Elective Reports 2015

Obstetrics and Gynaecology Department, Shaarei Zedek Medical Centre, Jerusalem

I spent three weeks in Shaare Zedek Medical Centre in Jerusalem, Israel. Shaare Zedek is a large non-profit hospital situated in the centre of Jerusalem. It has catered to the needs of Jerusalem’s uniquely diverse, multi-ethnic population from the day it opened, treating patients of every race, religion and nationality equally. The hospital has become recognized as a highly acclaimed medical provider throughout Israel and the broader medical community, due to its reputation for quality care and high academic standards. I was with the obstetric and gynecology department so I split my time between the labour ward, outpatient clinics and the fertility unit.

What are the prevalent obstetric and gynaecological conditions in a busy teaching hospital in Jerusalem compared to a busy teaching hospital in London?

Overall, the disease pattern in Israel is very similar to the UK as both are first world countries.  Some common conditions I came across included gestational diabetes, pregnancy –induced hypertension, miscarriage, fibroids, menorrhagia and subfertility. There is a large Ashkenazi Jewish population in Jerusalem and it is known that there is a higher prevalence of BRCA mutations in this ethnic group. As such there is a large BRCA centre which caters to this population.  Given the increased risk, there is a big emphasis on genetic screening for women over 30 years of age and of Ashkenazi decent, to try and prevent breast and ovarian cancer developing. They run clinics twice a week where patients have the opportunity to see a geneticist, a gynae-oncologist and a genetic counsellor who advise women on the most appropriate course of action. This area of practice is very different from what I have seen in London where BRCA screening is only recommended to women who have a history of early-onset breast/ovarian cancer. This highlighted to me how different population demographics influence medical practice.

How are medical services organised and delivered in Jerusalem? How does this differ to the UK?

All Israeli citizens are entitled to basic healthcare which is funded by health insurance tax that is different for all depending on one’s income. Everyone has to join one of the four health insurance companies known as “kupot.” These four companies are Clalit, Maccabi, Meuchedet and LKeumit. All the kupot are similar and offer the same benefits so people normally chose the one that’s nearest to where they live.  Joining a kupa entitles the member to hospital inpatient and outpatient care, dentistry for children, maternity services, fertility treatment and occupational, physical and speech therapy. There are optional opportunities to buy an upgraded package of healthcare which includes things such as adult dental care, but essential healthcare is provided to all citizens equally.

What are the most common obstetric complications in comparison to the UK?

The most common obstetric complication I encountered was post-partum haemorrhage. The hospital is situated in an area with a large ultra-orthodox population and it is not uncommon for women to have seven or more children. As a result of this grand multiparity, issues such as abnormal placentation (due to previous Caesarean section), uterine atony and uterine rupture are the most common obstetric complications. In the UK post-partum haemorrhage is also a common complication but this is more due to the increasingly high numbers of Caesarean sections performed as opposed to a grand-multiparous population.

How has this experience further shaped my view on a career in Obstetrics and Gynaecology?

The highlight of my elective was spending time in the fertility unit. As a student I have  had very limited clinical exposure to this area of medicine and so was very pleased for the opportunity to gain some experience in this fascinating area. The unit is renowned for its advanced techniques and the staff are from all over the world, with many doctors originally from Canada and the US. In the laboratory, I saw pre-implantation genetic diagnosis, in-vitro fertilisation, intra-cytoplasmic spermatic injection and in-vitro maturation. I also spent time in the clinics talking to patients. Overall, I am definitely keen on pursuing a career in women’s health, and at the moment a career in reproductive health, is something I am definitely aspiring towards; and I thoroughly enjoyed and gained from the time I spent in Shaare Zedek. All the staff were really friendly and very willing to teach and let me be involved and I hope to stay in touch with some of the people I met.

Gabriella Maurer

 

Obstetrics and Gynaecology Department(s), Hebrew University, Hadassah Ein Kerem and Shaarei Zedek Hospitals

I undertook my elective in Jerusalem, spending. three weeks at Hadassah Ein Kerem, and a month at Shaarei Zedek, both in the Obstetrics and Gynaecology department. I also spent some afternoons with a GP practice.  This was partly due to logistics but it did give me the opportunity to compare the two departments.

At Hadassah – the hospital is large and spacious, and there has been some lovely modern development with a brand new building with gorgeous views. The medical school is attached which means there is a library and lots of events, which meant that if you did not have a social network you could easily form one. They are very geared up for people who do not speak much Hebrew: signs are all in English and Hebrew and the doctors mostly speak both languages.

I spent a week in the delivery suite. Most of the deliveries were natural and unassisted compared to what I had seen in London. Even women who had epidurals were encouraged to have vaginal deliveries whereas in London a lot of these births had turned into Caesarean section or kiwi deliveries. I also saw twins being delivered naturally, which was really exciting – it happens twice a week in the unit. What was very different from the UK is that women have lots more babies, chiefly those from the Arab and Orthodox Jewish populations, so someone who is on their 5th baby is very normal, I saw multiple women who were on their 10th!

In Sharei Zedek I was allowed to be more “hands on” with the deliveries, delivering my own and scrubbing in and closing in Caesarean sections. The birth rate at the centre is the highest in Europe which means that there are deliveries around every 10 minutes. Amongst  the orthodox Jewish population many women appear to abstain from antenatal care and do not have regular scans or blood tests. This often led to surprise at the sex of the baby, but I also heard stories about women who did not know they were having twins till a couple weeks before. I was at a delivery where the baby was born with a significant club foot that would need surgical intervention. As the woman did not have any anomaly scans she was not expecting this. It was a shock to her to be told just after the birth of her child when she would have expected to learn that that was 100% healthy. I remember that the midwife gave her a few minutes with the baby before letting her know what was going to happen just to lessen the shock. If she had had the scans she might have been more prepared emotionally. Culturally I learned that you only say “mazal tov” to the mother once the placenta is out!

In both hospitals I spent a lot of time in the In Vitro Fertilisation (IVF) unit. I have an interest in fertility treatments so it was great to be allowed to see these processes. In England much IVF is done in private clinics and it is very hard to have access as a medical student. I spent some time in the laboratories watching the entire process from egg and sperm retrieval to incubation to insemination. Both laboratories were very similar. However, at Sharei Zedek as a religious institution they had a full time shomer (guard) from a religious fertility institution to watch to make sure there was no mix-up of embryos. They also performed a lot of pre-implantation genetic diagnosis (PGD), with halachic authority at Sharei Zedek, such as for BRCA gene. In Hadassah couples only have a Shomer if they pay extra for the service. The IVF laws in Israel are very different from those in the NHS: IVF cycles are covered under insurance for up to 2 children until the age of 40, and you can have a further level of insurance cover for more cycies. In these clinics I learned about the different protocols used for the IVF cycles. I met an interesting couple that suffered from Hepatitis C. The sperm had to be tested separately as even if Hep C is in the blood it does not mean it is in the sperm. The doctor had to make the couple sign a release form that if they have IVF and their baby is born with Hep C that they would not accuse him for failing to inform them about the risks. This opened my eyes to the insurance culture and the complexities with IVF – patients say they really want children but would that extend to one born with a chronic illness?

In Hadassah I spent much time in the gynaecology theatre where they operations daily. I was allowed to scrub up and saw regular procedures mixed with complex uro-gynaecology. In Hadassah they did perform some terminations whereas in Sharei Zedek, due to the religious nature of the community, these are rarely perflowormed. As the BRCA gene is more common in Jewish women I saw a couple of women having preventive oophorectomies and hysterectomies. Interestingly preventive mastectomy is not as common due to availability of mammograms and surveillance. I saw a lady have a hysterectomy for intermenstrual bleeding. When I spoke to the doctor about how this was quite a severe treatment for this he said the patient was a religious Jewish woman and when he mentioned this option to her she jumped at the chance as she was not allowed to use contraception in her community but did not want any more children. I was surprised how social factors influenced medicine in this way.

In Sharei Zedek I spent much time in the many different clinics.  I learned that doctors need to have a basic knowledge of Jewish ritual purity laws as these come up often in gynaecology, I was amazed when I heard a secular doctor arguing with a patient when she should go to the mikvah! Speaking to one of the orthodox patients, she really appreciated that the doctors had knowledge of this, as it was so important to her community. I also attended a very interesting fetal anomaly clinic. It is a one stop clinic where the patients have a detailed ultrasound by two consultants, amniocentesis if needed and genetic counselling. They are then brought back the following  week after the discussion about the results for the decision making. I think this was great for the patients, whose concerns were taken seriously and dealt with quickly.  Other clinics I saw was a clinic that dealt with thrush and bacterial vaginosis that in the UK would have been easily sorted in a sexual health clinic, not needing hospital referral. When I asked the doctor about sexual health in Israel she mentioned there was one clinic in Tel Aviv otherwise people could go to their GP. She also mentioned there is not much of a problem due to the religious populations. I think there is a blind eye turned towards sexual health issues and this needs to change for the health of young people.

Most of the antenatal care and basic gynaecology, like contraception, is done in the community as patients live far from hospitals. I think if I had known this before I started the elective I would have tried to do some community gynaecology.

Overall the doctors I encountered were very pleasant and happy to answer all my questions. At Sharei Zedek English was not as widely spoken as they were not as accustomed  to having foreign doctors – so I had to practice my Hebrew, which definitely improved. I did not spend as much time on the wards as it was harder for me to communicate with the patients; also the doctors had more time for me in theatre or clinic. I really liked meeting and being with all the different types of doctors: Jewish, Arab and Christian. It was reassuring to see no difference between them and no difference in the way all the patients were treated.

Spending some afternoons at a general practice, it was interesting to see the differences between UK and Israel.  As Israel uses insurance systems there is competition between each insurer. This means that GPs have to be “attractive” to win patients. These meant appointments were easy to book. You could get one on the same day, and mostly appointments were on time. You could also contact your doctor via an electronic system to make requests. There was not much difference from GPs in England, except that there are some things for which you could self-refer instead of seeing the GP, so the GP did not see any Obstetrics and Gynaecology, and family planning  – which is a large part of the work in England. Also, the insurance scheme means that patients get referrals and investigations quickly, as that was expected, rather than the GP trying to manage the patient initially.   What made it difficult was that the practice I saw was that it was in a very religious area, so that even when the female patients were being examined by a female doctor they did not like to expose themselves – even to roll up their sleeves to take a blood pressure.

I think the GP work-life balance in Israel is more attractive than being a hospital doctor. In the hospitals the pay is significantly lower than in the UK and doctors are expected to work many 24 hour shifts. Many hospital consultants do community private work as well as in the hospital for financial reasons.

Being in Israel

Being in Israel from Pesach to Shavuot is a great time to be there.  You hit so many festivals that you do not get a proper weekly routine!  You also experience Israel going through an emotional rollercoaster from Yom Hashoah and Yom Hazikaron to Yom Haaztmaut.

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Everyone in Jerusalem seemed to celebrate everything, even Lag Baomer, where you could see bonfires and barbecues wherever they were allowed to be placed.  I was also there on “Yom Hastudentim” which is “students day” which means (1) you get a day off; and (2) there is a massive festival concert in one of the large parks that goes on all night.

The country is well connected with buses so that it is really easy to take great day trips and travel round the country.  I did day trips to Tel Aviv, Jaffa and Zichron Moshe. My favourite trip I did was in Chol Hamoed Pesach when, with a few friends, we rented a car and drove to the North of the country, hiked around and camped overnight surrounded by fields and hills.

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The number of kosher restaurants is also a great plus!

Charlotte (Dodi) Levene
Imperial College School of Medicine

 

Emergency and Obstetrics and Gynaecology Department, Shaarei Zedek Hospital, Jerusalem

In April 2015 I left the UK to spend seven weeks in Shaarei Zedek Hospital – three weeks in the Emergency Department and four weeks in the Obstetrics and Gynaecology Department.

The Emergency Department had undergone a major reconstruction in 2004, increasing its capacity by 330%, and as such is the busiest Emergency Department in Israel. The Department is housed on the 2nd floor of the hospital, and it was explained to me how the lower 3 floors of the hospital had been built underground – including the Radiology Department and operating theatres – in order that the hospital would be able to continue functioning during wartime.

I arrived on my first day and was welcomed by the head of the department. He showed me around and explained the setup of the department. The emergency room is split into different sections including surgery, acute medicine and orthopaedics. Each section has its own set of doctors who exclusively see those patients. The Department is close to the Radiology Department and the operating theatres, allowing fast and effective diagnosis and management of patients. There is another smaller area in the Department called ‘mahalchim’. Patients are sent here by the triage nurse who deems their condition to be more minor, and the setup is similar to a GP clinic. It was here that I was able to sit in my own room and see patients alone, before presenting my findings to the doctor and agreeing on a management plan. There was a huge variety of patients here, including a patient taking warfarin who presented with minor bleeding and a patient with Crohn’s disease who presented with diarrhoea.

During my time in the Emergency Department I rotated around the different areas which enabled me to see a wide variety of patients. Whilst many of the doctors spoke English, very few of the patients did, which enabled me to practise both my conversational and medical Hebrew. Although it was challenging to work in such a fast-paced department in a language in which I am not fluent, I very much enjoyed the challenge and my time there.

After my time in the Emergency Department I spent 4 weeks in the Obstetrics and Gynaecology Department. This was a huge department with a large labour ward, daily clinics such as fertility clinics, In Vitro Fertilisation (IVF) clinics, antenatal clinics, general gynaecology clinics and more. Each morning there was a Multidisciplinary Team (MDT) meeting where interesting or complex cases were discussed and management decisions made. On the first morning I was welcomed by the head of the department and introduced to the team after the MDT.

Most of my time was spent rotating through the different gynaecology clinics. One patient who stands out in my mind is a lady of Ethiopian origin who attended the fertility clinic. She had had one pregnancy four years previously in Ethiopia which had ended in a stillbirth and a surgery of which type she was not clear. However, since then she had not had a period, bringing into question whether the operation she had had was a hysterectomy. The doctor had to break the news of this possibility to her, and arranged for her to have an ultrasound to determine if this was the case. Observing this case emphasised to me the difference in health beliefs between cultures and the importance of both an honest and an empathetic approach when it comes to breaking bad news.

During my time in the Department I was given the opportunity to spend some time in the IVF lab where egg retrieval was carried out. Follicular fluid containing eggs was aspirated and the fluid was then passed through to the IVF laboratory where a technician identified the eggs and prepared them for incubation. It was very interesting to watch the high level of expertise displayed by the laboratory technicians.

I thoroughly enjoyed my time in Shaarei Zedek and would like to thank the Jewish Medical Association UK for supporting me in my elective in Israel.

Miriam Sharman
Imperial College London

 

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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