Clinical electives in China: trends, experiences, barriers

Using convenience sampling data from 4 open-access elective databases, we sought to gain additional insights into motivations for and barriers to clinical elective experience in China. The analyzed elective testimonies and the very good (yet subjective) student ratings suggest that IMEs in China are potentially attractive for students from the German-speaking countries. The combination of structured clinical elective programs with English supervision, and the opportunity to learn more about the Chinese culture attracted many students in this small convenience sample from the past 2 decades. Yet, the reported challenges encountered by the elective students may also provide insights for improvement.

Several authors argued that IMEs foster important medical competences, including professional identity formation, interest in humanitarian efforts and volunteerism, and value-based communication as well as personal growth [21,22,23]. This may particularly the case with regard to structured electives, which are arranged through reciprocal faculty partnerships or philanthropic sponsorships, and which are characterized by continuous student supervision during the entire elective [24, 25].

Yet, most electives are still largely unstructured, and oftentimes student-driven [26]. This implies that students determine the elective destination on their own, and apply individually on a case-by-case base for an elective rotation at their desired host institution(s). Unstructured electives are thus often characterized by a lack of guidance, peer support and monitoring at all elective stages (including application, preparation, conduct and de-briefing). Such electives have been repeatedly criticized as potentially harmful and detrimental for trainees, sending institutions, and – above all - the host community [26, 27]. Such electives potentially contribute to the exploitation of vulnerable healthcare systems, and may result in ethical dilemmas [15].

While a detailed discussion of that particular topic is beyond the scope of this brief report, our data suggest that only 1/5 of students applied through a bilateral exchange program. The large majority of elective experience in this sample was self-organized. Whether this type of elective experience served as a rigorous channel of medical learning was unfortunately not ascertainable from the available data. We thus clearly acknowledge that our descriptive analysis is not based on actual measurements of learning competencies but based on students’ self-reports and self-assessments.

Whether for example the frequently reported “high-quality teaching in English for international students” actually translated into measurable improvements in medical skills and knowledge was not ascertainable from our data, and would also be beyond the scope of this analysis. Prospective interventions studies would be required for such questions, yet most elective research is based on retrospective cross-sectional analyses [28, 29].

However, apart from medical knowledge, we also argue that IMEs have additional assets. They may help to improve cross-cultural conversation [21], and potentially help to facilitate international exchange and dialogue in a world of increasing global geopolitical tensions and conflicts. Based on our tertiary experience, IMEs may constitute a platform of commonalities and intercultural exchange [30], facilitating cooperation in a key area of common interest: the promotion of global environmental and human health. Then again, one must also question whether it is indicated to offer electives to individuals looking for “travel and holiday” (as reported by some students in our sample) in a time when health workforce resources are so thinly stretched.

Regrettably, our data does not allow for an answer to these questions but suggests that students generally enjoyed their elective experience. The fact that most students in our sample rated their electives exceptionally well (grade: A), despite the non-negligible existence of language barriers (Chinese is not a common language taught in Germany), is an indirect indicator that IMEs serve a purpose far beyond simply exchanging medical knowledge and ideas.

International medical electives, as part of structured global surgery academic partnerships between institutions in high-income countries and low-middle income countries, may also play a pivotal role in developing surgical workforce capacity [31,32,33]. The latter is of utmost importance, given that nearly 5 billion of the world’s growing population lacks access to safe, accessible and equitable surgical care. In our sample, general surgery was the most frequently chosen elective discipline, and surgical disciplines accounted for 65% of total electives. Said factor must be kept in mind when discussing about the potential pros and cons of international electives, and is a noticeable feature of our sample.

While our report does not resolve the ongoing debate on the value (and pros and cons) of IMEs, we may contribute important data that facilitate the understanding of elective experience in China. Although largely from pre-pandemic times, our data may allow for important first insights in motivations for (and barriers to) electives in China. Data from the last 2 years would be most desirable, but is largely unavailable due to COVID-19 related travel restrictions and closure of international elective programs [13, 20].

The fact that the majority of elective experience in this sample was largely Shanghai-centered could be interpreted in a way that students mainly sought elective experience in one of China’s most dynamic and developed metropoles, which is a mix of East and West. Electives in the Western parts of China were rarely reported. Then again, Shanghai concentrates hospitals that offer regular teaching in English for foreign students during their elective – an important feature and magnet for all students who are unfamiliar with the Chinese language but seek to visit the country anyway [34].

Strengths and limitations

This brief report has strengths and limitations to discuss. The reservation must be made, that from a quantitative perspective the number of identified elective reports was only modest (n = 40). Notably, writing elective testimonies is not mandatory, and students usually receive no credit for this work [15]. Thus, it is likely that the actual number of students going to China for an abroad elective was much higher. Our sample is a convenience sample and may not be representative of the German medical student body as a whole.

As reported earlier, student testimonies are often subject to recall bias and may not replace face-to-face interviews [15]. In light of the COVID-19 pandemic and the COVID-related decline in elective activities, however, they serve a valuable purpose, are easily accessible and allow for additional insights into abroad elective trends.

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