Tygerberg Academic Hospital, Cape Town

Adam Sher travelled to Tygerberg Academic Hospital on the outskirts of Cape Town, South Africa. He has a BMedSc in Medical Ethics and Law, for which his dissertation was a consideration of the relative merits of the Israeli Patients Rights Act 1996 and English law when patients refuse life-saving treatment. He further developed his work on patient autonomy in South Africa, and considered the concept of ‘trust’ within physician-patient relationships. He found that due to the unique character of the South African healthcare establishment, paternalism reigned despite attempts to empower the local patient population. His full report is attached here.

Tygerberg Academic Hospital, Cape Town

Adam Sher travelled to Tygerberg Academic Hospital on the outskirts of Cape Town, South Africa. He has a BMedSc in Medical Ethics and Law, for which his dissertation was a consideration of the relative merits of the Israeli Patients Rights Act 1996 and English law when patients refuse life-saving treatment. He further developed his work on patient autonomy in South Africa, and considered the concept of ‘trust’ within physician-patient relationships. He found that due to the unique character of the South African healthcare establishment, paternalism reigned despite attempts to empower the local patient population. His full report is attached here.

Nephrology, Sheba Medical Centre, Tel Aviv, Israel

I spent three weeks in the Department of Nephrology at Chaim Sheba Medical Centre, Tel Hashomer, under the supervision of Prof. Eli Holtzman. During my time with the nephrology service, I was attached to the renal consult team and the peritoneal and haemodialysis team members.

The outpatient clinics I attended included general nephrology, which gave me great exposure to a wide range of renal medicine from Lupus Nephritis to Familial Mediterranean Fever to Polycystic Kidney disease. Many of the outpatients were post-transplant, and were being monitored for their immunosuppression regime and some were being investigated for transplant complications such as polyoma virus reactivation or graft rejection. I found the teaching on the interpretation of the various renal profiles and urine microscopy results to be invaluable to my understanding of basic nephrology.

I accompanied the attending consultant on the daily renal consults to the various inpatient wards, appreciating the necessity for nephrology input to patients who are oliguric or have raised creatinine. Interesting and challenging cases included a patient with Lupus Nephritis, another with suspected Churg Strauss Syndrome and a third with newly diagnosed multiple myeloma who had renal complications. The discussion of these cases with the consultant, and their proposed management and investigation was of real benefit to my approach to internal medicine patients.  The pharmacology of diuretics, ACE inhibitors and ARBs was particularly relevant on my elective, and I feel much more confident and aware of their indication and side effects on patients with renal impairment than before.

I attended the renal biopsy conference, and examined biopsies for patients with minimal change nephritic syndrome, focal segmental glomerulosclerosis and membranous nephropathy. This enabled me to appreciate the variety of investigations – from ultrasound to biopsy to renal profiles -that are indicated for various symptoms and signs in renal medicine.

I thoroughly enjoyed my elective at Sheba Medical Centre. The staff were wonderfully welcoming and educational in their efforts to include me as part of the team. I certainly learned a lot of nephrology which will be of great use to me in my clinical finals and as an Intern. My experience of Israel and Tel Aviv are extremely positive, and I am grateful to the Jewish Medical Association UK (JMA) for assisting me with the opportunity to visit such a culturally and medically enlightening place. I would strongly encourage other medical students to avail themselves of an opportunity to do elective with Tel Aviv University (TAU) – in fact I managed to convince my two best friends to come along with me and they both enjoyed their electives in general surgery and cardiology respectively.

David Mark Kelly
Trinity College Dublin

Geriatrics, Royal Prince Alfred Hospital, Sydney and Infectious Diseases, Royal Melbourne Hospital Melbourne

I began my elective in a rather rainy Sydney at the beginning of June in the department of Geriatrics at the Royal Prince Alfred Hospital. I worked primarily in the high turnover Geriatric Medical Admissions Unit which was a fantastic opportunity to see a wide variety of common presenting complaints. The department was large, modern and well-staffed by a dedicated multi-disciplinary team, which allowed a high level of patient care. I was particularly impressed that, despite a 48 hour time-limit on Medical Admission Unit stays, patients always had a comprehensive plan for the continuation of their care in place before they were discharged from the unit. I had not anticipated that I would encounter significant communication issues in an English speaking country; however, as Australia is relatively young country, many of the elderly population are immigrants and do not speak English. Particularly in Sydney, suburbs are often populated by specific ethnic groups who have maintained native-language speaking communities so we were frequently reliant on family members as translators – which is far from ideal.

The Jewish community in Sydney were very welcoming and I was able to attend a Shabbaton in the beautiful Blue Mountains during my trip. I was also able to reconnect with friends I had met in Israel on my gap year who showed me around the city and ensured that I had hospitality for Shabbat. I was also fortunate that, after my initial housing arrangements fell through, I was able to stay with a lovely local Jewish family who I met through connections with my synagogue at home.

In July I moved to the department of Infectious Diseases at the Royal Melbourne Hospital for the second half of my elective. In contrast to my geriatrics placement, I was mostly based in out-patients as the department holds clinics for the whole state of Victoria and is therefore very busy! The department holds clinics dedicated specifically to HIV, TB, Hepatitis and Travel Medicine as well as general infectious diseases sessions and clinics for refugees. All of the patients at the refugee clinic had been ‘picked up’ through immigration health screening with a variety of infectious diseases, particularly latent TB and hepatitis B, often at an advanced stage, and many had no idea that they had been carrying these illnesses for years. It was also very interesting for me to see tropical diseases that are rarely seen in the UK, such as Dengue Fever. I was fortunate to be able to stay with a friend from my gap year in Israel and then another friend I knew through volunteering at Limmud so I felt very much part of the community and get a true insight into the Jewish life in Melbourne.

I am very grateful to the JMA for their bursary which helped to make my elective possible.

Joanna Ish-Horowicz

Paediatrics – Sheba Medical Centre, Tel Hashomer, Israel

King’s College London allows students to organise their own 3 week placement as part of the paediatric rotation.  With a deep interest in Israel I decided to use this opportunity to get a feel for paediatric medicine at the Sheba Medical Centre, Tel Hashomer.

I spent the first week mainly attending paediatric outpatient clinics, mostly in the mornings, which included endocrine, respiratory, neurology, haemato-oncology and dermatology.  All the doctors were keen to teach me and patients and their parents were happy to have a foreign student present.  Tel Hashomer has developed a special interest in cystic fibrosis, and offers acupuncture as treatment alongside regular physiotherapy.

The afternoons I spent with the Tel Aviv university medical students on their paediatric rotation, joining them for their lectures and small-group teaching sessions about various topics.  Most of the lecture slides were in English, only the lecturing was in Hebrew (Ivrit), but both the students and doctors had very good English and were more than happy to translate words I didn’t know.

The second week I spent on the wards. The mornings would begin at 8:00 a.m. with a departmental morning lecture or grand round with all the senior and junior staff, followed by a handover of new inpatients from the previous night and a discussion of the ongoing care of the more challenging cases.  The department would then divide up into two teams and each team would review all the inpatients under that team’s care, and discuss their management and jobs that needed doing that day.  The patients would then be divided up amongst the team and each junior doctor and registrar would go and see their particular patients.  This was then followed by a ward round with the full team led by the consultant.

As a student, as well as joining this whole morning procedure, I was also given patients to clerk myself and then present to one of the doctors later on that morning in a teaching session with the other students.

During the third week I joined one of the student groups in the paediatric A+E department. We each clerked patients as they arrived and then presented to a junior doctor in a teaching session to discuss the cases.  Every afternoon the students had lectures and small group teaching usually in the form of case discussions.

The student teaching was at a high level, covered a wide range of topics and was generally, very well organised.  The doctors and students were very welcoming, and included me in everything that was going on, and were particularly keen to practise their English!  I watched bronchoscopies, attended physiotherapy sessions for cystic fibrosis patients, NICU, joined X-ray meetings and spent some time on-call.  Not all the doctors were Israeli Jews, many were Israeli-Arab, and there were Russians as well as Olim (immigrants) from America, South Africa and the UK.  As the patient population also encompasses patients from all these nationalities, it was particularly enjoyable to witness how everyone worked together to understand each other and ensure efficient use of resources and optimise patient care.  This also helped make me feel comfortable as a foreign English-speaker.

During my placement Operation Amud Anan (Pillar of Defense) against Hamas in the Gaza strip occurred, and thus I had experience of work in the medical profession in war time.  Tel Hashomer is located on the outskirts of Tel Aviv and is thus within range of missiles fired from Gaza. This meant that we had a number of siren “red alerts” (“tzav adom”) while in the hospital.  The first one occurred while I was in an outpatient clinic and we were all ushered into an “Ezor Mugan” – “safe area”.  This is an area surrounded by re-inforced concrete walls which when all the doors are closed becomes a shelter.  There are several of these areas located in every part of each floor throughout the hospital.  After ten minutes we were all allowed out to resume normal clinic routine. Everyone seemed to take the situation in their stride, though all were glued to the news on their phones to find out where the missile had landed.

Another siren was sounded while I was in the emergency department. The paediatric emergency department in Tel Hashomer was built with reinforced concrete and the whole department is effectively a safe area.  So business here continued as normal, with few even stopping for a moment to consider the possible missile target.  This was my first experience of war, and was a particularly interesting experience being both a civilian walking around and finding myself in a shopping centre during a siren alert, as well as in a hospital where life has to carry on as normal. Of particular interest given the political situation in Israel, is the prevalence of Palestinian patients in the Israeli hospitals.  During Amud Anan, several inpatient Palestinian children and their families found themselves stuck in the hospital and unable to return to their homes.  It was interesting to see the more human side of the political situation, albeit a very an unusual situation for a country to be in while at war.

I thoroughly enjoyed my placement in Tel Hashomer. The medical teaching and practice I saw was of a very high standard, with much enthusiasm for the profession. It was a good opportunity for me to speak to doctors who have moved to Israel from the UK in recent years and hear about how they have settled and acclimatised to their new environment.  I was able to use my current good Ivrit skills which improved dramatically as a result of my speaking to patients and listening to the doctors.

Thank you to JMA for the support and assistance in enabling me to have this fantastic experience.

Adi Gordon

Cardiovascular surgery, Sheba Hospital – Tel-HaShomer, Israel

I spent my medical elective in Israel assigned to vascular surgery at the Sheba Medical Centre in Tel Hashomer, a suburb of Tel Aviv. This is the largest tertiary referral hospital in the Middle East with 120 departments; originally built in 1948 as the first military hospital.

Every morning I would attend the vascular ward round, although I could not understand what was said between the patient and the doctors, the doctors would kindly translate for me. It was lovely to see the gratitude from both the patient and the relatives when they saw the medical team. It was clear that the doctors worked in a close knit environment. Surprisingly there were no juniors on the vascular team. I noticed that there were fewer nurses on the ward, but more health care assistants then in the UK. Once a week I would attend the vascular outpatient clinic, which was a mixture of referrals and post-operative checks. Clinics gave me the opportunity to practise my vascular examination and to perform small medical procedures such as removing stitches and changing dressings.

The majority of my time was spent in theatres and in the angiography suite. I was fortunate to watch several complicated procedures, such as axillary–femoral bypasses, femoral to femoral bypassing, carotid endarterectomy and open abdominal aortic repairs. It was interesting to see how the surgeons manipulated the blood supply of the patient creating new pathways to ensure good circulation. Having the opportunity to scrub in and assist in procedures allowed me to gain valuable experience and see the anatomy up close.

Academically I gained in depth knowledge on vascular medicine; I also had a morning’s master class on how to suture. I practised cannulation with the nurses which helped me to develop confidence in these skills. Overall, the quality of teaching was excellent. All the doctors spoke perfect English, they were very approachable and more than happy to share their knowledge and answer any questions that I had.

Whilst in Israel I stayed in a guest house near to the hospital. The accommodation was in a great location as I could catch a bus to both Tel Aviv and the hospital. I also visited some of the sites that Israel has to offer such as Masada, the Dead Sea, Haifa, Zichron and my favourite – Jerusalem. After placement, I would meet the other exchange students and we would often make our way down to the beaches in Tel Aviv, allowing us to consolidate what we had learnt and seen that day and experience typical Israeli culture. Weekends in Israel were from Friday to Sunday and most shops and public transport would not run, which took a bit of getting used to but only added to the experience. Wherever you were people were friendly and willing to help, this was great, especially when figuring out some of the bus timetables. Israel was a fantastic place for my elective; I would like to thank the Jewish Medical Association for their contribution and would recommend this elective to anyone who wants to experience what Israel is really like.

Charlotte Ziff
Southampton University


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