Elective Reports 2014
Accident and Emergency Department, Western Galilee Hospital, Nahariya
I was privileged to spend a five-week elective in emergency medicine at Western Galilee Hospital, Nahariya in the North of Israel. The hospital is located six miles from the border with neighbouring Lebanon, has 650 beds and is the largest in the Galilee region, serving a population of approximately 500,00 people. The hospital has a busy emergency department handling upwards of 120,000 visits annually. The emergency department is experienced in managing mass casualty events and has been designed as a “bunker” capable of withstanding missile and chemical weapon attacks. In 2006 the hospital’s 450 bed underground facility was put to the test when the hospital was targeted and suffered a direct hit. No casualties resulted as all patients and personnel had been evacuated to the underground facility.
Picture taken outside The Emergency Department
On my first day in Israel I arrived at Ben Gurion Airport, from where it was a very easy train ride to Nahariya: the train station is located below the airport and trains run hourly directly to Nahariya. I arrived in Nahariya at night – it felt a lot like starting a new placement on an “out block” back in the UK as my room key had been left with security and I was at leisure to collect it and find my accommodation and start settling in before starting at 8am the next day. The hospital did not charge for the (very comfortable) accommodation and food and drinks had been left in the fridge for me. During the elective I felt most welcome and had the opportunity to spend time with other departments in the hospital as well as the Emergency Department including Radiology, Paediatrics and Oncology.
Each day began at 8am with a consultant hand over of patients from the night before. The working week in Israel runs from Sunday morning to Friday afternoon- most Israelis have only Friday afternoon and Saturday or ‘Shabbat’ away from work. During my first days I learned the roles of the varied professionals in the Emergency Room – known as “Miyun” in Hebrew. In the north of Israel the professionals involved in patient care differ at each stage of the patient journey. The professionals involved also depend on the level of casualties involved for example as a result of mass casualty or war event.
During a chemical assault drill in April 2013: the hospital’s Emergency Medical team work together with the, Nahariya Municipality Health Ministry officials, and the Israeli Defence Forces.
Pre hospital care for those brought into the Emergency Department is provided by private ambulance services – the biggest nationally is Magen David Adom – and by the Israeli Defence Forces (IDF).
A Magen David Adom ambulance outside the Emergency Department.
Magan David Adom paramedics, emergency medical technicians, and volunteers (distinguishable by colour bands on their uniform) operate with a skill mix that includes advanced skills such as invasive airway management. In addition the ambulances carry protective suits and gas masks for the crew and maintain radio connection to the Emergency Department, the Police and the local IDF units. This is because the ambulance crews are often the first at the site of incidents which can include terrorist attacks, and ambulance crew can then notify the authorities immediately.
Once in the Emergency Department patient hand over of non-critically injured patients occurs between paramedics and nursing staff. The nursing staff triage the patients, ensure intravenous access, take blood samples for routine testing and perform an ECG on every patient.
During my elective several injured Syrian rebel fighters were brought in by IDF units. The injured had crossed the border into Israel and requested assistance, and soldiers with medical or paramedical training would arrive with them to handover to the Miyun staff.
During the last week of my elective the IDF brought in a Syrian rebel fighter whilst I was in attendance. He was in his mid twenties with three gunshot wounds to his lower abdomen. The IDF team had stabilized him en route from the Golan Heights border and handed the patient over to the emergency physician, anaesthetist and nurses. The patient remained awake and appeared calm and comfortable despite his wounds. The nurses attached continuous monitoring and took blood tests, and the surgical, orthopaedic and trauma consultant surgeons completed the secondary survey and assessed the patient’s wounds. No exit wounds could be found, and the entry bullet wounds oozed continuously. As in the UK the emergency department is linked directly to an imaging unit equipped with a CT facility and it was not long before he deemed safe to move to the scanner before being taken to immediate surgery. As with other similar patients brought in by the IDF he would be treated, admitted and managed, and the hospital would seek to recoup the cost from the government, but often has to absorb the cost itself.
During my elective together with all other staff in the Department I received teaching on medical management during mass casualty events (MCE) which could range from major traffic accidents, terrorist attacks, to war. On these occasions the team work has to change and in addition to physicians and other medical and paramedical personnel, Nahariya Municipality, Health Ministry officials, and IDF personnel may end up on site within the Emergency Department.
The strategic planning room, located in the centre of the Emergency Room, which is used for mass casualty events.
During an MCE – either actual or simulated – such as was seen in 2006 during the “second Lebanon war” and in the April 2013 chemical assault drill the staff have to work in several ways to meet the challenge. First staff are assigned to remove all beds and stretchers to the car park to meet patients. Inside all curtains dividing individual patient bays are lifted to create a single large treatment hall. Additional staff are mobilised and teams of one doctor / two nurses / one secretary are formed. Each team is assigned to a single patient one at a time. A consultant either from the emergency department or from trauma and orthopaedics is assigned to oversee the treatment hall and move between the patient care teams as a coordinator. This learning experience underscored the fundamental importance of inter-professional teamwork, rehearsal and flexibility in work as an emergency room doctor.
Many – most – days in Miyun do not involve MCEs. They are spent with patients with non-emergency problems: viral illnesses, sinusitis, osteoarthritic joint pain…In Nahariya most began their journey as self-referrals, others as referrals from their family physician. The Israeli system of health cover – the “kupot cholim” or sick funds to which every Israeli must belong – do not cover the cost of non-emergency trips to the Emergency Department unless sanctioned by the family doctor, so that patients with non-emergency problems risk having to pay the cost of the visit themselves. Despite this a number of patients attend with non-emergency problems on a self-referral basis, my consultant referred to this as “a sort of gambling” to avoid the referral fee charged by family physicians! As they have paid to be referred by their family doctor they are often highly motivated to receive treatment. I saw a number of patients whose presenting complaint changed multiple times while in the Department as they sought to “get value for money” by having as many minor problems investigated as possible. Several patients became upset, raising their voice and refusing to leave without first having x-ray’s or other investigations that the medical team felt unnecessary. Thus it was interesting to witness first hand some of the clinical issues that can arise from different configurations of health system provision.
I am grateful for the grant from the Jewish Medical Association UK, which enabled me to have an incredible – and enjoyable – learning experience. I gained further exposure to key skills such as x-ray and CT image interpretation, history taking and examination. also learned about management of mass casualty events as an aspect of emergency care I had not encountered in the UK. This experience taught me graphically what the General Medical Council (2006) intended when it stated that ‘doctors working within teams should behave as positive role models and act to motivate and inspire their colleagues.” I left my elective inspired to embrace the challenges that lie ahead of me in my new, professional career as a junior doctor, with a deeper appreciation of the necessary knowledge, skills and attitudes requires to provide exemplary patient-focused care.
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.
Primary care, Roatan, Honduras
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.
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.
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.
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.
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 NewSomersetHospital, 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.
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.
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. 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.
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. 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  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.
 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.
 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
 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
St George’s Hospital Medical School, London
Hospital in Nkhoma, Malawi
In 2013 I spent six weeks in a hospital in Nkhoma, Malawi. The hospital was in a beautiful rural village at the bottom of a mountain with limited resources, financed by Church of Central
Africa Presbyterian (CCAP). It had a handful of wards: general male, general female, paediatric, labour and two theatres. You could walk through the whole hospital in three minutes. Staffed by one senior physician and one senior surgeon from the US and Holland respectively. The nurses were all
Malawian and could speak English, but almost all the patients only spoke Chichewa. I was there over Rosh Hashana, Yom Kippur and Succot which was an interesting experience as there were unsurprisingly no Jews in Nkhoma.
Malawian culture places ample emphasis on traditional healers. There is no primary health care, general practitioners don’t exist. However, many patients will seek a traditional healer as a first port of call. It has a significant impact on healthcare because it results in many patients presenting with late stage diseases after the traditional healer failed to cure them for a period of time. Moreover, patients often trust traditional healers more than conventional healthcare, which can make management complex.
Investigations were not always readily available. Blood tests were often very limited if they didn’t have the money that week to pay for reagents required to run the tests. Chest x rays were sometimes not possible if there was no running water to develop the films. This meant having to triage the patients who most needed the tests.
Although I learnt some terms in Chichewa, the local language, most of the time I was taking histories and examining patients either with the aid of a nurse translating, or using solely non verbal communication. This made consultations both challenging and at times amusing when trying to portray vomiting or diarrhoea through the art of acting.
Tropical diseases were prevalent, but not as much as I thought originally. I learnt a reasonable amount about diagnosis and treatment of these diseases, e.g. schistosomiasis, but I learnt a lot more about the common diseases that one sees in the UK, e.g. heart failure and pneumonia.
Because patients presented late, clinical signs were more readily detected and the number of patients with organomegaly doesn’t compare to that which you see in the UK.
I was surprised to learn about the impact of religious beliefs. The local community were devout Christians and the Chaplain played a key role as part of the medical team. Many patients were either terminal, dying, or died in hospital. The chaplain was always called to see the patients and family to help explain, reassure or comfort them, making a huge difference to the patient, the family and the general atmosphere on the wards. It was interesting to discuss the similarities and differences with the Chaplain from a Christian and Jewish perspective on science, modern medicine and death. The patients trusted the Chaplain more than the medical team. He played such a crucial role in comforting the patients but also in explaining conditions to patients bridging the gap between their traditional religious beliefs and our modern understanding of science and medicine
Patient with breast cancer.
Three weeks into my elective, I saw a 52 year old female on the acute medical ward. She had presented with a cough and shortness of breath. I took a history from her with Catherine, one of the nurses, translating for me. After the history, I thought a simple pneumonia was the most likely explanation for her symptoms. Other infectious diseases would have to be on my differential as well, e.g. TB. As usual I proceeded to examine the patient, not expecting to find anything remarkable aside from maybe some respiratory signs. When it came to exposing the patient’s chest, I was shocked. On her right breast was a horrible fungating breast cancer.
Although I am uncertain as to whether or not I drastically changed my facial expression to express my shock, I doubt I was able to stop myself from reacting to it as I was totally unprepared. The patient did not seem to mind the cancerous growth spread across engulfing her breast. She simply said it’s been there for while. I completed the rest of the examination and heard some crepitations in her right lower base. She did in fact have a pneumonia as well as the fungating breast cancer.
This case had an impact on me in terms of understanding why patients seek medical care. This patient had a fungating breast cancer for at least a year yet she didn’t seek medical care until she contracted a pneumonia. This puzzled me. A woman in the UK would not wait for a breast cancer to grow through the skin, she would more often feel a lump earlier on and seek medical attention. People in the UK are educated, formerly or indirectly, about breast cancer. In schools, on television, or adverts on the tube, women know about breast cancer and are aware of what signs to look out for. Moreover, there is a national screening programme for it. This is diametrically contrasted with women in Malawi. There is little health education, formal or indirect, and there is no breast screening program. This patient did not know she had breast cancer because she did not know what breast cancer was or that it even existed. It did not bother her, she continued life with it. Ultimately her breast cancer did not disable her. As a mother, culturally her duty was to take care of the children, manage the home and cook the food. She was able to continue to do this until she developed a pneumonia. Although shortness of breath is seemingly a mild symptom relative to the gravity of a long standing invasive breast cancer, it was nonetheless more disabling for this patient. Patients in Malawi do not seek help because they are concerned about certain symptoms, they seek help if those symptoms are disabling because if they cannot work or fulfil their expected duty at home, they do not earn money, they cannot afford food and they starve. They do not go to hospital if there is merely pain, blood or deformities. They go to hospital if anything disables them, if it physically impairs their function.
This reminded me of the importance of public health education and screening programmes. People need to know about diseases so they can seek help before these diseases become untreatable. This patient’s prognosis was negligible. There’s no medical or surgical treatment available to her that will prevent her cancer from killing her in the near future. If either she sought medical advice when she first noticed a lump, or if there was a breast screening program in place, it would be a different story, one with a better ending.
Rosh Hashana, Yom Kippur, Succot
I knew before going that there was no Jewish community in Malawi, not even a Chabad, which was surprising. I therefore realised it was essential to bring a mascot, a religious item of sorts, to serve as a constant reminder my roots and religious Jewish persuasions. So I decided to be practical and brought with me a bulky, awkward to pack, space occupying Shofar. Despite the presence of my shofar, this was the first Rosh Hashana I had which did not feel like Rosh Hashana. I managed to find apples in the local market. Not really an M&S selection, not really golden or delicious. But there were four apples to choose from – apples bizarrely cost more than grapefruits in Malawi. I chose the two least bruised apples, some honey from Mzuzu. Very grainy. Bit too bitty. Semisatisfied with my apples and Mzuzu honey, I showered and donned my white shirt for the New Year, before struggling to explain the significance of eating honey on apples without sounding like a weirdo to the other medical students and volunteer doctors from around the world. Although Rosh Hashana wasn’t what it usually was for me, I invited a Malaysian and Dutch medical student round to my house to show them how it’s really done. Yom Kippur sadly also lacked the atmosphere which I take for granted at home. However, it was interesting to discuss with everyone, including the Chaplain the concept of a day of atonement, introspection and self reflection. And it was an experience breaking the fast for the first time on Malawian gin, something I will not ever voluntarily be doing again. As for Succot, the best I could do was find a large lemon and some willow from the garden.
There was, however, one small aspect about being in Nkhoma which I found connected me to my Judaism unexpectedly. There were oftenpower cuts which limited us to candle light and restricted gas cooking. This meant on Shabbat, towards the evening there was an atmosphere that reminded of me Bnei Akiva camp where everyone sits around a table with no phones, no tvs, no computers and talks as it gets darker and Shabbat comes to an end. The abundance of candles available also made Havdala very easy and accessible.
Thanks to the JMA for all the support and enabling me to have a fantastic elective in Malawi!
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.
Imperial College School of Medicine