If you are going to write a reflection on your international elective, here’s my advice.
(approx. 8-12 minute reading time)
Hi there. My name is Allan Kember. Welcome. I am a fourth- and final-year medical student at Dalhousie Medical School and an incoming resident in the Department of Obstetrics and Gynecology at the University of Toronto. I recently completed a five-week clinical rotation in the Obstetrics and Gynaecology Department at the Korle Bu Teaching Hospital (KBTH) in Accra, Ghana.
While I do enjoy writing, it requires time and effort – the former of which I lack. So I don’t tend to write unless I really need to. But after being approached by over two-dozen employees at KBTH about a foreign student’s recent reflection on KBTH, I feel that the time has come that I need to write something. The reflection was ignorant, insensitive, and insulting when read from the Ghanaian perspective. I can only hope that the reflection was in innocence and not malevolence, but regardless of the intent, damage was done. I have been in touch with the student’s school – a leader in the arena of global health – and have learned that an apology has been made and the situation has been sorted out.
The reflection went viral after my first week at KBTH. Almost overnight, I felt that the relationships I had built in my first week had suddenly changed. They became subtly guarded. When I introduced myself to staff I hadn’t met yet, they weren’t as enthusiastic about meeting this foreigner. I knew something had changed for the worse, but I didn’t know why. It wasn’t until I was starting a duty shift one night when I learned why. I had just greeted a nurse whom I knew well when, suddenly, a serious expression came over her face. “Are you going to write something bad about us?” She proceeded to tell me about the reflection, which I later found and read. This wasn’t the only time I was asked this question over the next four weeks. In my discussions with KBTH staff, I learned that many of them were deeply hurt by some of the statements in the reflection. My heart sank every time I was asked this question, but each time, it gave me an opportunity to allay any concerns and, thus, build stronger and deeper relationships with the KBTH staff, which is good, because one day I hope to visit them again.
For the remainder of this piece, I would like to give some advice for students who, having completed an international elective, intend to write a reflection about their experience. Note that much of this will be applicable to medical residents too. While I admit that I am not an expert, I have spent 12 months of my life immersed in various cultures with six of these months within three countries in Africa. As a researcher, I have also been involved in research in four African countries since 2013. Without further ado, my advice:
- Always remember your role. You are not a doctor (unless you are a resident) – you are not there to “work” or “practice medicine”. You are not a news reporter – you are not there to write a thrilling story or earth-shattering exposé. You are not an auditor for the WHO or FDA – you are not there to assess safety or the standard of care. You are not a professor – you are not there to instruct the medical faculty how to do things better. You are not an explorer – you are not there for an adventure. No, you are a medical student – you are there to learn. Don’t forget that. Even if you are a medical resident, you are not likely there to “work” unless you are legally permitted to do so by the laws of the country you are visiting and have extended your liability coverage from home (e.g., CMPA).
- Consider your choice of words carefully – it should reflect your role. If you were there as a learner, do not say, “I was working at KBTH.” Do not say, “I practiced medicine outside my home school and country for the first time.” Rather, you might say, “I was continuing my medical studies at.” Or you might say, “I completed a four-week elective clinical rotation at KBTH.” You weren’t “working”. You weren’t “practicing”. You are not a doctor (unless you are a resident or, in a unique situation, not a resident but holding an MD), and you do not hold a license to practice medicine in the country you were visiting. In fact, if you are a student, you do not even hold a license to practice medicine in your own country.
- Note, however, that if you were conducting research, that is different, and you may have been “working”.
- In remembering your role, it might be helpful to explain where you are in your medical studies in your introduction. Be cognizant that the medical education system in the country you visited may be very different than it is in yours. Medical school in Ghana is six years, so most Ghanaian readers would assume that a fifth- or sixth-year American or Canadian medical student is a senior whereas a third- or fourth-year student is a junior. However, it is important to note that medical school is only four years in the US and Canada, so a fourth-year student is a senior. This can muddy the waters, so it is important to give some context of where you are in your studies at home. This applies to residents too, for example, a residency in obstetrics and gynecology is five years in Canada and three years in Ghana; however, when the differences in programs are taken into account, it takes 13 years of post-secondary education in Canada to become an OB/GYN whereas it takes 14 years in Ghana.
- If your intention is to make your reflection public (e.g., a blog post), do not publish it until you have had it reviewed and approved by several individuals.
- First, you should have it reviewed by an individual with training and experience in cultural humility – the global health office at your school is a good place to look for such an individual.
- Second, have it reviewed by your supervisor at the site where you completed your elective.
- Third, I contend that you should also have it reviewed by your supervisor’s supervisor, i.e., the department head.
- Do not publish your reflection until you have the approval of these three individuals at a minimum. If these three individuals have approved your reflection, there is a high likelihood that your reflection will sit well with the majority.
- Note that this piece has been reviewed and approved by the above individuals (and more), so it is feasible.
- The reflection is about your experience. However, you need to also reflect on the language and sentiments you use to write about your experience.
- While it may be semantics, I avoid using “low-resource setting”. While “low-income country” appears to be the chosen language of The World Bank, it does make me a bit uncomfortable to use it in a public setting and especially when conversing with my colleagues from abroad. Albeit, I am happy that we have moved away from terms such as “undeveloped”, “under-developed”, “developing”, and “third-world”. “Low-resource” is a bit condescending. I use “limited-resource.” The beauty of “limited-resource” is that it applies to every hospital in every country, hence the existence of the principle of justice (fair distribution of scarce health resources) in medical ethics. You can say that KBTH is a “limited-resource” setting, and you can say the same about the Mayo Clinic. One is more limited than the other, but that doesn’t change the fact that both have their limitations.
- Do not label your elective site as “the most difficult of situations” and then proceed to tell your readers that if you could love your specialty in that situation, you could finally confirm that it is the right specialty for you. Not only is this incorrect (believe me, KBTH is not “the most difficult of situations”, and it is extremely unlikely that your school’s global health office will allow you travel to a country where such conditions exist), it is a blatant insult to all the staff at your elective site who happen to regard it as their place of employment – some for years, some for decades. Having sweat become an inescapable part of your life for a few weeks while on an elective in the tropics does not make it the most difficult of situations. Please!
- Although your international elective may be a grand adventure in your mind, this really isn’t the most professional way to express or approach your international elective or medical education. An adventure is “an unusual and exciting, typically hazardous, experience or activity.” If you use this word, what are you implying about your elective site?
- Be especially careful of the danger of a single story. It will be a great benefit to you if you watch the TED Talk called “The Danger of a Single Story” by Chimamanda Adichie. Remember that your reflection is painting a picture in the minds of your readers. If all they can imagine of Ghana is a scene of people wearing tattered rags for clothing amongst dilapidated and abandoned buildings, then you’ve told a single story and have led your readers astray. Far astray in fact. Over the past three years, I have spent more than two months living in Ghana, and most of the time, I feel underdressed. As a whole, Ghanaians are extremely well dressed – I contend, more well than my own culture.
- Think about your privilege. Do not be ignorant of it. When you are ignorant of your privilege, you become entitled. The decor of pleasant words, no matter how generously applied, will fail to hide the reprehensible backdrop of entitlement from the minds of your readers.
- Do not major on the negatives. Walking the tenuous line between accuracy and cultural sensitivity is likely the most difficult part of writing a reflection. Negatives can be found wherever one goes in the field of medicine – no matter the country or setting. The concept of relative disparity is helpful in understanding the ubiquitous nature of this phenomenon. Here is an example of majoring on the negative: the fact that patients’ families visit them at KBTH and stay nearby could be attributed to something negative by saying, for example, that family needs to be nearby in case the patient needs medication because they must pay for it out of pocket. But think about that for a second. If you were unwell and in the hospital, would you want your family nearby? Do patients’ families in Canada or the USA visit them while in hospital, bring them things, and help address any need they might have? Of course! There is a reason we call them “loved ones”. So there is no need to paint this fact in a negative hue. Further, virtually anywhere you go in the world (not just KBTH) you will learn that family is an integral part of patient care and that outcomes tend to be worse when family is not involved. A specific example from pediatrics includes “care-by-parent units”, which were invented in Canada by the internationally known and respected pediatrician, Dr. Richard Goldbloom.
- Avoid making comparisons between the healthcare system at your elective site, with all its gaps, faults, disparities, and tragedies, with your flawless healthcare system at home (I am being sarcastic – while some are better than others, no healthcare system is perfect and all of them have their flaws). It is very tempting to make the “copy-and-paste” error, that is, copying what seems to work in a Western context and attempting to paste it somewhere else (e.g., West Africa) even if it isn’t feasible, applicable, culturally-sensitive, or sustainable. If you are going to make comparisons, you better invest a lot of time to do a lot of research to make sure they are fair comparisons. Obviously, there will be differences between healthcare systems in high-income, middle-income, and low-income countries. The reasons for these differences are extensive and incredibly complex – only a handful of intellectuals in the world can explain them adequately, so I advise to stay away from comparisons unless you have truly done your homework. Why not leave such analyses to organizations like The World Health Organization?
- Check your facts. This isn’t always easy, so that is why review and approval by your site supervisor and the department head is imperative. If you don’t check your facts, you may end up repeatedly insulting one of the leading teaching hospitals in West Africa and its physicians, residents, nurses, and midwives! You may even imply, albeit indirectly, that they are incompetent in providing safe care. Further still, you may incriminate them as ones responsible for harming their patients. Be careful with what you state as fact. And, just for the record:
- Ultrasound, imaging, and continuous fetal monitoring are available at KBTH and in Ghana – I saw all three used multiple times during my elective at KBTH.
- Privacy is not a “luxury” at KBTH. This is why they have curtains and privacy screens available for use in every encounter. I set up the privacy screens and pulled the curtains dozens of times each day. Implying that something we take for granted in Canada and the USA is a “luxury” at KBTH contributes to driving a false wedge of disparity deeper and deeper into the minds of your readers who don’t know better (unless they are Ghanaian are are intricately aware of the situation on the ground there).
- The blood bank is not notoriously empty at KBTH. Stating that the blood bank is notoriously empty may capture the interest of readers, but it is simply not true. After many duty shifts, unused blood is actually returned to the blood bank by the senior resident; however, in saying this, I wouldn’t want to detract from the age-old need for blood donors. While I was at KBTH, I saw a presentation by a senior consultant regarding the blood donation issue, and one new change that was implemented while I was at KBTH was that the blood bank began offering a blood donation site at the antenatal care outpatient department in order to streamline blood donation from patients’ family members.
- IMPORTANT: A reflection is not the place to give a case-report. If you were to approach a major journal, for example, the BMJ, with a case-report, you would be absolutely refused publication if you did not have written informed consent from the patient. This refusal would be regardless of how well you anonymized the details of case. It is unethical to publish a case-report in a medical journal without written, informed consent of the patient, so why would it be any less unethical to do so in your international elective reflection?
- Be very careful with sensitive issues. One such issue you will encounter is religion. I can almost guarantee you that religion and faith play a much greater role in the society at your elective site than it does in your home country. If you are not a person of faith, you likely have no idea how it feels to have the most precious thing you hold constantly belittled, trivialized, and demeaned by society around you. So when you dismiss the patient and her family’s faith and prayers as mere futility in order to make room for your all-knowing savior-doctor complex, you’re trampling underfoot not only this patient, but the majority of the population of Ghana. You are also forsaking your duty per the CMA Code of Ethics, Fundamental Responsibility #3: “Provide for appropriate care for your patient, even when cure is no longer possible, including physical comfort and spiritual and psychosocial support.” If you knew anything about the faith that your patient and her family holds so dear, you wouldn’t dismiss their acceptance of her prognosis as “odd”. Further, you wouldn’t conclude that their understanding of death and dying are a result of the poverty that is a way of life in Ghana. Ouch! That’s an utterly ridiculous conclusion! It implies that poverty takes the sting out of death. When the child of an impoverished mother and father dies, do you think they don’t grieve because they are poor, or in other words, because the value of their child’s life was somehow inferior to that of a middle- or upper-class child? Poor people grieve too. Dr. Paul Farmer once aptly stated, “The idea that some lives matter less is the root of all that is wrong with the world.” Poor lives matter, so don’t say that poverty makes suffering and death easier. Maybe take a look at Gutierrez on liberation theology and the preferential option for the poor. If you happened to ask this patient about her faith, perhaps you would learn that her acceptance of her prognosis may not be so odd after all.
- Moving on now. You can’t speak the local language and you’ve had relatively little exposure to their culture, so don’t presume that you are in a position to evaluate patient-doctor communication.
- Likewise, you are not in a position to evaluate the residents ‘and staff’s decision making. Stating that physicians at KBTH order the one test they think is the most important and then hope for the best is incredulous. First, it assumes that all patients presenting to KBTH can only afford one test – not true. Second, it implies that physicians at KBTH have tossed evidence-based medicine to the wind in favor of shooting from the hip – also not true. In fact, far from the truth. The consultants at KBTH happen to be board-certified by the West African College of Surgeons (at least 14 years of post-secondary education and training), so I’m not sure what gives a student the credentials to go about casting doubt on their clinical judgment. Further, don’t sensationalize the physical exam as if it is the only tool that doctors at your elective site have at their disposal. With the modernization of medicine, we are, both literally and symbolically, losing touch with our patients. In the dawn of artificial intelligence, perhaps watching the TED talk called, “A Doctor’s Touch” by Dr. Abraham Verghese would be helpful for any medical student who doubts the importance of the physical exam in his or her own practice.
Thanks for reading. Happy reflecting!