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
Manchester 

Prevention of Food Allergies – from London to Tel Aviv

The London Presidential Lecture will take place on Thursday 16th November 2017 at 19:30. The speaker will be Prof Gideon Lack MBBCH (Oxon) MA (Oxon), FRCPCH who will talk about “Prevention of Food Allergies – from London to Tel Aviv”. Full details here.

St John of Jerusalem Ophthalmic Hospital / Hadassah – Hebrew University, Jerusalem, Israel

For my medical school elective I spent eight weeks studying Ophthalmology in Jerusalem and the West Bank. This time was split into four weeks with the St John of Jerusalem Eye Hospital and four weeks in the Ophthalmology Department of Hadassah Ein Kerem Hospital in Jerusalem.

St John (part of the order of St John) has many bases for Ophthalmological care across the West Bank and East Jerusalem which I was able to visit (and a base in Gaza which I did not go to). The main hospital in East Jerusalem is the tertiary referral centre for Ophthalmology for Palestinians in the whole of the West Bank and Gaza and therefore I met many patients from these areas. The consultations were mainly in Arabic but the notes were written in English and doctors were great at translating for me. I was able to spend time in many different clinics and theatres – for example in Occuloplastics, Glaucoma, Paediatrics, Vitreo-retina as well as time with a nurse doing imaging and diagnostic neurological tests (OCT, ERG), Orthoptists and an Optometrist. I also spent some time on-call with a resident who taught me how to use the slit lamp to examine patients. There are satellite St John Eye Hospitals in both Anabta and Hebron which I spent time at. The hospital in Jerusalem also runs an Outreach service throughout the West Bank many days a week. Everything needed to set up an Ophthalmology clinic (including slit lamps with their tables) is packed into the back of a mini bus which travels to a community building or doctors surgery in a village. The Outreach team sees difficult cases which may have been booked by a local doctor, common Ophthalmological conditions in the region (allergy, blepharitis, vernal catarrh, keratoconus) performs diabetic retinopathy check ups, makes referrals for further investigations and performs visual acuity screening. One of the times I was with the Outreach team we visited the Bethlehem Caritas baby hospital. This time the team included Orthoptists aswell. On this occasion, alongside the Paediatric Clinic I was able to accompany the doctor onto Paediatric Intensive Care for retinopathy of prematurity screening. A usual day would start around 7:30/8am and finish by 2:30pm unless I was on Outreach which may finish around 4 at the latest.

The opportunity to see corneal cross linking – a specialised treatment for keratoconus was incredible. Some of the conditions I saw in patients were a result of consanguineous marriages between cousins, for example congenital glaucoma. One morning in Jerusalem I joined in with a program run by a local school in co-operation with the hospital social worker to entertain children waiting for their appointment in the children’s play area opposite the clinic. I joined the case conferences which ran once a week (mostly in English) where patients with difficult conditions were brought in to see many of the doctors at once who would then discuss the case, examine the patient and plan together the future treatment or investigations. In Jerusalem I met students on the Specialist Ophthalmic nursing course run by St John. I was also able to attend the Third Ophthalmic Nursing Conference in Al-Bireh (a twin city with Ramallah) at the Palestinian Red Crescent Society where I heard a variety of presentations including one on blindness amongst Palestinians in the region supported by research carried out by St John, and one on the diabetic screening program St John is carrying out in the West Bank.

I found the staff of St John very welcoming and keen to teach me about various Ophthalmological conditions and I was given plenty of opportunity to examine patients. I was able to learn a fair amount of Palestinian Arabic whilst with St John – especially from the kitchen staff – which helped in building relationships and understanding consultations. I saw both positive and negative encounters of the Christian and Muslim Arabic staff amongst each other. I chose not to mention my Jewish heritage and as a result I think I may have heard more of people’s opinions on the political situation of the region.

For the second half of my elective I went to Hadassah Ein Kerem Ophthalmology Department, a tertiary centre in Israel with most patients coming from the Jerusalem area and nearby settlements in the West Bank. Israeli Jews including settlers in the West Bank and Israeli Arabs are seen alongside Palestinians from the West Bank and Gaza referred by St John (an Eye Hospital in East Jerusalem). The doctors working at Hadassah include Israeli Jews, Israeli Arabs, Palestinians including some who work or have worked at St John Eye Hospital and residents and fellows from South America. The hospital is a meeting place for people from different cultures who may not mix so much in life outside of the hospital. I loved seeing the diversity of patients in the waiting room. Within a few minutes of spending time with doctors, nurses and patients I could easily hear many different languages spoken – Hebrew, English, Arabic, Spanish and Russian for example! Hadassah struck me as an excellent community model of an organisation coming together for the benefit of quality healthcare and displayed good relationships amongst patients and staff.

Within the Ophthalmology Department is a large tumour service which is the only one in the country to treat retinoblastoma via intra-vitreal chemotherapy (which I was able to see happen in theatre!) and which developed the use of mitomycin-C drops for occular surface malignancies. Patients with retinoblastoma come from all over Israel, the West Bank and from countries such as Russia due to the expertise and commitment to save sight as much as is possible displayed by doctors at Hadassah. The department also has high quality services in Uveitis, Neuro-Ophthalmology, Retina, Cornea, General Ophthalmology including cataract and a large Paediatric department, all of which I was able to spend time with in clinics. I was able to spend time in theatres for cataract, retinoblastoma, retina and emergencies. The department has a large commitment and dedication to research which I found inspiring to be exposed to.

Every weekday began with lectures for the residents at 7:15/7:30 except Wednesday Grand round at 7 which all the doctors attended (all in English). The teaching was exceptional, in depth and spread across all areas of Ophthalmology, I felt really privileged to have been able to attend this . Whilst at Hadassah I was able to attend one of the monthly series of Ophthalmology lectures on a friday morning (weekend). Ophthalmologists from all over Israel and some from the St John Eye Hospital in East Jerusalem along with some Orthoptists gathered to hear case presentations and about new techniques in Ophthalmology and then discuss them. All but one lecture was in English aswell as most of the discussion. I don’t think anything like this happens in England, representatives from Ophthalmology Departments across a whole country gathering once a month with a commitment to collectively improving and developing Ophthalmology treatments!

Clinics/theatre ran from after the resident’s teaching until they finished which could be anytime from 11:30 to 16:30 depending on the day and speciality! I was given plenty of opportunity to practice using the slit lamp and even a couple of times the opportunity to use additional 78/90 lenses for visualising the retina – accompanied by teaching by the friendly residents. The residents worked 24 hour emergency on-call shifts and were happy to teach me and have me join them on these. Being with the resident on call meant I got to see more of the hospital out of hours including the Adult and Paediatric Emergency Departments, a Maternity Ward and the Paediatric Oncology Intensive Care Unit. I saw some emergency surgery for retinal detachment during one of these emergency on-call times. I saw a huge variety of cases during the emergency on call shifts, a few Arab women with burns to their faces from cooking stoves, a soldier with viral conjunctivis, someone with a large conjunctival haematoma, foreign bodies etc.

Most consultations were in Hebrew, with some in Palestinian Arabic and some in English. I could speak a fair amount of Hebrew before I started at the hospital which was really useful in conversation with staff and patients and in understanding consultations.  Doctors, nurses and patients were very keen to help me learn more and as a result I picked up lots of new words especially during quieter moments of on calls when I would chat to the nurses on the ward. Being able to read and write somewhat in Hebrew also proved a useful skill. I was able to speak some Palestinian Arabic (that I had learnt at the St John Eye Hospital in East Jerusalem before coming to Hadassah) with doctors and patients which was valuable in building relationships and understanding consultations. Again I found doctors helped me to pick up some new words. Neither Hebrew nor Arabic are needed for a placement here as all of the doctors speak exceptional English.  Many of the residents were from South America and were fluent in English and knew varying amounts of Hebrew. The nurses I met spoke varied amounts of English.

I felt very welcomed at Hadassah by all of the doctors and nurses I encountered. Their enthusiasm for Ophthalmology, the excellent teaching I received, and the opportunity to see a wide variety of cases and treatments which I had not been exposed to as part of my medical school curriculum in the UK was amazing.  I am seriously considering applying to do an Ophthalmology residency there in the future.

This elective has undoubtedly been the highlight of my time at medical school as I have been able to explore Ophthalmology in much greater depth, alongside meeting people, building relationships and travelling in Israel and the West Bank. During my time in Israel I was able to visit the Kotel during Pesach (Passover), take part in Yom HaZikaron (Memorial Day) and Yom Ha’atzmaut (Independence Day) with Israeli friends and experience Israel at Shavuot. I also went to Mount Gerizim in the West Bank to the Shomronim Pesach Festival (Samaritan Passover) which was an incredible experience.

I am really grateful to the Jewish Medical Association for their support in making this elective possible for me and would like to say a huge thankyou to them. I can unreservedly recommend an elective in Israel to anyone considering it!

Rebecca Chislett
Nottingham 

Adult Learning Disabilities, Sheba Medical Centre / Tel Aviv Medical School, Israel

Intellectual Disability Psychiatry team at the Chaim Sheba Medical Centre, Israel

Aims & Objectives

  • To develop an understanding of healthcare in Israel and appreciate differences in their health and welfare system.
  • To gain an overview of the care of people with intellectual disabilities, including psychological aspects, physical aspects and social care.
  • To enhance my experience of psychiatry, with particular emphasis on the impact of culture on mental health diagnoses.
  • To work on an audit or research project during my time in Tel Aviv.
  • To learn some basic Hebrew and discover the culture of Israel.

Why this elective?

Throughout my time at medical school and previously, I have had an interest in the care of people with Intellectual and Developmental Disabilities. I have been able to explore this through an SSC with the paediatric neurodisability service at Ryegate Children’s Centre, Sheffield, through volunteering with Sense and Teddy Bear Hospital and through my part-time employment at Step Up Support currently. However, I wanted to use my elective period to fill a gap in my experience in the medical care of adults with Intellectual Disabilities (ID). Through contacts at the medical school and beyond, I was able to arrange an elective with the Intellectual Disability Psychiatry team at the Chaim Sheba Medical Center, Tel Aviv in Israel.

Meeting my aims & objectives

To develop an understanding of healthcare in Israel and appreciate differences in their health and welfare system.

Israel’s National Health Insurance Law requires all citizens to register with one of the four Health Maintenance Organisations (HMOs), the largest of which is Clalit (כללית). I was able to see during my placement that Clalit serves a significant proportion of the underprivileged, including people with disabilities (Balicer, et al., 2011). As far as I witnessed, health funds seemed to fulfil the principles of “justice, equality and mutual assistance” (State of Israel: Ministry of Health, n.d.) upon which they were based. While they have their differences, both Israel and the UK have universal health coverage.

To gain an overview of the care of people with intellectual disabilities, including psychological aspects, physical aspects and social care.

While describing in depth the health policy and welfare systems in place for people with ID in Israel may be instructive for the reader, I have the advantage of being able to refer to authors I met in the country for this information (Halperin, et al., 2005). I have gained a good understanding of health service commissioning in Israel for people with ID through discussions with two of the authors of the above, as well as with professionals I met on placement and during the interview stage of my research project.

I have been able to see many aspects of care for people with ID. I have met doctors, nurses, psychologists, behavioural therapists, speech and language therapists, teachers and researchers. However, time constraints did not allow me to visit other specialist services, such as a dental service specifically for people with ID. More planning of activities before my arrival to Israel would have allowed me to organise this more effectively, although my time was more than filled adequately.

Enhance experience of psychiatry, with particular emphasis on the impact of culture on mental health diagnoses.

The Bnei Brak clinic is specifically for the Jewish Orthodox population. However, in all of the clinics I was in I was able to see how culture influenced the relationship between doctor and patient, the acceptance of treatment and the role of the family in the process. In terms of differences in psychiatric care in Israel, there is one issue which stood out for me. I saw that challenging behaviour was not an uncommon indication for prescribing antipsychotic medication. This is not an indication I have seen here in the UK, and I need to do further research to find if it is common practice. As a result of my hands-on experience, I am inclined to promote non-medical management for challenging behaviours, and I am not convinced of the ethics of this method of ‘chemical restraint’ when experience has shown me how behaviours are usually a response to the environment.

To work on an audit or research project during my time in Tel Aviv.

The title of my research project was: ‘Stakeholder perceptions of guardianship and supported decision making for people with intellectual disabilities in Israel.’

Background

Recent research has promoted the use of supported decision making, in contrast to historical methods of substitute decision making when working with people with intellectual disabilities. In Israel, people with disabilities are protected by the Legal Capacity and Guardianship Law of 1962, which was amended in 2016. This research considers how these recent changes are perceived by professionals in Israel.

Methods

Professionals with experience in policy making, law, social work and with direct experience working with people with intellectual disabilities (ID) were interviewed using semi-structured interviews and one focus group. Interviews were recorded and subsequently coded and analysed qualitatively.

Results

Two major themes were identified. These were: The Law and its Phrasing, and Changing Culture. Findings highlight the process of change within guardianship law and practice and the challenges in implementation encountered so far and anticipated in the future.

Conclusions

Results from this study support those that have been found in previous studies from other parts of the world. More evidence is required to identify the most effective way to manage capacity and guardianship issues for people with ID.

My project is now complete, and we are in the process of submitting the final report for publication.

Learn some basic Hebrew and discover the culture of Israel.

I had hoped to find a class (Ulpan) to be learn some Hebrew while in Israel, but this was not possible. However, after some time in the country I was able to understand much more of the language.

During consultations I was surprised how much I could understand from expression and the little I had picked up of the language. I was also able to assess the majority of a mental state examination through only observation, and I certainly feel more competent with this.

Reflections on my experiences

My choice of Israel was a surprise to many of the people I met there, as I am not particularly religious. I was raised Catholic, and Israel is predominantly a Jewish state. However, the country held an interest for me as a place steeped in history and political controversy. Security threats were a minor concern: I reasoned that in light of recent attacks throughout the rest of the world, the danger for me in Israel was not much more than my colleagues in other parts of the world if I followed government advice. Whilst in Tel Aviv, I was surprised and comforted by the level of security displayed. My bag was searched at hospitals, bus stations, supermarkets and train stations and on some occasions I was asked to show my passport. On further reflection, I can see that while this increased security was a new phenomenon for me, the experience may have been less unpleasant as suspicion towards me as a white British female is relatively low.

On my first day at Sheba Medical Centre, I met with Joav Merrick who explained much of the information contained in the referenced article on health policy (Halperin, et al., 2005), as well as directing me to spend time with many of his colleagues. One of these was Mohammed Morad, another of the authors, who welcomed me with true Middle Eastern generosity into his town of Beer Sheva a few weeks later.

In one morning at his clinic, I encountered a traditional Jewish Israeli man, an orthodox Jewish lady, a Russian lady and an Ethiopian man. I understood that the clinic and its branches also serve the Bedouin community in the area. It is an incredible example of Jewish and Muslim living harmoniously: the doctor I met with was Muslim, his partner at the centre was Jewish. They talked to me for a long time about how they formed a group years ago to highlight the importance of doctors acting ethically and not be influenced by race, religion, politics or any other factor. In my position as a privileged and open-minded person, I have never considered allowing those things to alter the care I provide. However, it was clear that driven by propaganda, fear sets communities in this continent apart. As educated professionals, I hope, as they do, that we can set an example around the world of how to transcend these differences.

Looking to the future

My interest in the care of adults and children with Intellectual and Developmental Disabilities has not changed as a result of this trip. I am still passionate about this population. However, what I have found is that my career interests lie primarily in the diagnosis of children with developmental disability, and the behaviours they present with. As I am approaching foundation programme applications, I will be considering training pathways in more detail.

I am also finalising my research report and I am in constant contact with my supervisors to continue progress towards publication. I hope to do more research in this area.

I have been able to network abroad and attend conferences. I plan to attend the next conference at Beit Issie Shapiro and I am looking at further conferences closer to home.

Bibliography

Balicer, R. et al., 2011. Reducing Health Disparities: Strategy Planning and Implementation in Israel’s Largest Health Care Organization. Health Services Research, 46(4), pp. 1281-1299.

Halperin, I., Shupac, A., Morad, M. & Merrick, J., 2005. Health Policy for Persons with Intellectual Disability : Experiences from Israel. The Scientific World, Volume 5, pp. 71-92.

State of Israel: Ministry of Health, n.d. Rights of the Insured under the National Health Insurance Law. [Online]
Available at: http://www.health.gov.il/English/Topics/RightsInsured/RightsUnderLaw/Pages/default.aspx
[Accessed 02 08 2016].

Rebecca Davies
Sheffield

Aerospace Medicine Association Conference, Denver, Colorado USA

I undertook my elective at the Microgravity Centre in Porto Alegre, Brazil. This facility was part of the Pontifícia Universidade Católica do Rio Grande do Sul.

During my time in Brazil I was involved in two projects, both in the field of space medicine. I have always been interested in extreme environments, and especially space travel. I saw my elective as an excellent opportunity to gain experience in the field of space medicine and conduct original research in this area.

The Microgravity Centre specialises in simulating microgravity and hypogravity to investigate the effects of these environments on the body and on medical procedures. This is achieved by means of body weight suspension and lower body positive pressure (LBPP). The primary focus of my own project was to use a LBPP and treadmill system that had been set up to simulate walking on Mars. Once this was accurately achieved, open circuit spirometry was used to measure respiratory gases. This data was then used to investigate the metabolic changes that occur when walking in simulated Martian gravity. Details of the project were summarised in the abstract below:

The metabolic cost of walking in simulated Martian gravity and its implications 

Elliot Brown, Thais Russomano, Brenda Bueno, Leonardo Bandeira, Leandro Disiuta, Ingrid Lamadrid, Michele da Rosa, Julio C M de Lima, Rafael R Baptista, Raquel da Luz Dias

INTRODUCTION: Understanding the metabolic cost of walking is vital to the success of future missions to Mars. Lower body positive pressure (LBPP) is an effective way of simulating hypogravity. A small number of studies have shown that oxygen consumption (VO2) decreases when walking in LBPP simulated Martian gravity. This study measured the submaximal VO2 and other respiratory gases when walking on a LBPP treadmill at 1G and simulated Martian gravity (0.38G). Specific focus was given to analysing calorific expenditure and substrates metabolised.

METHODS: Twelve healthy participants with mean age (± SD) 22.75±5.38 years took part in this study with full consent. The LBPP box used was designed and built by the Microgravity Centre. A VO2000 gas analyser measured respiratory gases and a Polar S610 heart rate monitor measured heart rate. Volunteers walked for 8 min at a control of 1G and then for another 8 min in simulated 0.38G two weeks later. Student’s t test for paired samples determined if the data from the two environments were significantly different.

RESULTS: Mean (± SD) VO2 was 1.00±0.61 ml/kg/min in 1G compared to 0.68±0.33 ml/kg/min in simulated 0.38G (p<0.05). Average Calorific expenditure was significantly reduced (4.79±2.80 Kcal/min) when compared to the control (3.37±1.49 Kcal/min) (p<0.05). The average heart rate at the control weight was 118.49±15.07 bpm, significantly reduced to 106.20±11.17 bpm when body weight was unloaded (p<0.05). Average respiratory quotient (RQ) was significantly increased (p<0.05) from 0.83±0.13 to 1.14±0.19 in simulated 0.38G, with no significant difference seen in the fraction of expired carbon dioxide.

DISCUSSION: Energy consumption significantly decreased when walking in LBPP simulated hypogravity. This agrees with previous studies which also measured a reduction in VO2. Reduced calorific expenditure was also measured during the Apollo 15 Lunar landing. Observed calorimetry and respiratory gas findings can be used to calibrate EVA suits and advise on diet and exercise regimes for future astronauts. RQ indicates that a higher proportion of carbohydrates were used as an energy substrate. On Earth, LBPP can be used to remobilise patients effectively whilst reducing joint loading. Rehabilitation regimes can now be tailored with an understanding of how metabolism changes.

During this elective I was also able to participate in two other projects.

One of these focused on testing a novel method of delivering cardiopulmonary resuscitation (CPR) for use on the Moon and Mars. Hypogravity was simulated by using a body weight suspension system. This project was mainly led by another medical student from Glasgow Medical School.

The other was a telemedicine outreach clinic to the village of Palmares do Sul. I helped to run a cardiology and dermatology clinic with the aid of 2nd year Brazilian medical students. Clinical information such as ECGs and dermatological photographs were gathered by our teams and sent back to consultants in Porto Alegre. Through this system, patients who live far from specialist care could be reviewed. Acutely ill patients were treated by the outreach team on site.

In addition, I also scrubbed into surgical theatre at the São Lucas Hospital in Porto Alegre and attended lectures on hypoxia and space suit physiology.

Following the elective I was fortunate that my research abstract was accepted for presentation at the Aerospace Medicine Association (AsMA) annual scientific meeting in Denver, USA. The Jewish Medical Association (UK) made my attendance at the five-day conference possible. This gave me a unique opportunity to present my work internationally, and to network with professionals in the medical specialty I would like to pursue.

AsMA was founded in 1929, and is the largest international meeting of aerospace medical professionals. Over 50 nations were represented, and approximately two thirds of the delegates had a military background in the air force or navy. The medical staff from major space agencies such as NASA and ESA were also present. Several NASA astronauts were also in attendance at the conference.

My abstract was selected for a 15 minute slide presentation in the session ‘Future of Space Medicine Part 1’. Following my presentation I discussed my project with experts in the field and explore ideas for future work. The medical student from Glasgow also presented her work on CPR.

This experience provided me with an unparalleled opportunity to gain career advice from a multitude of flight surgeons working in both the military and in space agencies. Everyone was extremely welcoming to us, having come all the way from the U.K. In particular, it was wonderful to meet and talk to Dr J D Polk, Chief Medical Officer for NASA, and fascinating to gain insights into his job in Washington and his opinion about the future of manned space flight. Dr. Chuck Berry, the flight surgeon for the ill-fated mission of Apollo 13 was also present. In his lecture, he discussed the medical challenges that were faced during the crisis. From the U.K. it was a pleasure to meet Dr. Kevin Fong from the UK, who delivered the Royal Society Christmas lectures on space medicine in 2016.

Whilst I was in Denver I made the most of engaging with the local Jewish community. I spent the first Shabbat spent with the one of the local Chabad families and was invited to their son’s barmitzvah! I spent the second Shabbat with the Hillel House at the University of Colorado in Denver. I got to know many Jewish students studying there university and I am still in contact with them today.

Elliot Brown
Birmingham 

Medical Professionalism in the Practice of Medicine

Prof Ora Paltiel (Hadassah / Hebrew University School of Public Health) organised a meeting on the theme of Medical Professionalism for the Israel National Institute for Health Policy Research (NIHPR).

The keynote speaker was Prof. Pali Hungin, President of the British Medical Association, and former Dean of Medicine at Durham University. He delivered what was described as “a thought provoking session regarding the current crisis faced by the profession, due in part to changing demands and expectations of the public, on the one hand, and the relative conservatism of the profession on the other”. He delineated the symptoms of this crisis, including attrition / dropout, burnout and even decreased enrolment in UK medical schools, and suggested some of their causes – including loss of status, time pressure and loss of clinical autonomy. He warned that “Medicine as an esteemed profession is threatened because of changes both in societal expectations and rapid technological transformation”. Despite genuine cause for concern, he predicted that as the use of digital technologies to their full potential, and as expertise is refined, medicine will evolve. The paradigm will shift and he foresaw enhanced professionalism, increased professional satisfaction, and improved patient outcomes in the long term.

Prof David Katz also spoke at the workshop on the theme of “Professional Regulation”.

A full meeting report has been published in the Israel Journal of Health Policy Research and can be accessed here.

 

 

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