A Reflection Comparing Healthcare in England and Sri Lanka

I split my elective into 2 four week blocks. The first block took place in the UK and I spent the time with the head and neck surgery department at Manchester Royal Infirmary. The second four week block was spent in Sri Lanka, in a government hospital called Karapitiya Teaching Hospital in the town of Galle on the south west coast of the island.

During this second block I spent time with the general surgeons in the surgical department, I wanted to spend this time in theatre observing new types of surgery that I had perhaps not seen before, perhaps different techniques to the ones used in England, and how surgery is performed in a less developed country in a hospital with very little money to waste. I also wanted to see how medicine is practiced in Sri Lanka compared to the UK.

The first thing I can say is that it was a complete culture shock when I arrived on the first day. There could not have been a much starker difference between hospitals in the UK and Karapitiya. The throngs of people waiting in the corridors that meet you as you step through the door, all queuing up for an appointment, the lines out of the emergency department with patients lying down wherever there is some sort of a trolley if they cannot stand. This was only the things I noticed as I walked in. As I walked down to the ward I was based I realised that the hospital has no windows, just balconies with enough cover to protect from the rain. The list of what we would consider deficiencies could continue for quite a while. Of course, this is just something new for me, I have never seen anything like this, definitely a shock to the system.

Government hospitals in Sri Lanka generally provide the poorest patients with healthcare. The patients often pay privately for investigations, any equipment that may be needed in hospital (special surgical tools for example), and their medication during their stay. However, the rest of the care is provided free of charge, including doctors and nurses etc.

These initial thoughts made me question lots of things about the ability of the healthcare system in Sri Lanka actually to care for their patients…and there were in truth many other negative thoughts.

Once I got over this initial reaction and was able to spend time in the hospital I realised that although the cleanliness and order and western identity was not present in this hospital it did not need to be. They do things differently here, and the do amazing things with what is available to them.

Another observation is that in Sri Lankan surgery a high number of thyroidectomies are performed. Having spent my previous month on a head and neck cancer placement I had seen how common thyroidectomies are  in England where they are usually performed when cancer is a possible diagnosis, either as a diagnostic investigation or as curative treatment. In Sri Lanka, thyroidectomies are very common due to a high prevalence of iodine deficiency leading to hyperthyroidism. In the UK this is a rare cause due to the inclusion of iodine in table salt.

This leads to another salient difference between Sri Lanka and the U.K. In the UK we use diagnostic tests more often to ensure our diagnosis before performing surgery or treating conditions. In Sri Lanka there is a greater reliance on clinical examination and judgement due to the issue of cost.

Everyone appreciates the high number of patients seen by doctors in the UK. This however, has been put into perspective for me since my arrival in Sri Lanka. As alluded to earlier, patients queue up in the corridors to wait for clinic appointments. There appears to be very little in the way of organisation when it comes to the number and order of patients for each clinic, but more of a first come, first served. Each clinic involved a revolving door of patients being seen quickly and then sent away for the next one to be seen. A 10 minute appointment is not something that exists here. This leads to a very paternalistic practice of medicine that no longer exists in the UK. Due to the time and patient pressure there is no time for doctors to explain things to patients. The doctors ask the questions and then tell the patients either: surgery, medication, or discharge. There is also a lower level of education in Sri Lanka, further compounding the problem.

A personal experience of the effect this has on patients took place one weekend. I spent one weekend in the capital and was discussing what I was doing in Sri Lanka with a few people. A Sri Lankan gentleman overheard me and then proceeded to hand me his medical notes (which are written in English) and ask me if I could explain what was wrong with him. This gentleman was not the only person who did not know what was going on with his health – this is quite a common occurrence among patients who attend government hospitals.

This really has made me think about my future career as a doctor. Although there will be a large amount of pressure for me to see patients quickly it is still important to take my time with patients, communicating what is going on, so that they better understand what is happening and what will happen next. I think this is an extremely important lesson from my elective: To appreciate the time that we in the UK have with patients and to use that time effectively to help improve their experience within the healthcare setting.

English is an official language in Sri Lanka. In fact, medicine in Sri Lanka is taught in English, and the doctors generally discuss patients in English. However, the patients that I encountered were less well educated and did not speak English. This made taking histories quite challenging. This meant a lot of the histories I got were second hand from the doctors. However, I was able to gain consent to examine patients. I was able to do this using non-verbal communication, for example mimicking coughs when doing a hernia examination. This was possible but could be challenging. It required lots of patience in my part and on the part of the patients. It taught me how to cope in situations where communicating with patients is not so easy. This happens in England too, with patients who do not speak English as a first language, with deaf patients, or mute patients as some of the examples. I will use this experience to help when I encounter patients like this in England, and hopefully will be more successful than I have been previously.

Thus the things I have taken from my elective are:

The importance of communication with patients, in order to help them understand what is happening with them and to give them the opportunity to make an informed decision. It is important to ensure that patients are able to make autonomous decisions. Doctors should work alongside patients in decision making and not enforce courses of action.

Appreciate the NHS and the level of care afforded to patients in the national health service compared to other, less developed countries.

It is easy to jump straight into ordering diagnostic tests, but sometimes good history, examination, and clinical judgement is all that is necessary to make diagnoses.

Use non-verbal communication and have patience with people where verbal communication is difficult.

I would like to thank the Jewish Medical Association for the contribution they made to my elective. It allowed me to appreciate how fortunate we are in the United Kingdom and taught me many ways of improving my clinical practice.

Joshua Caplan

Published in General News, on October 25th, 2017


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