Elective in The Oncology Department, Shaare Zedek Hospital Medical Centre, Jerusalem

Shaare Zedek Hospital is located next to Har Herzl in southwest Jerusalem and is the fastest-growing hospital in the capital. The hospital has 1000 beds and treats over 600,000 patients a year in over 30 inpatient departments and 70 outpatient clinics. In 2014, over 22,000 babies were born in Shaare Zedek, more than any other hospital in the Western World (1).

I spent three weeks in the Department of Oncology at Shaare Zedek, with the generous support of the Jewish Medical Association. There is a friendly electives coordinator who helped me arrange the elective. My objectives were to gain a deeper understanding of the diagnosis and management of the malignancies; to learn how these conditions affect the lives of patients of different cultures; and to practise speaking to staff and patients in Hebrew and improve my vocabulary.

My time was split between the oncology ward, outpatient clinics and departmental meetings. On the ward, there were weekly ward rounds with Dr Amiel Segal, the Director of Inpatient Oncology, and also Prof Nathan Cherny, head of palliative care. I was included in the ward rounds and doctors went out of their way to explain what was going on and to ask me questions. I used the ward rounds to learn as much Hebrew as possible, and found the medical Hebrew surprisingly easy to pick up. The ward staff were very friendly and I was constantly fed coffee and cakes by the head nurse!

The outpatient clinics were an opportunity to learn about the diagnosis and management of the common cancers, mostly breast, bowel and lung. I spent time with five different consultants, each with a unique approach, and learnt a lot about communicating difficult news and patient-centred management plans. I also had the chance to take my first ever history in Hebrew, and with some difficulty I succeeded in gathering a full history of a patient recovering from a colonic resection due to cancer. I was also encouraged by one consultant to read a paper from the Israeli medical journal Harefuah, and so I spent the next week reading my first Hebrew paper, on the treatment of bowel cancer with peritoneal metastases with cytoreductive therapy combined with intraperitoneal hyperthermic chemotherapy. These experiences gave me a lot more confidence in communicating and learning in Hebrew and using every patient encounter as a linguistic as well as medical learning experience.

There was a wide variety of departmental meetings that I had the option of attending. For my first few days the doctors were kind enough to speak in English for my benefit! Every Thursday morning at 8am there was a kosher breakfast with presentations about the latest clinical research in oncology and how it might affect practice. There was also a weekly gynae-oncology meeting, a breast cancer meeting, radiology meeting and nuclear medicine meeting, which involved the review of PET scans. The weekly ward meeting included very interesting discussions and debates about the management of difficult cases, for example a lung tumour which histologically was identified as a squamous cell carcinoma but also had a component of adenocarcinoma.

Yom Hazikaron was a special day with a ceremony outside the hospital led by Professor Halevi, director of the hospital. This was attended by many staff and patients and particular attention was given to those soldiers who died while fulfilling medical duties.

I am very grateful to the Jewish Medical Association for their generous support of my elective.

Reference:

  1. http://www.szmc.org.il/About/2012Statistics/tabid/1448/Default.aspx

Eitan Mirvis 
Imperial College School of Medicine

Elective in The Anaesthetics Department, New Somerset Hospital, University of Cape Town Medical School, Cape Town, South Africa

As part of my elective I spent just over three weeks in the busy anaesthetics department of New Somerset Hospital, a public hospital based in the picturesque Waterfront area of Cape Town. I had a number of objectives, which included getting hands-on with all the different aspects of the anaesthetics role, and gaining an insight into the different lifestyles and healthcare needs of the diverse population and, in particular, of the Jewish community.

The elective more than lived up to my expectations. The whole team, from the doctors to the nurses to the porters, were all extremely friendly and welcoming and I got to know them quite well during my time there. My days started at 7.30am and tended to finish at around 6pm. From day one, I was allowed to get involved with the entire care of the patients. This started with meeting the patients, getting to know them a bit, performing a thorough anaesthetics assessment, explaining the anaesthetic and reassuring the patient. This was a very rewarding and educational part of my role. I was then allowed to manage the patient’s airway and perform a variety of practical procedures. These included some more routine things such as intravenous cannulation and also some more difficult procedures such as endotracheal intubations and LMA insertions, depending on the operation and patient. This was an amazing experience as I am considering a career in anaesthetics but had never had the opportunity to perform these procedures. It was such a thrill to learn these new skills and every procedure on every patient was very rewarding, as was helping to wake the patients up and ensure their post-operative care was optimal.

During my time in the operating theatre, I learned a lot about how the anaesthetic machine works and essentially how to give an anaesthetic from beginning to end. The staff  were often keen to teach and I learned a great deal of physiology and pharmacology as well. I spent quite a lot of my time in the Obstetric Theatre and was lucky enough to learn a lot more about obstetric anaesthesia in addition to performing the spinal anaesthetics.

Although the hospital did not have a formal outreach service, the anaesthetists would go and assess sick patients on the ward, particularly those who were post-op or who were being considered for an operation. I went with, and helped, in the assessments and treatment and found this a very useful and rewarding part of the elective. This really gave me the confidence in assessing and treating the critically ill patient, which will help me in my role as an FY1 next year.

In addition to getting a very hands-on experience of anaesthetics, I was also able to see a lot of conditions and scenarios that I had not seen in the UK. These included end-stage AIDS patients, systemic TB infections, trauma such as stabbed hearts and much more.

My day started and ended with attending daily services in the Sea Point area of Cape Town, which, in addition to staying there over Shabbat, allowed me to get to know the Jewish community of Cape Town. I met doctors, medical students, dentists and a few teenagers considering a career in medicine and enjoyed interacting with them and getting to know them. I was also able to see quite a bit of Cape Town and beyond, which is truly a beautiful city, with so much diversity. Thanks to the grant from the Association, in addition to being able to get to Cape Town, I was able to see and do a lot more and really felt that I got a flavour of what life is like for the Jewish community of Cape Town and for all the diverse population of Cape Town, from a healthcare perspective and what life in general is like.

Edgar Brodkin
 UCL

Elective in Primary care, Roatan, Honduras

Introduction

When deciding elective destinations, I searched for a placement where I could make a contribution, whilst gaining confidence in my clinical skills in a challenging environment with limited resources. Clinica Esperanza on the island of Roatan, Honduras had all this and so much more! The clinic functions as a combination of primary care and emergency medicine, in part due to the fact that the local hospital with an A&E has not received medical supplies for over 6 months.

Reflection

One of the most challenging parts of working in a foreign environment, yet also one of the major benefits, is the vast cultural differences that inevitably exist. Roatan is no exception. Learning more about such differences was one of my elective objectives, and one that was most certainly achieved. I was soon struck by the fact that the typical age of first pregnancy is 18, malnutrition is widespread with limited opportunities for work and an endemic obsession with sugary, fizzy drinks. I saw that it is not enough to simply take a history and examine a patient. The area they live, the job they do and their religious beliefs are completely intertwined with their health outcome. For me, this was a learning point that I will undoubtedly take with me everywhere I go.

I relished the opportunity to practice health promotion in a place where few patients achieve more than a primary school education. One example of this was a patient we diagnosed with type II diabetes for the first time. This diagnosis required me to educate the patient about nutrition, such as avoiding fried and sugary foods, as well as trying to warn her of the potential complications, her treatment options and invite her questions, all of which while talking in a foreign language. I found this to be surprisingly rewarding, especially when she returned for a follow-up appointment the following week with much improved glucose levels, and bringing stories of the changes she had made to her diet.

There were certainly aspects of the placement which far exceeded my expectations and even surprised me. One example was having the opportunity to gain new perspectives towards global health and learn about the differences in medical practices across the world, such as the local ‘bush medicine’. In an area with a large obese and Afro-Caribbean population, there is an unusually low incidence of cardiovascular disease. Whilst of course there are many factors that can cause this, I learnt not to be too quickly dismissive of remedies that have been used for thousands of years.

One of my learning objectives was to practice clinical techniques such as cannulation and suturing. Unfortunately I do not feel I had sufficient opportunities to fulfil this objective, owing to the fact that the clinic functioned mainly as a primary care unit, and thus most emergencies went to the emergency room at the local hospital. However I don’t believe this negatively impacted on my experience but it does mean I will endeavour to gain more exposure to such procedures during my DGH placement.

I was, however, very pleased to have the opportunity myself to make a difference to the clinic, one that will hopefully be sustained long after I leave. I was delighted to be awarded a bursary from the RCOG to allow myself and Rebeca to complete a research project during the elective placement. The recently introduced cervical screening programme was highlighted as an area that is underfunded and in need of improvement. The haphazard introduction of this programme has meant many patients may be being missed due to the opportunistic recruitment of patients, as well as results not being delivered appropriately. Through developing a new data collection system, as well as retrospectively collecting data from the smears already completed, we have identified patients who need to be recalled for urgent follow up, as well as making recommendations that hopefully ensure that the limited resources of the clinic are directed more effectively, thus allowing more patients to be helped.

During my elective, I found that the impact of poverty further compounded in a health system requiring patients to pay for consultations, investigations and medications. Decisions weren’t made solely on the basis of what would be best for the patient and, having been educated within the luxury of a National Health Service, I found this particularly challenging. However, I recognise that in a time of austerity and budget cuts, we will all have to factor limited resources into patient care. Thus, having more confidence in my ability to diagnose, or at least treat empirically without expensive investigation as well as recognising when these are justified will benefit all of my future patients.

The impact on my professional practice

The time I spent at the clinic has undoubtedly changed my professional practice, as well as my own outlook. Early on in our placement, we had an emergency situation of a young boy who was desperately ill. Seeing a team pull together so seamlessly, needing few words to communicate whilst battling with limited resources was incredible, despite the heart-wrenching circumstances. On a daily basis I had to adapt to the limited availability of tools we so frequently take for granted, which left me with no option but to develop my clinical accumen. Further, being able to work in an independent manner but with plenty of supervision from experienced doctors encouraged me to hone my decision making skills, and gave me confidence.

I enjoyed the diversity of the patient presentations and had the opportunity to work in gynaecology, saw many paediatric patients and managed a vast array of general medical patients. Communicating complicated information in another language was a difficult but important lesson. I realised that the challenge of working with patients from different cultural and ethnic backgrounds is so much more than just a language barrier, and this is even more relevant when working back in the UK. I will endeavour to understand how to approach topics such as sexual health or alcohol drinking in each new community I work with.

Limitations

If I returned to the clinic, which I certainly hope to do, I would change some of my objectives to allow me to gain even more from the opportunities we were presented with. One would be to learn more of what is normal. Seeing such an array of patients daily is the perfect opportunity to practice many clinical exams, such as using otoscopes and ophthalmoscopes to be able to appreciate physiological variants as well as pathology. Clinical knowledge can also be gained in the specialities of tropical diseases and nutrition. Members of the clinic run nutrition classes in the community and I would have liked to be involved in running such classes.

Another area which can be developed in this environment is decision making skills. The wealth of support from experienced doctors encouraged me to be independent whilst still being safe within my personal limits. Whilst at the clinic I took part in a community outreach programme, where members of the clinic go to local communities and give nutrition classes, hand out food parcels and education to prevent delayed presentation when illnesses develop. I would love to have done it more often. We have suggested that the clinic includes a weekly visit to the community in the volunteer program in the future.

Conclusion

I believe I was able to contribute to the clinic through our research project, and providing recommendations which will be used to apply for funding for an HPV testing programme. Further, each volunteer gave a teaching session, and I contributed to the shared knowledge of hypertension, and was able to highlight differences between UK prescribing practices, and the USA.

I would like to continue to help the clinic by raising awareness of their work. I will have the opportunity to do this when I present our research to the RCOG, in the hope of encouraging visiting gynaecologists to choose a placement in Roatan, which could allow the re-opening of the birthing unit at Clinica Esperanza, and provide expertise that could be used to train local doctors in techniques such as colposcopy and ultrasound.

I had many exciting, unexpected and educational experiences during my placement at Clinica Esperanza and would thoroughly recommend it to any medical student considering an elective in the developing world.

Brooke Calvert (
UCL)

 

Elective in The Trauma Unit, Chris Hani Baragwanath Academic Hospital, Soweto

In December 2013 I left the UK bound for Johannesburg for my medical elective in the Trauma Unit of Chris Hani Baragwanath Academic Hospital, Soweto. Affectionately known as Bara, this vast hospital is the only one in Soweto, serving the entirety of its 5 million inhabitants. With a world-wide reputation matched only by that of the area in which it nestles Bara is the polar opposite of the hospitals in which I have been so far; as such I was excited but extremely nervous about working in the Trauma Unit.

The trauma unit alone has 184 inpatient beds, 4-round the clock trauma theatres, a triage area with space for over 50 trolleys, 10 resuscitation bays and 10 dedicated ICU beds. This all sounds very impressive and gives the illusion of a well-resourced, adequately funded unit. However it is important to bear in mind that Baragwanath rarely operates under 100% capacity, more often 150%, and is underfunded to the degree that the doctors need to provide resources such as paper, printers and sometimes gloves.

When pay-day rolls around for 5 million Sowetans or the famed Pirates play The Kaiser Chiefs in front of 90,000 strong crowd the World’s most infamous township gives it’s only hospital a run for its’ money; often causing the unit to close for 2-hour periods in order to begin to clear the backlog. The level of violence in Johannesburg is like nothing I had ever seen before, not saying much for a middle-class 24-year old from West London, but when you consider that not a day went by at Bara without more than twenty stabbings or shootings this statement would ring true for most.

What is the source of the endless stream of accidents and emergencies at Bara? Well, quite simply it is The Sauce. A lethal mixture of township-brewed hooch, unemployment, overcrowding in a vicious cycle of poverty. Whether shot for a wage packet, hit by a drunk-driver, involved in a bar brawl, crushed by a collapsing wall or caught in a shack fire, it is fairly certain that at least one of the above is to blame.

My days began at 6:30am with ward-rounds followed by ward jobs, assisting in theatres and manning the surgical ‘pit’. Students were expected to do two 30-hour on-call shifts a week in addition to normal days. Apart from infinitely improving my clinical skills, teaching me procedures seldom needed in UK hospitals and honing my decision making prowess, this enabled the trauma team to truly bond. Everyone who works in the trauma unit is extremely helpful and friendly, no matter how busy the day is everyone is pleased to see you and all the registrars and consultants take the time to teach you, whether it’s for an hour during a ward round or for the two minute walk to the CT scanner at 3am. Every moment was used as a teaching opportunity and every teacher was happy to do it.

The demographic of patients seen at Bara often only complicated the task in hand, with 80% HIV positive, 60% with TB and drug resistance on the rise; treating patients was always a balancing act of treatment, adverse-effect and seemingly unsurmountable infection. Confounded by ever-changing available medication, some thirty different language profiles and more often than expected losing patients in the 10km of corridors and shack-like wards, sometimes for days at a time.

I learnt a huge amount at Baragwanath, not least volumes about trauma medicine and working in a resource-scarce environment. However more importantly I gained infinite teamwork skills and now understand that no matter how difficult the working environment and how busy each day, a good, cohesive team, at every level from porter to consultant can transform a potentially disastrous scenario into one that is difficult, stressful and unbelievably exhausting but ultimately extremely satisfying, most importantly successful and even enjoyable.

This was not an easy elective to go on, I did not have weekends or evenings to explore and I found the level of violence in a community that lacks autonomy extremely challenging; however it is definitely one of the best experiences of my life, which cannot begin to be expressed in a page. I met an immensely capable and welcoming team who gave me a unique opportunity to work with staff and patients who are some of the most friendly, vivacious and appreciative people I have come across. I am extremely grateful to the Jewish Medical Association UK for helping me to go to South Africa and I would recommend Baragwanath as an elective for anyone in search of a brilliantly satisfying yet challenging experience.

Leah Rosenbaum
UCL

Elective in the Plastic Surgery Department, Hadassah Ein Kerem Medical Centre, Jerusalem

I undertook a medical elective in Jerusalem, Israel. This involved six weeks in the Plastic Surgery Department at the Hadassah Ein Kerem Medical Centre.  Plastic Surgery was my chosen speciality in this elective, because I have had very little exposure to the specialty prior to commencing this elective.  Israel was my chosen destination, being renowned for its infrastructure and innovations in healthcare.

The Plastic and Aesthetic Surgery department at Hadassah is renowned on a global level and in Israel for its work in reconstructive surgeries for trauma and congenital malformations, and cosmetic surgery. It is also well known for its work in paediatric plastic surgery, hand and microvascular surgery.  The hospital, a very modern sprawling complex in the Judean hills, which includes a medical and dental school sits at the forefront of Israeli Healthcare, and is known for its progressive and high standard quality care.

Healthcare in Israel is universal, and all citizens are mandated to have medical insurance with any of the four Health Maintenance Organisations, which receive funding from the government, derived from the health insurance tax.  This entitles access to basic medical and dental health coverage. Individuals also have the right to purchase additional private insurance to cover additional treatments not covered by the basic insurance.

At Hadassah, the day commenced very early with ward rounds assessing new emergency surgical intakes to the department, and reviewing the progress of postoperative patients. This was followed on alternating days with time spent in the operating room, or the day and minor surgery clinics.  Furthermore there were afternoon pre-operative meetings for patients admitted for elective procedures, to make final assessments and discuss with the patient and other surgeons about the proposed surgical procedure.

Being a student in the department I was well received and strongly encouraged to have hands on participation.  Despite having no previous experiences with plastic and reconstructive surgery, I was able to apply knowledge from other specialities I had come across.  Most notably dermatology, seeing as the most common presenting cases were dermatological related especially with the high prevalence of lipomas, congenital nevi, skin cancers (BCCs, SCCs and melanomas), and burns.  It was surprising to note how much crossover knowledge from other specialities are involved in managing cases, such as in the repair of cleft palates and ear reconstruction for microtias, drawing knowledge from other specialities like ENT and Maxillofacial surgery.

Furthermore it was surprising to know that most of the breast surgery (in particular reconstructive) was performed by the plastic surgeon, in comparison to being performed by the specialist general surgeon in the U.K. In my time in Hadassah I got to observe and participate in various types of breast repair from implants, flap reconstruction, fat grafts as well as nipple reconstruction and breast augmentations Having a good knowledge of anatomy is key to achieving good aesthetic results, and the six weeks in plastics afforded me time to revisit and reapply knowledge of the subject.

As a surgical speciality, I had many occasions to scrub in and assist with surgeries both in the operating room and day clinics. Which made for greater appreciation of surgical procedures, as well as serving as an avenue to practice suturing, whilst learning new suture techniques.  Towards the end of my elective I had the chance to perform minor procedures under supervision, such as the excision of suspicious moles and lipomas.

As a foreigner in Israel, cultural differences such as having Sundays as a working day, differing dietary customs or the cessation of activity within the city on Shabbat made for rapid readjustments.  More so was getting used to a new language. Although most Israelis speak English, Hebrew is the working language and was the language-spoken in majority of consultations, however this didn’t hinder my learning as the doctors always readily provided translations. Jerusalem is a very dynamic cosmopolitan city, and having Spanish and French for second languages certainly had its benefits within and outside the hospital.

Summertime in Israel also meant having time to do a lot of travelling, from exploring Israel’s stunning and diverse landscape, to adventuring along its numerous hike trails.  From experiencing its colourful and vibrant urban life, to marvelling at its ancient monuments, learning and appreciating the history, cultures and religions that enrich the Israeli heritage.

My time in plastic surgery has provided much insight about the specialty, removing misconceptions about the profession.  I got to see how integral the plastic surgeon’s role is in relation to other medical and surgical disciplines, and also appreciate the science, craft and artistry involved in this discipline.  My hospital experience coupled with this cultural discovery, have surely made this elective both a unique and memorable experience.  I would like to express my gratitude to the Jewish Medical Association (UK) for their support of my elective.

Adeoye Debo-Aina

Elective in the Emergency Room, Sinai Hospital of Baltimore, Baltimore, Maryland, USA

Going into my elective, I had the following learning objectives:

1. To consolidate clinical skills needed for practical procedures such as cannulation and venepuncture, using equipment that may initially be unfamiliar.

2. To gain an understanding of the fundamental similarities and differences between America and Britain with respect to the delivery of acute healthcare.

Introduction

Sinai Hospital of Baltimore is a 600-bed community hospital serving the 600,000-strong population of the city of Baltimore, in the State of Maryland. Sinai is a teaching hospital for medical students from the Schools of Medicine at Johns Hopkins University and the University of Maryland, with all full-time faculty staff holding academic positions at one or other of these two institutions. The vast majority of patients seen are African-American or African-Caribbean, and there is a high burden of cardiovascular morbidity.

The Emergency Room (ER) at Sinai is known as ER-7 because it is divided into seven departments, each catering for various acute presentations. It accommodates a total of 30 beds. Much as in the UK, the ER has a triaging system, an urgent care centre for minor complaints, a paediatric unit and an observation centre. However, as opposed to having one unified majors area as I have been used to in UK hospitals, Sinai ER has a dedicated chest pain centre and an emergent care centre. The purpose of the latter is to provide high-intensity care for critically ill patients. Like St George’s Hospital in London, where I trained, Sinai is also a trauma centre, accepting victims of gun crime amongst other presentations.

In my time at Sinai, I worked 8- to 10-hour shifts (including 4 nights) with multiple emergency physicians, nurses and physician assistants in all areas of the ER except paediatrics. This exposed me to chronic, subacute and acute presentations covering all body systems, including those with which I had perhaps been less familiar, such as dental problems and wound management.

I chose America because I wanted to experience medicine at its most advanced. Additionally, having relatives in Baltimore was a good reason to spend my elective in Maryland. Lastly, NICE recommends that all junior doctors be familiar with its guidance on managing acutely unwell patients in hospital.[1] I chose emergency medicine because I reasoned that since it deals primarily with acute disease management, it would be a valuable experience at my junior stage irrespective of my eventual chosen specialty.

Discussion of learning objectives

Prior to starting my elective rotation at Sinai, though I was knowledgeable in the theory of suturing and gluing wounds – including the requirement to maintain sterility, irrigate and anaesthetise the wound and provide wound care advice to the patient following closure – and though I had practised on synthetic skin, I had not actually sutured a real wound in a live patient. The ER was a perfect setting to increase my proficiency in managing real wounds. I sutured, glued or stapled several patients’ wounds, all in different anatomical areas and resulting from various mechanisms of injury. I thus became comfortable at performing these skills.

Additionally, I had the opportunity to further my skills in venepuncture and cannulation, since nearly all patients seen in the ER required basic blood panels and/or intravenous access. I occasionally also had the opportunity to practise taking an arterial blood gas (ABG) sample. Being cognisant of the fundamental technical principles of venepuncture, cannulation and ABG-taking was vital in allowing me to successfully complete these skills despite using equipment that differed slightly from what I had been used to back in the UK. Finally, I continued to develop my skills in recording and interpreting ECGs (EKGs) as well interpreting radiographs and CT scans in the acute setting.

From my time experiencing healthcare in the UK and now America, I have realised that the fundamental difference between the two health systems is the extent to which they are publicly or privately funded. Whereas the UK subscribes to a public, tax-funded system, the US employs a private, insurance-driven system. Simply speaking (and this is perhaps overly simplistic), whilst the UK has adopted a socialist healthcare system since 1948 with the setting up of the National Health Service (NHS), the US continues to operate by the capitalist principles of competition and ability to pay. Indeed, many Americans with whom I spoke whilst on elective referred to the UK system as delivering “socialised medicine”. In political terms, you might say that the UK NHS is rooted in left-wing ideology (it was the Labour party who established it in 1948), whereas the US system adheres to right-wing thinking.

It is true, however, that in recent years we have seen both countries’ health systems veer politically more towards the centre ground. In the UK, the Conservative-Liberal Democrat coalition, by introducing the Health and Social Care Act (2012), has abolished Primary Care Trusts (PCTs) and replaced them with Clinical Commissioning Groups (CCGs), which allows newly-established consortia of GPs to commission health services from bidding providers, so as to meet the specific health needs of their respective local populations. This has strengthened competition within the NHS, aiming to increase patient choice and drive up standards of care. In the US, under the Affordable Care Act (2010), or “Obamacare” as it has come to be known, the number of Americans now able to access basic health insurance has increased by an estimated 8-9 million. This still leaves approximately 30 million Americans with no medical insurance, potentially denying them of urgently needed treatment. Notwithstanding these recent legislative reforms, which have brought both countries more towards the political centre ground, the aforementioned public-private comparison, broadly speaking, remains valid.

As a way of increasing efficiency and expediting the treatment of patients, Sinai Hospital ER employs a team of scribes working in conjunction with emergency physicians to record histories and examination findings. I have not seen such a system in UK hospitals. Many of these scribes were prospective medical school applicants, using the opportunity to gain experience of healthcare with practising emergency physicians. The partnership worked well and I thought it led to a more efficient use of the doctor’s time, with less emphasis on paperwork.

Finally, the 4-hour A&E target in the UK is non-existent in the US.

Evaluation

The most common presenting complaints I saw at Sinai mirror those I saw during my final-year Emergency Medicine placement in the UK: namely, dizziness; chest pain; shortness of breath; abdominal pain; back pain; headache and lacerations. These symptoms have wide differentials, so it is important to rule out life-threatening diagnoses early, for example, stroke, acute coronary syndrome, deep vein thrombosis, pulmonary embolism, pneumothorax, ruptured aortic aneurysm, sepsis and cauda equina syndrome. I saw well in excess of 100 cases at Sinai and had the opportunity to observe the response to trauma calls. Several patients with gunshot wounds were admitted and managed in the trauma bays in accordance with the American ATLS guidelines.

In discussions with emergency physicians and in observing their practice, the litigious culture that seems to pervade all aspects of American society, including healthcare, became apparent. The unceasing threat of litigation prompts many emergency physicians to order investigations that may not strictly be necessary, for fear of missing a diagnosis and being subject to a resulting lawsuit. This lack of monetary stewardship is often compounded by the very palpable mind-set amongst some patients that because they have medical insurance, they almost have the “right” to any and all investigations and treatments, which will duly be paid for by their insurance company. Although this probably results in a lower diagnostic miss rate than in the UK, in my opinion it detracts from the doctor’s clinical judgment. If any and all investigations are ordered every time without diagnostic indication, this reduces the importance of a prioritised differential diagnosis list. It also means patients are exposed to unnecessarily high radiation doses in CTs, radiographs, angiograms and nuclear scans.

I have inevitably considered which of the two systems I prefer. The American, privately-funded system results in shorter waiting times for referral to secondary care specialists compared with the UK – there seems to be no such difference in the delivery of acute healthcare.[2] However, about 30 million (or one tenth of) Americans still have no medical insurance even with “Obamacare” having been in full force since the beginning of 2014.2 In contrast, the publicly-funded NHS provides a universal, comprehensive service, free at the point of need that does not depend on ability to pay, but also leaves open the option of private healthcare where the individual can afford it. Funding the health service, rather than being an individual problem as it is in the US, is a national problem in the UK. It cost the government £108 billion in 2012-13 [3] and puts a heavy burden on the UK annual public spending budget. The US spends twice the amount on healthcare per capita as the UK, but this offers no health advantage over the UK.2

Having gained experience of American healthcare, I have come to appreciate the value of the NHS in providing a high standard of care to patients, free at the point of need. We have a unique health system in the UK, which it is vital to protect and sustain into the future.

I think it is worth adding that my experience of Baltimore’s thriving Jewish community was very positive. I had the opportunity to attend an AIPAC regional policy meeting, which brought together under one roof hundreds of AIPAC members from several neighbouring American States. This meeting alone exuded a tremendous sense of unity in the common goal of protecting the interests of the State of Israel.

In summary, I can confidently say that my elective rotation at Sinai was a worthwhile experience, both for my personal and professional development. I would like to express my thanks to the Jewish Medical Association (UK) for supporting my elective.

References

1. National Institute for Health and Care Excellence (NICE). Acutely ill patients in hospital, NICE, 2007. Available at: http://www.nice.org.uk/CG50. Accessed 10 June 2014.

2. K. Davis, C. Schoen, and K. Stremikis, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally 2010 Update, The Commonwealth Fund, June 2010. Available at: http://www.commonwealthfund.org/publications/fund-reports/2010/jun/mirror-mirror-update. Accessed 10 June 2014

3. NHS Choices website. About the National Health Service (NHS), 2013. Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx Accessed 10 June 2014

Aryeh Greenberg
St George’s Hospital Medical School, London

 

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