This study evaluated data provided by MSOD for a relationship between elective experience in resource poor settings and student career preferences for primary care and work with underserved populations. This analysis did not detect any association between elective experience and career preferences.

The lack of a statistically significant correlation in these data must be interpreted carefully, as failing to find a significant correlation is not the same as demonstrating that it does not exist [16]. However, these findings provide an opportunity to compare and contrast the conditions under which Australian medical students undertake electives and the conditions reported in previous studies. Two aspects in particular may help explain this disparity in results; namely student characteristics and the nature the elective programs.

First, previous studies used selection criteria that likely recruited participants with systematically distinct motivations and career intentions that may have caused selection bias. For example, the elective program studied by Godkin and Savageau required students to submit a written application and essay [4]. The International Health Fellowship Program studied by Ramsey and colleagues considered applications from across the United States and made selections based on their “commitment to international, cross-cultural, or community-oriented primary health care” (p.567) [17]. Gupta and colleagues acknowledged that many trainees chose their site for training based on the opportunity to participate in the IME program [6].

In contrast, the MSOD data were collected from students from across Australia, many of whom arranged electives independently. It is reasonable to infer that this population has diverse motivations for completing electives in LMIC settings. A recent literature review provides insight into what motivates medical students to undertake IMEs. It identified three dominant motivations: (i) altruism; (ii) self-serving rationale, such as language acquisition, exposure to range of illnesses, or access to high patient volumes; and (iii) the opportunity to work beyond the scope of practice typically allowed for medical students [18]. Electives that meet these expectations likely provide considerable learning experience to participating students in terms of clinical competence, confidence, procedural skills, and leadership [1, 19]. However, they also carry risk for students and patients, especially if students are pushed to perform beyond their knowledge and ability with variable quality and availability of supervision [20, 21]. Indeed, such students are at risk of engaging in ‘medical tourism’ , which describes students who visit resource poor settings, but are underprepared, lacking structured educational objectives, and are unable to offer benefit to the host institution [22]. At the time of writing, there are no published studies describing the motivations or experiences of Australian medical students undertaking IMEs in resource poor settings. The present study reinforces the need for further research in the interest of student wellbeing and the welfare of host communities.

Second, the present findings may reflect differences in the electives themselves. Elective programs studied previously tended to include student support and structured learning outcomes. For example, participants in the study reported by Ramsey and colleagues were required to complete a two week full-time course prior to departure and were expected to participate in community health activities as well as clinical placements [3, 17]. Also, several studies make reference to desirable learning outcomes such as cultural competency, international understanding, and development of values of social responsibility achieved through immersion in culturally diverse settings [4, 6, 17].

In contrast, Australian students often organize electives independently and receive limited and variable support and structure. In a recent study, 12 of the 16 medical schools interviewed in Australia reported that they offered pre-departure training, but only half of those programs were mandatory and had an average duration less than five hours [8].

The contribution of these two key differences to understanding the disparity between past and present findings is offered tentatively and subject to confirmation through further research. Subject to this limitation, these findings suggest that the previously established association between elective experience and career preference may be limited to well-structured and supported elective programs that accept students with specific motivations.

It is worth noting that the students and programs previously studied aspire to the recommendations for safe and educational elective programs described in the literature [23–25]. Specifically, these programs tended to select students that had reflected on their motivations for undertaking an IME, provided them with suitable pre-departure training, and supported them throughout the elective to maximize learning opportunities.

While Australian medical students are likely to benefit from the electives that they undertake, the differences in program characteristics invite the question; does this disparity in results reflect substandard structure and support for Australian medical students undertaking electives in resource poor settings to the detriment of student wellbeing, learning, and professional growth? At the very least, these findings establish the need for further research into ways to minimize risk and maximize learning and hopefully encourage medical educators to critically examine the elective programs for which they are responsible.

There are important limitations to this study. First, due to limitations inherent to secondary analysis of data, the analysis employed national GNI as a relatively crude indicator of resource poor elective setting. Inevitably there is considerable within- and between-country variation in terms of healthcare resource allocation. Visiting a LMIC does not guarantee exposure to the kind of resource poor settings previously studied.

Second, there is a large discrepancy between respondent attrition from CMSQ to EQ for speciality of practice (n = 1383) compared to location of practice (n = 702). This finding is consistent with survey results published on the MSOD website, however the reason for the consistently poorer response rate to the specialty of practice question is unknown [14, 26].

Finally, the parallel between interest in work with underserved populations and rural practice is made tentatively. Despite the fact that rural populations remain relatively underserved in Australia, what constitutes underserved populations in previous studies may be very different. It is possible that if asked directly, LMIC elective students would indicate a greater preference for work with the underserved.