ELECTIVE EXPERIENCES OF FOREIGN MEDICAL STUDENTS AT THE TEACHING HOSPITAL OF TRIBHUVAN UNIVERSITY INSTITUTE OF MEDICINE, NEPAL

This paper has attempted to document and analyze the trend and experiences of foreign medical students enrolled in the elective programme organized by the Medical Education Department (MED) at the Teaching Hospital of the Tribhuvan University (TUTH), Institute of Medicine in Kathmandu. Elective documents have been analyzed for the period between 1997-2000 and a written questionnaire survey has been administered to a total of 73 foreign medical students who completed elective in the year 2000. Over a period of four years a total of 268 students had undergone elective posting in various departments of TUTH. More than half of the students (55%) came from European universities. More than 60% of respondents (n=73) considered the opportunity to see variety of patients as the main strength of the elective programme. Overwhelming majority of respondents (95%) rated the learning experience as good or excellent. The most favoured department was the Internal Medicine. The study demonstrates the unique value of elective in enriching student learning in medical education. The traditional belief that all students should have a uniform curriculum throughout their training has been largely challenged.1 The insights gained could perhaps, inspire medical schools to seriously think about introducing elective provision as an essential component of their undergraduate curricula. 1. Medical Education Department, TU Institute of Medicine. Address for correspondence : Dr. D. S. Pant, MD, MHPED, Assistant Director & Elective Programme Coordinator, Medical Education Department, TU Institute of Medicine, P.O. Box: 1524, Kathmandu, Nepal. Email: dspant@healthnet.org.np, Home Page: www.nchped.org.np


INTRODUCTION
The Medical Education Department since its inception (started as a Medical Education Support Unit in 1986 at the TU Teaching Hospital) has been fostering and promoting international collaboration in medical education.One of the cherished goals of MED is not only to introduce and blend progressive world trends in health professions education with the needs and local contexts for Nepal, but also to share our own philosophy and experiences at TUIOM with other schools of medical education abroad.The Elective Programme for Foreign Medical Students offered by this department has provided unique opportunity for hundreds of overseas medical students to gain first-hand experience and insights of how health and disease are managed in an economically backward but ethno-culturally rich country such as Nepal.Over the last decades elective provision for students has been an important educational strategy in most of the medical schools with innovative curricula in the world.According to one report in the US some 61 medical schools had instituted elective program as early as 1968. 2 There has been a significant increase in curricular flexibility where electives are incorporated into the programmes. 3Today more than 72% of US schools provide more than 16 weeks for elective experiences, twelve of sixteen Canadian medical schools provide 8 to 12 weeks for electives. 4At Mc Master 20% of the curriculum is elective time. 4hy do these medical schools emphasize so much on electives?The questions frequently raised in medical education are two folds: Firstly, how can curricula effectively and efficiently cope up with an ever-increasing and diversified body of scientific information in medical fields?Secondly, how can schools provide greater opportunity for and cater the individual needs and interests of students during a formally prescribed curriculum time?Harden et al 1 suggested that there is a need to liberate medical education from its present factual overload.Experts in medical education agree that the problem of information overload demands a fundamental reorientation of the curriculum and introduction of new strategy.Similarly, Bandaranayake 5 has emphasized that 'some degree of flexibility must be provided in the basic medical curricula for individual students to pursue their respective interests.'In this context medical schools have adopted the strategy of core and elective options which constitute one of the most significant current advances in medical education. 1The essence of elective is to allow freedom of curricular choice for the students.The elective gives opportunity to select subjects or projects of students' own choosing and expand their individual interest.There is also growing demand for humanistic paradigm in medical education.The appreciation of the need to learn medicine in a diversified socio-cultural contexts (learning 'content in a context'!) has inspired students to choose a range of elective offerings made in various disciplines in various corners of the world.A survey carried out among 184 medical students who returned from elective postings, at the University of Queensland, 6 revealed that half of the students (51.1 %) spent their elective in overseas countries outside Australia.The destinations included countries in Europe, Asia-Pacific, South-East Asia, America and Africa.Nepal is world famous for her diversity in terms of different ethnic groups, cultural practices, geographic terrain, and climatic conditions, and that is reflected in the diversity of morbidity patterns (as the saying goes "from snake bite to frost bite!") seen in Nepal.Hence, the country could offer unique opportunity for overseas medical students to get insights into how the science and art of medicine is practiced in a complex socio-economic and cultural contexts of Nepal.On top of that electives also provide students responsibility to plan and learn on their own, hence 'electives represent epitome of self-directed learning'. 1Electives can help students to identify their deficiency and motivate to fill in the gap, it also helps students to choose their future career and shape their attitude. 2,1e main objective of this paper is to document the foreign medical students' experience of elective posting in Nepal and analyze the trend of student enrollment at TUTH.We hope that the information generated through the study could be utilized to further strengthen and expand the elective programme.It could, perhaps, even inspire us to be self-critical about our own academic progrmmes at the TU Institute of Medicine and other health science institutions in Nepal.

METHODOLOGY
We examined all document files of the overseas medical students who enrolled into the Elective Programme through the Medical Education Department during the period between January 1997 to December 2000.A written questionnaire survey was administered to 73 foreign medical students who completed elective posting at the TUTH in the year 2000.The survey used a mix of close-ended and open-ended questions.The study has attempted to address the following key questions: • What is the existing pattern in the enrollment of elective students (country, specialty and season wise) at the TUTH?
• To what extent do students find the elective experience relevant?
• What are the strengths and shortcomings of the existing programme?
• How can the Programme be further improved?Table 1.shows the main issues on which information has been collected from the participants.All questionnaires were administered on the last day of the elective posting.The interviews taken were open in an informal setting during the posting as well as after completion of the elective term.

RESULT
Over the past four years (1997-2000) a total of 268 foreign medical students have been enrolled into the elective programme.A profile of distribution of students according to the country they are studying in is given in Table 2.
Table 2. shows that among the medical students who undertook clinical elective Germany is on the top-most rank (21.6%), that is followed by the UK (18.6%) and the USA (17.5%) respectively.Out of a total number of medical students, more than 55% came from the educational establishments of Europe.Over the years there is a growing trend of students coming from different countries of the world.Table 3 shows that internal medicine is the most popular specialty selected by the students (32%); followed by surgery (24.2%), and emergency medicine (20.5%).The table also shows that there is a growing trend to apply for elective posting in various specialties other than medicine, surgery, emergency medicine and obstetrics and gynaecology.
demand was lowest (9%) for the months of April, May and June.Highest demand (43%) was recorded for the months of July, August and September.
All 73 (100%) students enrolled in the year 2000, responded to the written questionnaire and returned the response sheet to the MED on the last day of their elective term.Students' responses has been summarized as follows:

SELECTING NEPAL AS ELECTIVE DESTINATION
As to 'What was the reason for selecting Nepal as an elective destination?'All students remarked that they wished to know how medicine is practiced in a developing country such as Nepal and were also interested to explore the country and her culture.Some 62 students (85%) also additionally stressed that they were particularly interested in Nepal because they wanted to go for trekking and sightseeing the Himalayas.Some 40% remarked that they were advised to visit Nepal by their friends and relatives.

SOURCES OF INFORMATION
In response to the question 'Where did you get information about the elective progrmmme?' more than 30% of students got information through the previous students who completed elective at the TU Teaching Hospital in Nepal.Some 12% collected information through Internet.More than 40% collected information from other sources.

EXPECTED GOAL/S
For the vast majority 86% (63) the main goal of the elective posting was to learn practical skills in medicie (e.g.drawing blood, putting IV lines, putting plasters, doing surgical suturing, putting catheters, giving anaesthetic and examining new  Table 4. shows a seasonal fluctuation in the enrollment of students over the years.Elective patients).For 45% (36) of students the additional goal was to better understand the tropical diseases and the health system of Nepal.Students also remarked that they could learn the practice of medicine without much use of technical devices here in Nepal.
Table 5. shows students' rating to various types of support obtained during the elective postingteaching/learning support, supports from the consultants, nursing staff, peers, and the administrative support.A four-point rating scale (1-very poor, 2-not very good, 3-good and 4excellent) has been utilized.Majority considered that the overall support they received was good or excellent.Among those who considered that the support provided was poor -in the teachinglearning aspect (3%), peer (3%), administration (3%), nursing staff support (11%), and consultant support (16%).Almost 20% of respondents expressed that they were not satisfied with the performance feedback obtained from the consultants.

WEEKLY WORKING HOURS
On the question 'How many hours on average did you spend a week on teaching-learning activities?' 46% (34) students stated15-30 hours a week and 46% (33) 31-50 hours a week.Education-related activities included ward rounds, bedside teaching, case discussions and out-patient teaching.Only about 5% of students spent less than fifteen hours a week in such activities.

PATIENT CONTACT
More than 85% (63) students felt that the amount of the patient contact during the elective was adequate or most adequate.Only 7% (5) expressed that the patient contact was not adequate.

PERFORMANCE OF PRACTICAL PROCEDURES
38% (28) students considered that the performance of practice was adequate or most adequate, 39% (28) felt that it was just adequate, about 23%(17) felt it was not adequate.

CLINICAL SUPERVISION
About 65% (48) students felt that the supervision by clinical teachers was adequate or most adequate.Some 11% (8) felt that it was not adequate.

SUBJECTIVE WORKLOAD
77% (56) students found the weekly workload just right, 14% (10) found the load moderately heavy.Non found it extremely heavy.

OVERALL LEARNING EXPERIENCE
While rating their overall learning experience during the TU Teaching Hospital elective posting overwhelming majority of foreign medical students 96% (70) expressed that it was good or excellent.The students were asked to write three strengths, three weaknesses, opportunity and threats experienced during the elective posting.The following responses have been compiled and calculated into percentage as to how many students referred to the same issue or problem.One student could give one or more comments, hence, the total percentage could exceed 100%.Evaluation of students and the faculty doctors 2(3%) Others (5 day working weeks, provide lodging for, help for visa, private family hosts, adequate language course for long term students) Needs responsible person for the maintenance of equipment in wards 13(18%) Table 6.shows that more than 80% respondents did not comment on 'What they feel threats during the elective?'Similarly, about 40% students did not comment on the opportunity offered by the elective.More than 60% of respondents considered the opportunity to see variety of patients/cases as the main strength of the programme.About 65% considered "language barrier" as the main weakness of the existing elective term.Interestingly, less than 10% of respondents considered HIV/AIDS as threat during the elective.

WORTH/VALUE OF THE ELECTIVE PROGRAMME
52% (38) students found the elective programme extremely worthwhile and 47%(34) found it moderately worthwhile.One student found it only slightly worthwhile.

OPEN COMMENTS
34 (46%) students did not respond to the item.The open comments made by the rest has been categorized into three main groups: 1. Words of Appreciation: "Thankful for your time and effort in language and culture session (at MED)" "Great time good experience!" "Organized program" "Individual were friendly and helpful" "Effective program" 2. Insights gained: "It has opened my eyes a bit about how things can go in a non western country" "Helped me to dream, to create, to inspire" "Very enriching rotation" "Knowledge was gained from cultural perspective"

Recommendations:
The students made the following recommendations - • Please talk and explain in English, otherwise, it will be useless!• A map of in location of the TUTH campus could be really valuable One student considered the worth of elective experience in Nepal as the opportunity to see 'patients with really rare cases', while the other acknowledged the opportunity 'to observe another healthcare system in action' and gain complete experience through realizing the context of medicine.

DISCUSSION
The medical students underwent the so-called block elective (Certain units of the curriculum designed solely for the individual activity), 7 as part of the formal requirement of the respective academic programmes.The minimum duration accepted for the elective attachment at TUTH was four weeks.The total duration and the timing of the elective term in the respective curricula varied from school to school.In most of the medical universities in Europe students had the opportunity to experience elective during their fourth, fifth or sixth year of studies, whereas, the electives in North American schools started early during the first or second years and continued till third and fourth years.Some newly commenced graduate programmes in Australia offered elective during the end of fourth year.This variation in timing and duration was probably influenced by the total number of study years to be spent in medical schools and also by the specific educational strategy adopted by that particular school.In contrast to the conventional schools, most innovative schools offering early clinical exposure and the problem-based learning, provided elective options to their students quite early in the programmes.
We feel that some serious issues unfolded in the study needs to be further discussed.In order to address the problem of language (some 64% students identified 'language barrier') MED has been organizing orientation on basic Nepalese language and culture for each new batch of students.We agree with students' suggestion to provide a small phrase book with commonly used terms and sentences.We have also advised students to work together with Nepali students, which could be beneficial to both.This could even help to promote sharing of knowledge and skills and better understand each other's perspectives in medical education.
With the growing demand for elective posting at TUTH faculty teachers will have to definitely manage greater burden.Even though the study shows a possibility of sharing of burden among departments as students have been increasingly applying in disciplines other than medicine, surgery and emergency medicine.The overall competition for learning clinical skills will definitely increase in years ahead.Some faculty teachers have already expressed concern about the matter.Paradoxically, we feel the way to overcome this problem is to further expand the programme through creating greater opportunity by organizing visits to district/rural health clinics.
In fact, many students regarded the lack of community attachment as one of the serious weaknesses of the existing programme.We strongly agree that community attachment will help enrich students'learning experiences through providing first-hand experience of the Nepalese rural life and also getting insights into the practice of medicine in a primary health care set up.This, of course, demands extra resources including greater management capacity in terms of organizing faculty time, supervision, vehicles, accommodation etc.However, part of the institutional fee generated through the elective programme could be spent for strengthening and expanding the programme itself.Over the years the elective money has been spent to build the resource capacity of the Medical Education Department and other clinical departments at TUTH.We consider this resource-generating activity an important dimension of the Elective Programme.
Increased flow of students in the months of July, August and September could, perhaps, be explained in terms of students taking holidays this time of year in North American and European medical schools.September is also the beginning of tourist season in Nepal.85% of students identified trekking and sight-seeing the mountains as the additional reason for selecting Nepal as their elective destination.The seasonal variation could be utilized as advantage-more students from Australia and News Zealand could be attracted during the months of December and January, when they have summer vacation in the south.This could even help to spread out the current burden of student flow in the departments.
The question 'How much the elective exposure should actually be structured?' is still debatable.While maintaining the current flexibility in the programme, a clear cut prior agreement on a set of learning objectives between the preceptor and the student before starting the elective posting ought to be there. 8Some students during informal interview even requested to organize formal lectures during the elective.However, Harden et al (1995) identified essential difference between the elective and the so-called Special Study Module (SSM) offered as options in some medical schools.
In the latter the teachers play greater role in terms of planning and providing formal input in the programme.The elective provides students with greater freedom and flexibility in management of their own learning.They are encouraged not only to identify their own area of interest and taste but also to discover their limitations.The students will decide themselves what particular area to focus on more, how to go in depth to solve the problem or how to adopt a strategy to cover a broad range of problems and remain general.In the SMM students' learning is formally assessed.We found variation among medical schools regarding the assessment of elective experiences.In most of the cases the assessment is informal.A separate study could be undertaken on elective assessment pattern among schools.

CONCLUSION
The elective programme has certainly provided unique opportunity for overseas students to broaden their medical experiences in a different cultural set up.Even though 99% of students expressed that the elective at TUTH was either extremely or moderately worthwhile we give due consideration to one student who expressed that the elective was only slightly worthwhile.The explanation that the respective departments should better plan the exposure is fully understandable.On top of that we add that students should be given better attention to learn practical skills and opportunity to receive feedback on their performance.This issue is crucial as 20% of students expressed that performance feedback from the consultants was poor and some 23% felt that the practical exposure was not adequate.We recommend that these shortcomings must be improved in order to enhance quality in the programme.
Finally, organizing elective could be a highly satisfying experience in itself.There are multiple dimensions and perspectives associated with the experience.We hope that the elective helped the students to learn the humility and an acute awareness of their own limitation. 9At the same time, the students also probably got insights on how the western medicine with great hope has been functioning in a different system-a lesson no textbook can teach them. 10The overall insights gained through the study could be an eye-opener for all of us.In case of the Institute of Medicine that has been championing the cause and value of innovative medical education since 1972 it seems rather ironic that it has not yet been able to offer Elective as an innovative curricular strategy in its academic programmes.The study has demonstrated that elective provision has a number of advantages during a formal course namely, managing the everincreasing burden of facts and information in medical curriculum; providing freedom of choice to the students; and facilitating learning of medicine in different contexts.We would, therefore, very much recommend medical schools in Nepal to offer elective options in their medical education curricula.
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Table 3 Specialty choice by students (1997-2000) Specialty Number of Students enrolled in each year
MonthsNumber