Limiting clinical activities of students from HIC in LMIC settings

30 September, 2019

Dear HIFA Colleagues,

As some of you might know I am an advocate for critically thinking about how we structure international electives/rotations, both for students and residents. There has been calls for reform ( and evidence that professionals and students from high-income countries (HIC) are practicing beyond their scope of training when in low and middle-income countries (LMIC) ( And that this has led to patient harms and is against the competencies of outsiders who are engaging for short time periods in a novel setting/culture/clinical context both from the perspective of educators and community members ( and

Alongside colleagues from University of Minnesota and AAMC, I have published this piece which I think captures a key aspect of this dynamic, the breakdown of the social contract that occurs when students are abroad in settings where they will not actually be sustainable/longitudinal members of the healthcare workforce in the long-term (thus the hands-on clinical activities and resultant risk to patients must be modified).

I wanted to get your feedback and perspective about this idea and pose the following questions:

- Should we modify the hands-on clinical care done by HIC students when abroad in LMIC settings?

- Is the social contract at play here?

- What other arguments or considerations come to mind?

Here is the article "How the Social Contract can Frame International Electives" (AMA Journal of Ethics, Sept 2019)

Thank you in advance for your thoughts. Best, Jessica


Jessica Evert MD

Executive Director, Child Family Health International

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