Ethical Guidance for Medical Schools and Medical Students in High-Income Countries for Clinical Electives in Low- and Middle-Income Countries: A Systematic Review

What

The significance of humility for HIC students during LMIC clinical electives is highlighted in 17 articles [40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56]. Humility, particularly cultural humility, is described as “an interpersonal stance that is other-orientated rather than self-focused, characterized by respect and lack of superiority towards an individual’s cultural background and experience” [43(p467)] and “a lifelong practice of self-reflection and critique that involves entering relationships with the ability to adapt one’s own beliefs and values in consideration of the other” [40(p1109)]. The emphasis on culture is explained by the differences in cultural norms between HIC students and patients, and staff and students in LMIC settings. These are inextricably linked to healthcare, as illustrated by this quote: “[…] perhaps the preparation needed would be to help them (elective student) understand how they see their practice of medicine as having a cultural bias” [53(p1431)].

The articles that discuss humility in broader terms emphasize open-mindedness and curiosity about different cultural norms and values on health and healthcare, religion [41], language [42], health literacy of the population [41], the conditions endemic to the host site [41, 43], economics linked to the macro level of a health system and to the micro level of individual patients and how they cope with illness [41], and healthcare professional roles at the host site [43]. In one of the articles, there is reference to the term ‘global humility’ [47]. It is defined as “the sense of awe and wonder at what we do not understand in relationship to health and illness combined with the acknowledgment that we have much to learn from host communities” [47(p33)].

Why

It appears that students are encouraged to practice humility during their LMIC clinical electives to improve patient care and patient communication, and secondly to benefit staff relationships. It is best summarized by this quote: “Ultimately, a focus on nurturing cultural humility […] may further diminish ethnocentric attitudes in both the clinical and interpersonal arenas and foster richer relationships between hosts and visitors” [43(p467)].

A third reason to practice humility and maintain an open mind is its positive impact on the student’s future healthcare work upon return to their home country. HIC students reported significant improvements in their intercultural communication skills only after their return home [43].

Who

Although there is a clear role for the HIC students themselves to adopt and nurture the virtue of humility, most articles emphasize the responsibility of HIC medical schools to support students in doing so. There is one article that specifically calls upon students to take up this responsibility. This article encourages students to reflect on cultural humility by completing a reflection tool which they can do independently or with the guidance of a HIC faculty member who is familiar with the host setting. The majority of the articles call for Pre-Departure Training that should be organized by HIC medical institutions to help students adopt and nurture the virtue of humility.

Apart from students having to develop the virtue of humility supported by their sending institutions, there is one article that suggests international electives take place within formalized equitable partnerships, and within this context suggests “to promote and role model cultural humility at all levels of the partnership (ranging from institutional to individual host–visitor interactions)” [43(p466)].

Implementation and tensions

Although humility is consistently emphasized as a key attribute for students undertaking LMIC electives, its operationalization is largely limited to Pre-Departure Training and individual reflection tools, with little guidance on how it is reinforced in practice during electives. Moreover, responsibility is primarily placed on HIC students, with limited attention given to the role of HIC institutions in structuring, governing and modelling such humility within program design, and even less consideration of how host institutions engage with, shape, and evaluate these processes.

What

Most articles emphasize the need for HIC students to practice reflection during LMIC clinical electives. One type, hospital-level reflection, involves HIC students critically examining their role within the host hospital, aligning their motivations and learning goals, and considering their impact, such as potentially overburdening local staff [40].

The other type of reflection is a deeper reflection that addresses global inequalities shaping these electives. Terms capturing this approach are ‘critical reflection’ [42, 45, 46, 50, 57], ‘structural awareness’ [47], ‘contextual inquisitiveness’, and ‘critical engagement in the pursuit of creating equitable and just societies’ [47]. Structural awareness, described by Ventres and Wilson, is about “systematically attending to the historical, social, cultural, political, and economic contexts of host communities. It is the first step toward generating an honest understanding of the root causes of inequity and poor health”. [47(p34)] To foster such understanding, Reynolds et al [40] suggest that HIC students answer the following reflective questions: “How will I reconcile the tension between working for health equity while using resources for personal development?” and “How can I promote reciprocity between my hosts and other partners?” and “Have I discussed ways I could provide benefit to my partners?” [40(p1108)].

Why

Hospital-level reflection aims to build trust and strong relationships with local staff and students while reducing the burden of HIC students’ presence. As Peluso et al. explain, its goal is “both to benefit students and to provide ongoing feedback to global health faculty as to the adequacy of existing training” [56(p59)]. Reflection on global inequality, while less tied to the host staff, focuses on HIC students’ transformative learning. Nine articles made mention of ‘transformative learning’, for which the LMIC clinical elective serves as a tool. This was explained in terms of “fostering the development of global mindedness and community involvement” [45(p6)], “working cooperatively in the pursuit of social justice” [47(p34)], and to “develop a strong sense of global citizenship” [48(p3)], and lastly, “[…] to create a worldview that considers issues such as colonialism, imperialism and systemic social inequality. […] It is essential to understand how the developing world is subjugated by the developed world, historically and today, and how poverty can be reinforced through one’s day-to-day actions” [19(p8)].

Who

HIC medical schools play a central role in facilitating transformative learning and teaching students not only what to reflect upon but also how to reflect. Pre-Departure Training (PDT) and Post-Return Training (PRT) were frequently mentioned, with specific mention of PRT in the context of facilitating and encouraging student reflection and, thus, transformative learning.

Implementation and tensions

Although reflective practices are widely promoted, their implementation is largely confined to structured Pre-Departure and Post-Return Training, with limited attention to how reflection is sustained during electives or translated into practice. This narrow framing positions reflection primarily as a tool for individual learning during LMIC electives, while overlooking its potential role as a sustained critical practice for recognizing and addressing health inequities within students’ own HIC contexts as well.

What

Local embeddedness, emphasized in nearly all articles, refers to how well HIC students’ work and attitudes align with local expectations during LMIC clinical electives. Three overlapping elements are identified. The first element is ‘appropriate hospital engagement and clinical care’ and encompasses working with and under supervision of local health workers to ensure alignment with clinical practices. The second element is ‘clarity on HIC students’ learning goals and training level’ which is about clear communication to align learning opportunities with local possibilities [41]. The third element is ‘navigation of unequal power dynamics’, to prevent power dynamics hindering local embeddedness of LMIC clinical electives [43, 46, 58, 59].

Why

Some health workers in LMIC host hospitals have expressed frustration with visiting students’ clinical care that was impractical or inappropriate to the local context [43]. Ensuring appropriate hospital engagement and context-specific care is vital to avoid such issues and promote safe, effective clinical practice. The clarity on HIC students’ learning goals and training levels is crucial to mitigate risks such as POST and to facilitate good clinical care [40, 41, 43, 44, 45, 46, 47, 48, 49, 51, 53, 54, 56, 58, 59, 60]. Navigating unequal power dynamics is essential to prevent situations where host staff feel disrespected or discriminated against, such as patients overestimating visiting students’ qualifications or preferring their care over that of local trainees [43, 58]. Instances of cultural insensitivity by visiting students—like rejecting customary hospitality, inappropriate donations, or neglecting basic greetings—highlight the critical need for culturally sensitive practices [43].

Who

HIC medical schools are identified as key actors in implementing strategies for ‘appropriate hospital engagement and clinical care.’ A commonly highlighted approach is Pre-Departure Training to prepare students for differing disease burdens, care standards, and sociocultural norms [40, 41, 42, 43, 45, 46, 47, 48, 50, 52, 53]. Suggested organizational strategies include sending fewer students at a time to reduce the burden on local staff [60, 61], facilitating longer elective durations [43, 46, 51, 53, 62, 63], and limiting participation to students with advanced training [43, 51, 53, 60]. Students are also encouraged to engage in cultural immersion and local orientation to better understand the context of staff, students, and patients [45, 53, 59]. The literature rarely addresses the role of LMIC host hospitals. Only three articles mention involving host hospitals in HIC student screening and selection, emphasizing their insight into a student’s suitability for the local context [43, 53, 59]. Transparency in selection processes is also recommended [43]. With regard to ‘clarity on HIC students’ learning goals and training level’, HIC students are seen as responsible for communicating their goals. However, further research is needed to align learning goals and opportunities for LMIC clinical electives [41]. For navigating unequal power dynamics, no clear recommendations or responsibilities were identified, possibly reflecting the underrepresentation of host perspectives in the literature.

Implementation and tensions

While several HIC organizational strategies are proposed – such as limiting student numbers, extending duration, and improving preparation – there is limited evidence on their implementation or effectiveness. More importantly, there is little attention to how host institutions shape, direct, or meaningfully govern elective activities, suggesting a risk of instrumentalizing ‘the local’ without fully recognizing the agency of host institutions’ staff.

What

Most articles (all but one) highlight the importance of institutional partnerships between sending and hosting institutions, emphasizing sustainability and reciprocity. Sustainability refers to long-term institutional collaboration for structured elective programs. Reciprocity involves three aspects. One is mutual benefit, including recognition and financial compensation for LMIC supervisors [43, 53, 59]. Second, reciprocity may take the form of ‘involvement of LMIC hosts in program development’, for instance through calling on HIC medical schools to extend the duration of the electives and/or only send advanced-level medical students. Third, reciprocity is about creating exchange opportunities for LMIC students and health workers like those for HIC students.

Why

Sustainability enables HIC institutions to better understand and mitigate the risks and burdens of LMIC clinical electives, such as reducing instances of POST [49, 52, 53, 58]. Sustainable partnerships foster accountability, as inappropriate student behavior can be more easily communicated by host hospital representatives to their home institutions’ faculty [48] and they strengthen meaningful relationships at both institutional and individual levels.

One article highlights the benefit of a sustainable partnership to mitigate climate impact [62]. The authors emphasize the value of international clinical electives for medical education, but also call for recognizing the ethical conflict of duty posed by air travel by HIC students, combined with the inequitable burdens of climate damage on LMICs. The authors propose long-term institutional HIC-LMIC partnerships to reorganize electives programs based on the principles of decolonization and decarbonization. This approach includes setting minimum elective durations, supporting host hospitals, and engaging in climate advocacy: “STEGH agreements could incorporate climate and health-associated infrastructure development as identified by the host institution as a component of the partnership. For example, funding a transition to renewable energy such as solar panels might provide reliable electricity and uninterrupted patient care while also improving air quality, mitigating climate change, and providing health co-benefits. Academic institutions can also deepen their interdepartmental collaboration to support novel host country initiatives. […] In addition, through bidirectional learning, academic medical centers could develop and implement sustainability practices that fit the local context of host countries” [62(p508)].

Reciprocity in recognition and compensation for LMIC health workers remains critical. Financial or resource contributions by HIC institutions often do not directly benefit supervisors, reducing their incentive to engage with students. This lack of direct compensation can lead to conflicts between responsibilities to local and visiting students [43]. Recognizing individual contributions through direct incentives is essential.

Involving LMIC hosts in program development ensures that their needs and priorities are addressed, resulting in benefits like increased training opportunities, expanded knowledge, satisfaction from teaching, and opportunities for scholarship. Bidirectional exchanges further support career development, networking, and equitable institutional partnerships [40].

Who

Based on the articles reviewed, the predominant focus is on the role of HIC institutions. Remarkably, the study results show that HIC institutions can have contrasting ways of dealing with certain risks associated with LMIC electives. For instance, to mitigate the risk of overburdening LMIC staff, in two articles the suggestion was made for HIC staff to accompany their students on their LMIC trips for supervision. In contrast, HIC authors from another article advised against it as their LMIC respondents were not in favour of this practice, and benefits have not been evaluated well [59].

Formalizing institutional relationships can be done by establishing a Memorandum of Understanding to foster meaningful conversations on commitments and priorities. As mentioned by Reynolds et al.: “Be aware, even formal MOUs require supported, intentional plans for collaboration and accountability, or else risk becoming relics of good intentions. With today’s widespread technological connection, there are numerous ways to structure sustainable partnerships for long-term interconnectedness” [40(p1109)].

Also clearly addressed is the role for HIC students to transcend the personal level of their own elective experiences, and become actors within the partnership, representatives of the HIC institution, and actively advocate for and contribute to the sustainability of the partnership. One way to do that is by providing feedback that can support the building of equitable partnerships [40, 43, 48, 50, 59, 61]. Lastly, the role of host hospital staff in building sustainable partnerships is mentioned, e.g. through HIC student supervision, selection and guideline creation [43, 44, 50, 51].

Implementation and tensions

While equitable partnerships are widely emphasized, their operationalization often centers on reciprocity, capacity building, and relational continuity, with limited attention to broader structural and planetary dimensions of equity. Only one article explicitly addresses the climate implications of LMIC electives, highlighting the ethical tension between the educational value of international placements and the carbon-intensive nature of air travel by HIC students, alongside the disproportionate burden of climate change on LMICs. The authors propose reconfiguring electives through long-term HIC–LMIC partnerships grounded in principles of decarbonisation and decolonisation, including minimum elective durations, institutional investment in host settings, and engagement in climate advocacy. However, such considerations remain largely absent from the broader literature, suggesting that current conceptions of “equitable partnerships” insufficiently account for climate justice and its implications for global health education.

What

Students’ mental and physical well-being is critical in LMIC clinical electives, with risks including emotional distress, guilt over limited care, and culture shock in low-resource settings [41, 43, 45, 48, 49, 50, 52, 53, 57, 58, 60, 62]. For some students, such challenges can lead to traumatic experiences [49] and poor long-term coping [58].

Why

Prioritizing students’ health and well-being is essential to ensure their safety during activities, protect patient care, and avoid straining local health workforce capacity. A significant risk to both students and patients is practicing outside scope of training (POST), which is more common in understaffed rural clinics than in larger academic centers in LMICs. Causes of POST include a mismatch of HIC students’ skills and host expectations, suboptimal supervision at host sites, poor preparation to refuse POST, perceived lack of alternatives, and emergencies. POST often results in lasting moral distress for students [49]. When local health workers must manage visiting students’ well-being amid staff shortages, it strains resources and may impact patient care. Conflicts over care standards, especially in settings of extreme poverty or patient suffering, further burden local staff and compromise workforce capacity.

Who

According to the articles included in the review, the responsibility for student health and well-being primarily lies with HIC institutions. There are two crucial moments: pre-departure, to prepare students for managing expectations and culture shock in low-resource settings, and post-return, to help process difficult experiences and emotions. Addressing POST involves both preparation and debriefing, particularly for those exposed to traumatic events, emphasizing the need for emotional and moral support [49(p8)]. Post-return training also aids educators in identifying students needing further resources and fosters reflection and transformative learning [58].

Shared responsibility between sending and hosting institutions is noted for emergency preparedness, ensuring students have access to mental health resources and familiarity with them before departure. Regular check-ins during rotations are considered critical [57]. Lastly, host institutions also play a role in student well-being through adequate supervision and providing guidelines, though it is unclear whether these should focus on clinical, behavioral, or cultural aspects.

Implementation and tensions

While student well-being is consistently emphasized, responsibility is predominantly placed on HIC institutions, with limited consideration of the burden this may place on host institutions or how support is coordinated in practice. In addition, the focus is predominantly on HIC students, with comparatively limited attention to the well-being of LMIC supervisors and healthcare workers, highlighting an imbalance in whose vulnerabilities are recognized and prioritized.