Electives appear in the curricula of medical schools worldwide and are a required component for all Australian medical students. The purpose of an elective is to offer medical students the opportunity to undertake supervised clinical practice in a discipline of their choice. Electives offer a choice not only in what to learn, but also where to learn. In addition, the elective term is perceived as an opportunity to experience health care overseas, especially in developing countries. Medical students are highly motivated to participate in electives, where they can become immersed in the challenges of clinical work without the necessary distractions of lectures, tutorials and exams. However, unlike other teaching and learning, which comes with a defined curriculum and assessment, electives require students to take responsibility for their own learning, not only in organizing and implementing it, but also in evaluating it.
In most electives, learning is assessed, by the submission of a written report, portfolio or diary. Written reports such as these depend on students’ ability to reflect on their experiences in order to identify and appraise their own learning. Nevertheless, despite the large number of Australian medical students undertaking electives nationally and internationally, there is still very little research into how students describe their experiences and evaluate their learning no matter in which country they choose to study. The purpose of this thesis is to contribute to existing understanding of learning in electives by exploring the nature of reflection and quality of learning over three global areas (developing countries, developed countries and Australia) as described in 186 written reports submitted by 126 medical students on completion of electives taken during the Sydney Medical Program elective term of 2013.
Using quantitative and qualitative research methods, this work was completed in two studies. Study 1 involved the measurement of students’ reflection in the written reports they submitted on completion of their electives. Study 1 revealed that overall levels of reflection were low, casting doubt on the use of reflection as an assessment strategy. Study 2 involved in-depth, iterative reading and interpretation of 186 written reports. Analysis using phenomenological and hermeneutic strategies uncovered nine distinct yet overlapping themes in students’ descriptions of learning in electives. These nine themes were then aligned within a validated framework for learning.
Students described a wide range and large number of contextually situated, emotionally complex and socially mediated learning events that highlighted the importance of the affective domain in maintaining motivation in learning. In addition, the pervasive influence of stress and anxiety on learning featured strongly, particularly for students who took electives in developing countries.
Findings from this research revealed that in the absence of prior learning, numerous students were unaware of the ethical issues they would encounter and and, as a result, experienced profound emotional and cognitive dissonance when working in developing countries. This dissonance, in many cases, diminished their ability to achieve positive learning outcomes. Students who remained in Australia or went to developed countries received consistent mentoring and support, which facilitated knowledge transfer and led to new understanding in a range of contexts.
Further research needs to be given to the value of pre-departure training in authentic simulated conditions for students intending to go to developing countries. There should also be more emphasis on Global Health education, cultural compentency, ethics of volunteering and medical professionalism in the developing world. Additionally, in order to facilitate reflection, students need greater opportunities to develop their reflective writing skills and to generate deeper, more critical reflection in order to meaningfully engage with, and truly learn from their elective experiences.