reflective observation

  2. 2.

    Abstract conceptualisation

  3. 3.

    Active experimentation

  4. 4.

    Concrete experience

In this cycle, individuals of each learning style will prefer at one learning experience or the other—e.g. the pragmatists will prefer the active experimentation stage of learning [20,21,22]. Thus, we sought to develop content which would allow our students to experience all aspects of the learning cycle and improve their technical and non-technical skills. We thus chose simulation, as it allowed students to go, throughout the afternoon and each session, from reflective observation and abstract conceptualisation, to active experimentation and concrete experience and back again to reflection.

Indeed, simulation-based medical education has been shown to achieve mastery standards, which translate to improved patient outcomes as well as improved skills and knowledge retention [23,24,25].

The course proved to have a positive impact in developing both students’ non-technical and clinical skills. With respects to non-technical skills, it led to highly significant improvements in almost all elements of the ANTS non-technical skills framework [26]. We hope that the better acquisition of these skills will empower students to not feel pressured in engaging in practices, which are potentially unsafe for them and for their patients, as well as increase their confidence in task management, team working, situational awareness, and decision-making.

Confidence in performing core procedural skills and managing common clinical scenarios also improved. The effect of this must not be underestimated, given that these are all practical skills, which many survey respondents found they were called upon to perform during their electives and could have had a direct impact on patient outcome, e.g. being able to administer IV antibiotics and set up IV fluids for a septic patient could be lifesaving in a department lacking the human resources to do so or where normal human resources are overstretched at that time. The highly statistically significant improvements in clinical paediatrics and obstetrics and gynaecology practical skills are also worth noting as these were skills, which a large proportion of survey respondents indicated they felt uncomfortable performing prior to undertaking their electives. We also note that these improvements were still highly significant despite most course participants having completed rotations in those specialties prior to undertaking the course (89% each). This is similar with surgical skills where 94% of course participants had completed surgical rotations but still found their skills significantly improved by the course. The surgical skill which did not improve significantly was continuous suturing, and the authors put this down to the course not allowing enough time to teach this more challenging skill and will remedy that at future iterations of the course. This is the same with orthopaedic tasks (fracture and dislocation reduction, plaster casting), which, despite featuring highly amongst survey respondents as tasks they felt uncomfortable performing prior to their electives, the course did not attempt to address due to lack of time. Thus, as part of the next steps in our research, we hope to be able to offer this course over a full day and include stations, which will teach orthopaedic skills and trauma management simulation stations, as trauma simulations have been shown to improve technical and non-technical skills when carried out appropriately [27]. Future research will also look at the correlation between self-reported confidence correlates with competence as judged by objective observers, as this will provide more information on the effectiveness of the course. This is important, as it has been shown that self-reported confidence and competence have not always been correlated with objective judgements of competence in the medical education sphere—though it has been shown to correlate in cases where participants received training such as ours, including amongst medical students [28,29,30,31]. This is particularly true of technical skills, where participants appear to have retain what they have been instructed [29, 32,33,34,35].

Limitations

We acknowledge some limitations to the present study. The response rate for this questionnaire was relatively low, and this study may be subject to non-response bias; however, the response rate likely reflects both the pragmatic design of this study, the use of social media, and the fleeting nature of social media posts. It may also reflect the relative novelty of medical electives, with significant numbers of the doctors who received the survey, perhaps not having undertaken medical electives during their medical training, and therefore, the survey was not directly relevant to them. We also acknowledge that a semi-qualitative approach to this work would have represented a more complete assessment of medical students’ and doctors’ views towards elective experiences; unfortunately, the study’s design made this impractical. Furthermore, as recruitment was based on the willingness to participate, selection bias cannot be ruled out, nor can the possibility of recall bias be excluded, given that this was a questionnaire-based study, which may be even more significant for doctors reflecting on their competences as students. We also recognise that self-reported confidence in one’s ability to perform a task may not necessarily represent ability to carry out that task.

Conclusion

Medical electives are an important aspect of undergraduate medical training. Such experiences are most beneficial when medical students are afforded the opportunity to become an active and participating member of a health care service provision team, which is often in a foreign country and environment. With that said, patient safety, regardless of the geographical location of the patient, has to be maintained. Steps must be taken to ensure that medical students undertaking medical electives are well prepared for their roles and that they do not pose a danger to themselves or patient safety. We propose a period of simulation training prior to commencement of the elective period, which would focus on refreshing clinical and non-technical skills to a high level as a method of preparation. A programme of pre-elective focused education, such as the medical elective suitcase, offers the opportunity to enhance the medical student elective experience and improve patient safety; it may prove to be a long-term, beneficial addition to undergraduate medical education.