Introduction - Preparations for your elective
Get that much-needed approval from your medical school, the first time round.
The excitement of an elective can often be subdued (only temporarily!) by the due diligence your university requires of you to embark on a safe and legitimate healthcare placement.
Most medical schools require the following paperwork (including, but not limited to):
- Elective Justification Form
- Elective Risk Assessment (what we will focus on here)
- Confirmation of Elective
The purpose of this guide is to take you through the key principles of a risk assessment, and take you through the common considerations that could be relevant. This guide will provide a framework for you to identify and manage any risk that may entail.
Introduction - The importance of risks assessments.
What do you think are the most common risks associated with medical elective in resource-poor settings? Name at least 4 types of problems that could arise.
Electives in resource-poor settings significant increase the exposure to
- 'infectious illness,
- trauma,
- sexual health problems,
- excessive sun exposure,
- mental health issues, and
- crime' (Johnston et al, 2018).
Where the infrastructure and provisions may not meet the standards of your country-of-residence, it is paramount that adverse events are avoided where possible and a sophisticated plan is made to address them if they arise.
Fortunately, case-studies, literature and travel advice are widely accessible online. Oftentimes, your medical school's graduates will leave behind their own Risk Assessments that you can increase your insight into the planning of electives.
- Niall Johnston, Nichola Sandys, Rosemary Geoghegan, Diarmuid O’Donovan, Gerard Flaherty, Protecting the health of medical students on international electives in low-resource settings, Journal of Travel Medicine, Volume 25, Issue 1, 2018, tax092, https://doi.org/10.1093/jtm/tax092
Introduction - What is a risk assessment?
In one sentence, how would you describe a risk assessment?
= it is a process that allows "individual risk events and overall risk to be understood and managed proactively, optimising success by minimising threats and maximising opportunities and outcomes"
-
APM Body of Knowledge. / Murray-Webster, Ruth; Dalcher, Darren.
7th ed ed. Princes Risborough: Association for Project Management, 2019. 230 p.
Introduction - The risk assessment framework
Risk Identification: What could possibly go wrong? Start with a 'brain dump'. Think, between starting your elective and finishing, what activities you will be doing and the problems that could be encountered during them.
Using this framework, take the risk of malaria in Tanzania, how would you process this into a risk assessment framework?
- Start with the risk category, so you can group the types of risks together.
- Identify the risk itself
- Analyse the risk. How likely? How severe? This is somewhat subjective, but demonstrates that you can consider the risks.
- How will you control the risk? Here you can minimise the likelihood of malaria and also reduce its impact if it occurs (e.g., by knowing the early signs, by seeking medical attention early).
Risk Analysis Grid:
Once you've score the likelihood and severity of each risk identified, you can map out where they fit in the risk grid.
The risk grid is useful as it allows you to visually illustrate your priorities. The 'red zone' risks are the ones you should take the most seriously.
Travel-related risks - Introduction
Whether you stay at home or fly abroad, it's likely your elective will involve getting transport to-and-from the hospital to your accommodation. If you're headed abroad, you need to consider how you're going to reach the host country, and get to your accommodation from the airport. In your downtime, how are you going to move around?
In this section, we'll look at the risks associated with transport.
Travel-related risks - Getting to your host country
Think about how you'll be going from your country of residence to your elective hospital and reach the accommodation you'll be staying in.
What could go wrong here? How will you reduce the risk of any problems at this stage?
Now look at the feedback section of the last question. Did you miss anything? If so, try again by identifying risks, analysing them and responding to them.
- Niall Johnston, Nichola Sandys, Rosemary Geoghegan, Diarmuid O’Donovan, Gerard Flaherty, Protecting the health of medical students on international electives in low-resource settings, Journal of Travel Medicine, Volume 25, Issue 1, 2018, tax092, https://doi.org/10.1093/jtm/tax092
Travel-related risks - Transport within the country
Think about your chosen country/region and its transportation safety. What are the risks associated with this?
Road Safety: In many countries, road safety standards may differ from what you are accustomed to. Risky driving behaviours, poorly maintained roads, and a lack of traffic regulations can increase the risk of accidents. Socioeconomic limitations leave large proportions of the population to be limited to dangerous transportation methods. Just because everyone else is doing it, doesn't mean that it is accepted is safe.
Public Transportation: Depending on the destination, public transportation options may vary in terms of safety and reliability. Crowded buses or trains can also pose health risks.
Driving Risks: If the placement involves using vehicles, especially in countries with different driving norms or road conditions, there may be increased risks of accidents.
Vehicle Maintenance: Assess the condition and maintenance of vehicles provided or rented during the elective.
Now, using the information provided, improve this risk assessment section with each of the sections, making sure to identify, analyse and respond to each of them.
- Niall Johnston, Nichola Sandys, Rosemary Geoghegan, Diarmuid O’Donovan, Gerard Flaherty, Protecting the health of medical students on international electives in low-resource settings, Journal of Travel Medicine, Volume 25, Issue 1, 2018, tax092, https://doi.org/10.1093/jtm/tax092
Work-related risks - Risks of healthcare work overseas
In the same format as before, list all the risks that could arise whilst working in an overseas healthcare setting. Think about the risks to you, to patients and further afield.
- Niall Johnston, Nichola Sandys, Rosemary Geoghegan, Diarmuid O’Donovan, Gerard Flaherty, Protecting the health of medical students on international electives in low-resource settings, Journal of Travel Medicine, Volume 25, Issue 1, 2018, tax092, https://doi.org/10.1093/jtm/tax092
Work-related risks - Avoiding unintentional harm
Try to list all the different people & organisations that could be adversely affected by events that could occur on your elective.
- Patients (e.g., never-events, adverse outcomes)
- Medical colleagues in the hospital (e.g., finding it hard to adjust to international colleagues)
- International colleagues accompanying you (e.g., witnessing or contributing to poor patient outcome)
- Host hospital and/or regional health board (e.g., ethical concerns or reputation damage)
- Your medical school (e.g., ethical concerns or reputation damage)
- Your national medical council/regulators (e.g., reputation damage, time spent resolving international incidents)
- Yourself (e.g., guilt, psychological harm, professionalism proceedings)
Thinking about this list, and any others you thought of, specify how each stakeholder could be affected by events that occur on your elective?
Taking the impacts on yourself as an example...
Physiological factors factors (hot climate, poor fluid intake, poor health)
Environmental factors (alien settings, lack of proximity to social circles)
Cultural issues (language barriers, exposure to adverse living conditions, health inequality, poverty, culture shock)
Occupational factors
- Seeing extensive morbidity and mortality in circumstances preventable in your home country.
- Sense of helplessness or incapacity to help, owing to own skills and/or lack of resources.
- Feeling pressure to fulfil clinical tasks beyond your station and competence because of staff shortages and pressure from patients and colleagues/supervisors who might have unrealistic expectations of you.
- If/when scenarios lead to an increased sense of responsibility and adverse outcomes occur, guilt, self-doubt and psychological harm may ensue for you.
- You might be frustrated if local health beliefs oppose evidence-based medicine could ensure, where witchcraft, magic, and alternative medicine is practised. It is, however, important that these beliefs are respected. As we've learned from medical ethics, patients are at liberty to make decisions you may feel are unwise.
How could each of these issues be mitigated? Complete answers to these questions may enter the realm of medical ethics.
- Niall Johnston, Nichola Sandys, Rosemary Geoghegan, Diarmuid O’Donovan, Gerard Flaherty, Protecting the health of medical students on international electives in low-resource settings, Journal of Travel Medicine, Volume 25, Issue 1, 2018, tax092, https://doi.org/10.1093/jtm/tax092
Work-related risks - Beyond your competency
Avoid getting involved in routine care that is outside your level of competence.
Check this link to look into this issue.
Environment-related risks - Risks of the environment you'll be in
Will you be living in rural or urban areas? Where will you be visiting in your downtime? Think about how your environment will be different. What could be cause issues here, and how would your resolve them?
Climate and Weather: Extreme temperatures can lead to heatstroke or hypothermia. What is the UV index in the country? What is your 'Fitzpatrick' skin classification? Think about how sun-related skin damage could affect you and how you will prevent serious burns. Certain medications, such as antimalarials, can make your skin more sensitive to the sunlight than it usually would be.
Think about the prevalence of natural disasters such as hurricanes, earthquakes, or tsunamis. Is your location consider higher risk?
- Niall Johnston, Nichola Sandys, Rosemary Geoghegan, Diarmuid O’Donovan, Gerard Flaherty, Protecting the health of medical students on international electives in low-resource settings, Journal of Travel Medicine, Volume 25, Issue 1, 2018, tax092, https://doi.org/10.1093/jtm/tax092
Location-related risks - Thinking about the local setting
Think about the characteristic of the country/region you are visiting, what are the considerations of going there? How will you have to adjust or exercise caution?
Now you've seen the general factors to consider, please now make a broader list with specific considerations of your host country/regions locational factors. Then think about how you should mitigate these.
- Niall Johnston, Nichola Sandys, Rosemary Geoghegan, Diarmuid O’Donovan, Gerard Flaherty, Protecting the health of medical students on international electives in low-resource settings, Journal of Travel Medicine, Volume 25, Issue 1, 2018, tax092, https://doi.org/10.1093/jtm/tax092
Personal Health & Wellbeing - Health and wellbeing considerations
How are you going to ensure your health and wellbeing is maintained during your elective? What could adversely affect this whilst you are away and how could you prevent them?
Local Healthcare Access: Familiarise yourself with the healthcare infrastructure at your destination. Know the location of nearby healthcare facilities and their contact information. Understand how healthcare services are accessed in case of illness or emergencies.
- Gastroenteritis
- Schistosomiasis
- Malaria
- Rabies
- Blood-borne diseases (HIV, Hepatitis B & C)
- Tuberculosis
Compare your own answer with the feedback, and improve your list of risks and responses.
- Niall Johnston, Nichola Sandys, Rosemary Geoghegan, Diarmuid O’Donovan, Gerard Flaherty, Protecting the health of medical students on international electives in low-resource settings, Journal of Travel Medicine, Volume 25, Issue 1, 2018, tax092, https://doi.org/10.1093/jtm/tax092
Summary - Summary
You've learned:
- The basic framework for a risk assessment: identification, analysis, & respond
- The considerations of travel, work, environment and location during your time overseas.
At the end of the course, you can download your original and improved answers as a PDF that you can use to use as a draft risk assessment for your own medical school's desired format.
Thanks for reading, and we hope you have an amazing personal and professional experience on your elective!
If you have any questions, don't hesitate to contact us on info@electives.net and we'll get back to you as soon as we can.