Episode Transcript
[00:00:00] Cheryl: Welcome to the podcast from Cambridge University Medical Education Group or CUMEG for short. This is a podcast from the University of Cambridge Clinical School focusing on medical education. We'll be touching on a range of topics that medical educators are dealing with. I'm your host, Cheryl France, Head of CUMEG.
[00:00:33] Today, I would like to introduce Dr. Jonathan Fuld. Jonathan is a consultant physician at Cambridge University Hospitals NHS Foundation Trust, or Addenbookes as we often refer to it. In addition to this important role, Jonathan works closely with the University of Cambridge Clinical School to assist the students with placements at Cambridge University Hospitals' NHS trusts. Today, I will be chatting with Jonathan about the electives component of medical students' training and the significance of these electives.
[00:01:07] Welcome, Jonathan. It's wonderful to have you with us today.
[00:01:10] Jonathan: Thank you, Cheryl.
[00:01:12] Would you be kind enough to tell us more about your background and about the roles that you hold?
[00:01:20] Jonathan: Okay. So, I did my training in Sheffield and I think one of the early things I came to understand is that moving around in medicine is something of significant value. So, having spent a year in Sheffield doing what was then called House Officer jobs, now known as a Foundation Year, I went to Glasgow. And, so I had done my PhD there and I've ended up in Cambridge, where I finished my training and took up a consultant job and more laterally took on additional roles and one of them being with the University.
[00:02:02] The elective experience that I had was probably quite formative to my recognition that doctors bring more value to the places they work when they've had the opportunity to work else. So, I actually undertook my elective in an exciting location, I went to Papua New Guinea.
[00:02:24] Cheryl: Oh, wow.
[00:02:25] Jonathan: Yeah, I would like to think my motivation was very noble about the place I could learn most medicine and have the greatest furthering of my clinical competence. but clearly, there are other things going through the mind, which is the richness of personal experience and challenges, give yourself an opportunity you know, an opportunity to do something different.
[00:02:50] So, myself and a friend went to Papua New Guinea, worked in the Highlands, learned some Pidgin English, assisted across a range of medical scenarios, and ended up having a relatively valued role there, particularly in the context that the sole doctor working in the hospital was a non-functioning alcoholic and not in practice for any of the time that we were there. And all clinical care was given by non-medically qualified practitioners.
[00:03:20] Cheryl: Oh, wow. That's fascinating in itself.
[00:03:24] Jonathan: It's veering off on the context, but what it does bring us back to some of the ethical issues that surround the elective program that I might want to touch upon later. But, you know, lucky Jonathan, he had a good experience, he went off for six to eight weeks, had all that great learning. But I'm not sure there was any great legacy for what I did, I'm not sure that I was always providing the best of care to those that were there. And I think these thorny issues around the elective placement continue, and it really is a rewarding interesting, and challenging aspect of the medical curriculum.
[00:04:07] Cheryl: Yes, and I will be asking you loads of different questions about the electives component, but I think it's fantastic that you've almost jumped in there and told us about your experience, because that is a very different experience from my understanding of most medical students and what they learn. Could you tell us a bit more about the student elective component and where that fits into the medical education schedule? And the types of electives that students often go for or may choose, I should say.
[00:04:38] Jonathan: So, as I'm sure many will be aware, the amount of medical knowledge that is available for people to access, that perhaps at some time people would've been expected to learn, far exceeds the capacity of individuals to absorb. So, in Cambridge, as in most medical schools, we follow a core set of learning that we enrich with a number of opportunities where people, by going to much more depth in specific areas, learn generic professional skills as well as skills around medical practice and medical learning that are really key.
[00:05:15] So the GMC is absolutely clear that a proportion of the medical course needs to be, student selected in nature. And there are different ways that medical schools try and deliver this for students. So, for example, at Cambridge, we have, two placements; one in the fourth year, and one in the fifth year, where students are selecting the kind of areas they focus in on, and the kind of skills they want to gain. Often taking part in projects, getting closely involved with clinical services, understanding, how to present data, how to, present work to others, and how to write medical reports and, manuscripts.
[00:06:03] That's one way of framing, student selection. The other part is by providing an elective period and the elective period is where we, and most medical students, medical schools offer the greatest degree of freedom to students about how they use their time.
[00:06:24] You've always got to take a step back and anchor what the student's trying to achieve for the GMC outcomes for graduates.
[00:06:32] Cheryl: Sorry. Can I just clarify? So the GMC is the General Medical Council here in the UK, is that correct?
[00:06:38] Jonathan: yes, and it sets the expectations of what doctors professional and doctors who's gone through medical training should achieve; the knowledge, the attitudes, the skills, the behaviors they should be able to exhibit and put into practice. And the elective is an important element of helping students reach that point.
[00:07:00] So to give a specific example in Cambridge, we give a lot of freedom to students. They have a seven-week placement at the beginning of their final year, where they can go anywhere in the world or remain in Cambridge, undertake a virtual project or a face-to-face project, undertake clinical research, or work in a highly specialized clinical environment and work out what they're going to do and what they're going to gain from it, such that they are further towards being a practicing doctor.
[00:07:30] And so on one hand, it's a huge sense of freedom and opportunity that we provide to students. On the other hand, it places quite a lot of responsibility on them to gain the most from it and help further their learning and development.
[00:07:52] Cheryl: I can imagine, cause it could be very exciting or very scary depending on where you stand as a student. And I recall from the beginning of the series, we spoke with Diana Wood and she was saying that sometimes placements, as you were talking about these selections that students can make earlier on as well as this elective period, can be really beneficial and help them to understand what they may want to do later in their career.
[00:08:16] But equally can be just as beneficial to realize that that was interesting, but not for me. So I think that is a helpful way potentially for students, but I'm sure some students need more guidance than others in terms of thinking about this elective opportunity.
[00:08:32] Jonathan: It can be quite tough as a medical student because it is so common to find some students have absolute clarity from an early stage about what their future self is going to be. So you'll have people going on elective who've known for a couple of years that they will go to a world center in paediatric oncology and because that's the academic and clinical field they're going to end up in.
[00:09:01] At the same time, it's really important that students understand that it's okay not to be clear about what type of doctor you want to become. And a very general elective that provides you with learning about communication skills or clinical procedures or, teamwork, or helps you feel better after the hard work you've put in and the toll that's taken on you, are all good outcomes. I think one of the most satisfying elements of supporting people's electives is you can see how individuals shape it to meet their own needs. And I think it's very important as a medical school to be very, very supportive of that flexibility, so that the best outcomes can arise.
[00:09:58] Cheryl: I would agree, that sounds like they're lucky to have you as somebody who's supporting them through that process. Cause it can be tricky, but also incredibly exciting. So you spoke about your opportunity. Do you get a lot of students going abroad and having an enriching opportunity through that?
[00:10:18] Jonathan: so we have about 70% of our students go abroad. So a proportion are undertaking UK or Cambridge-based electives. Some of those make that choice on the basis of preference and some do so because of financial constraints. And that's something where highly aware of, is that the elective can be a point that widens the kind of opportunity impact of financial hardship that students can face.
[00:11:00] So of our students that go abroad, about half go to some of the world's poorest countries, and about half go to the wealthiest countries where they might be more likely to undertake, and clinical and research-based electives, often in the US or in a Australasia or Asia.
[00:11:27] Cheryl: Okay. So if our students are going elsewhere, I presume we're accepting as many students here as well. Would I be correct in that?
[00:11:33] Jonathan: So we have an incoming elective program of which we're proud, we're able to accommodate 60 students a year. So the reality is, we are taking in fewer students than we have going out around the world, cause we now have close to 250 students on electives each year or more.
[00:12:01] So I think this raises some particular issues and I'm grateful to colleagues who've highlighted them. This is no disrespect to the Australians. Their Australians are really successful at sitting on the cusp of us opening our application process and applying en masse. And it's an absolute joy to welcome them. We have traditionally had much lower numbers of students come from the world's poorest countries. And if we look at the proportion of our students that go to the lowest income per capita countries, it is higher than the proportion we take in.
[00:12:47] So we've taken a step back over the last year and formed two particular goals. One is to remove financial barriers to our students who may wish to go overseas elective, who might face hardship. And the second is, to try and ensure that our elective program most supports those who come from the world's poorest countries to make a Cambridge-based elective as accessible and available, to all irrespective of financial means.
[00:13:23] Cheryl: Okay, and can you describe more about how you've done that?
[00:13:27] Jonathan: On the outgoing side we've made use of the new Turing Scheme. So there used to be an Erasmus scheme, which actually had no implicational medical training, it wasn't something that we could use as a scheme to fund placements.
[00:13:43] Cheryl: So, can you describe what the definition of these different schemes.
[00:13:47] Jonathan: Right.
[00:13:48] Cheryl: Apologies, because we do have an international audience. Sorry.
[00:13:50] Jonathan: Yes, and I know less about the Erasmus schemes, such to say that it was an integral part of our membership of the European Union. And then when we left the European Union, a new scheme was developed called the Turing Scheme, in memory of Alan Turing. And this was to forge partnerships and to really support UK presence, globally.
[00:14:12] And what this has meant is we are now able to support our students to establish partnerships globally through the elective scheme. And we have, this last year awarded all our Turing grants to students from the poorest households. So those students who come from households with an income of less than 25,000 pounds.
[00:14:40] And I'm very pleased that we've been able to take this board and we hope to grow it, such that all our students when thinking about electives, think only of what's right for them not what the financial cost is.
[00:14:55] Cheryl: That is brilliant because you're right, it's about what's right for you. But often individuals may not be able to go for those sorts of electives because it's just out of reach. So I think it's fantastic that we've taken advantage of that in order to help our students, but also to get students coming here as well. So you've talked about our students going elsewhere. Can you tell me more about the students that are coming to Cambridge?
[00:15:21] Jonathan: So I think this is going to take time. so we've started with some steps to make access easier. So that is, those students applying from countries categorized as having a very low per capita income, are students that we've been able to waive the initial application fee for. So that at least gives them a no-cost opportunity to put an application in.
[00:14:48] The next thing we've done is to preferentially process applications from those students, such that we can see whether appropriate students have submitted applications that we could draw into our elected program before we open it up and process applications from higher-income countries.
[00:16:11] There are two more stages we need to drive forward. The first is to provide bursaries to remove the financial barrier. We've been lucky enough to receive a couple of bursaries from Cambridge Africa to support students coming from Uganda. And we've also had generous donations, given in relation to Ukrainian students, which I'll probably come onto, but also from Bidwells to support us to take students in. So that next phase, if we can raise these bursaries, is to have layered financial support for people, who similar to our students, would face financial barriers to gain the benefits from coming here and try and get rid of those barriers.
[00:17:00] And then I think the last element is to really socialize and circulate this opportunity, to make it something that people from the world's poorest countries can become more aware of. It doesn't seem quite right to publicize it until we have sufficient bursaries, because it's not such a great thing to tell everyone about a super opportunity that's inaccessible to them.
[00:17:26] So I would say this is something we recognize might take a few years to get to. On the other hand, Cambridge can be, a place of surprises where opportunities arise for people to help projects move forward at pace. So developing this vision was important to us and it's something we can sort obviously track. We can see year on year, how successful it being, and changing the makeup of the students that come into our program.
[00:17:59] Cheryl: It's quite exciting. And I think it's wonderful that we're looking at that from both perspectives and helping those that need it the most. I think the other thing I wanted to touch on is you talked about your experience earlier on and you said it would be useful to come back to some of the ethical issues around placements. Can you tell me what those are and what sort of implications they could have?
[00:18:24] Jonathan: So, it's quite layered and a number of medical schools spend time thinking about how best to support an ethical approach to an elective. So, the first thing is we're facing a climate emergency and here we are, supporting people to fly all over the world. Now, on one hand, We can say, goodness, we're a university that's got to get a house in order first. And before we stop students having a once-in-a-lifetime opportunity, we need to be aware of our academics, traveling all over the place all the time.
[00:19:03] However, we need to be sensitive to what students feel about this and really support those who want to undertake their elective virtually, who really would feel uncomfortable with having a high carbon cost of what they do. And it is expected for our students to explain the mitigations that they might take for the carbon cost of their elective. For example, if someone's undertaking a UK/European-based elective, it would be normal for us to seek justification for why it be a plane, not a train journey, for example. And the students have strongly welcomed this and promoted it.
[00:19:41] Once you get on placement, you need to think, and I think the broadest way of thinking this, is what is the net impact of my presence here? Have I left this organization enriched by my attendance with greater learning and having felt supported by my presence or am I perpetuating a kind of saviour mentality and an ethos of personal gain? And I think we are so supported by students in this because this is something that particularly troubles them. And, many students put a lot of effort into to ensure the net impact of their presence is a positive one.
[00:20:29] A third element is that students will end up in situations that unfortunately, can be deeply distressing to them. We've had students facing violent crime just by the nature of travel, students who find themselves alone with a patient that's come to harm where they felt helpless and knew that this patient wouldn't have come to harm or died in a different clinical setting that had more resource.
[00:21:00] So, one of the things that I think medical schools think about and something we think about a lot is how to support students to be okay following what may have been very tough experiences. So our bedrock of support is through something called a Schwartz round, where away from faculty, students are able to share the emotional impact of the experiences they've had and support each other. And it's a well-evidenced approach for kind of socializing and supporting distress in, a community and individuals.
[00:21:40] And then other elements of the support we might give are through professionalism debriefings, as well as through individual support that people might require. In conclusion, there are ethical issues that sit around elective, and then there are practical issues around risk. And all medical schools and educators need to really, take time to consider how best to support students as well as, balance that with their role as adults and, ability to make choices and your wish to support their choices.
[00:22:21] Cheryl: Yeah. And some of those issues that you talked about, I can imagine would be really upsetting in the moment. So you talked about the Schwartz Round and, and some of the emotional support, that you can provide these students. Do you do that with them abroad or when does this support happen?
[00:22:40] Jonathan: It's tended not to be while people are on placement and I think that's because people often get on with a situation in the moment and rely on local support. But some things you face linger and we know that in all our lives and help identifying those situations that you've come across is important to do at a later date.
[00:23:09] I suppose this is going to be the first elective after the destruction of COVID, where people will have so much greater access to video support, even to contact their GP or have a conversation in a way that people wouldn't have had before. So I think the whole framework of how welfare support is delivered to students has been massively transformed through the ability of online technology through COVID and I don't see why that wouldn't continue through placements away.
[00:23:45] Cheryl: That's a good point. And thank you for bringing up COVID, because obviously these experiences abroad did not happen for the past two years, so it's only this year that students are able to go out again. So students the past two years have had different experiences and from what I understand a lot more research-based and or local-based, is that correct?
[00:24:06] Jonathan: yes, it's very difficult to frame it as anything other than really sad that these students miss this opportunity, what I would say, and what we say to the students is, there is not a rush in progressing through your career as a doctor. As a doctor, you can be paid to work abroad. You can be paid to support learning in different environments. And one of the most, common times for this would be an FY3 year.
[00:24:43] I think we'll find a lot of the students who had opportunities taken away from them by COVID will make choices further on in their career to do things that perhaps some of us really wish we'd done, like taking a year out or work for VSO. I really hope that's the case, but I agree with you, it's a real shame that students were so disrupted in relation to their opportunities.
[00:25:09] Cheryl: They were, and you know, it was inevitable for everybody. So I hope you're right and they do take some opportunities. I think thinking about current events and disruption, I'd like to talk about the conflict in Ukraine. Obviously, the medical students who are studying in the Ukraine are severely disrupted at the moment with everything that's going on. The University of Cambridge Medical School has agreed to host medical students from the Kharkiv National Medical University to partake in a six-week program of training here. I know this is something that you've been involved in, do you want to tell us a bit more about the program and what's going to be happening?
[00:25:51] Jonathan: So these medical students have been able to continue their training, but only through online support and online lessons. And then the men and the women have had different experiences depending on their requirements in relation to supporting the war effort. So these students have had incredibly disrupted times, many have been dispersed out of the country and it's very difficult for a medical school to progress students when all clinical placement stopped and that's what's happened.
[00:26:33] There is, I mean, the tiniest bit of positive news about this is medical schools have the experience of how to grasp students during COVID. And we saw during COVID, the collapse of clinical placements and yet a real wish to help our students become doctors and a flexibility from the GMC. And something similar is happening in Ukraine. What we, and other medical students and medical schools, are seeking to do is to provide some face-to-face clinical placements that will cover some core skills and training that will allow Kharkiv to progress their students towards graduation.
[00:27:18] So the hope is that by the end of July we'll have 22 students come from Kharkiv, they'll have a week-long introductory course that'll include practical skills sign-off and training, communication skills, and some clinical reasoning teaching. But actually, a key element of that is we're going to top and tail occupational health clearance, because tuberculosis has a higher prevalence around Ukraine and we have to have TB clearance before these students can come into the clinical setting. So we've got this accelerator pathway where we hope that by the end of that Friday, those students will have clinical clearance to enter our hospitals.
[00:28:04] And then they will have three, two-week placements across core medicine, core surgery, and a student-selected component, which could be a role at Royal Papworth Hospital and could also be at pediatrics. Each of those two-week placements will end in formative assessments so we can build some narrative to help Kharkiv make a decision about progression for the students. And a particular asset in the Cambridge system is we can align each student with a clinical supervisor who'll give weekly supervision and then give a formative assessment at the end.
[00:28:44] So the hope is we can bring students for six weeks, while we've got a reduced footfall of students on our wards due to elective and leave for the fourth years, Give them something that is meaningful to their training, and allow their home university to help them progress. So that's the hope, the biggest challenge to it is getting visas in time and we'll just have to see if it all, comes together.
[00:29:27] Cheryl: I sincerely hope it does because it sounds like a wonderful program and opportunity for those students to get to come here. As you said, it's not just Cambridge, who's offering this opportunity, but it's useful for the university as well, as you mentioned the fact that there will be assessments in there as well. So I sincerely hope it does pan out.
[00:29:50] Jonathan: I should say you cannot take initiatives like this forward without institutional support and funding. And this happened to have been made possible by an unrestricted educational grant from Illumina, which has allowed us to take it forward. But it's elements of philanthropy, as well as core university support, that can realize these projects.
[00:30:16] Because without that, it's all very good and well to have quite a lot of willing and hearts and minds, but you need to be able to fund programs.
[00:30:27] Cheryl: That's a really important point. And I think we often forget those important elements of being able to fund the wonderful things we want to do. So thank you for highlighting that as well. It's been really interesting to hear about the opportunities that students have. Do you have any top takeaway points from today?
[00:30:47] Jonathan: So I think with anything where you get a choice about what to do, it is so important that it's something that interests or excites you. And it magnifies every element of success if it comes easier to you, because you're really engaged as a student in what you want to take forward. So that would be my top tips to students.
[00:31:16] And then to institutions, I suppose I would say I really think the elective program has value, we should work hard to preserve it. We should support our students to have a choice and shape their own learning and recognize that it's a really special opportunity in what can be a very prescriptive medical course and prescriptive clinical placement in your career that we should do everything we can to maintain and support.
[00:31:52] Cheryl: I would agree. I think talking to you today has been fascinating and enlightening and realizing what opportunities students have is wonderful. And we need to keep that, just as you said, the fact that it's about going for something that you're passionate about and being able to explore that further is a really wonderful opportunity. So thank you once again, really appreciate your time today.
[00:32:22] Jonathan: Thank you.
[00:32:23] Cheryl: Dr. Jonathan Fuld, thank you once again for such an interesting discussion. If listeners are interested in learning more about the elective programs or how to support students from lower income or growth countries, please contact us via the CUMEG website. You will also find other podcasts on the website at www.cumeg.cam.ac.uk, or look for us wherever you get your podcasts.
[00:33:10] This is the last in the series, we hope that you've enjoyed listening. We will be back in the autumn with another diverse set of topics and interesting individuals that we'll be interviewing. We are grateful to you, our listeners, thank you for taking the time out of your busy schedules to listen to us today. If you would like to hear more from this and our next series, please like and subscribe to our podcast. Until next time, I'm your host, Cheryl France, thank you again for listening.
