Elective Reports 2016
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.
Anaesthetics Department, Rambam Hospital, Haifa
This summer I was fortunate enough to spend a month with the Anaesthetics department at the Rambam in Haifa. It was a really great experience and I felt welcomed into the team immediately. The doctors were warm and friendly and despite my lack of Hebrew I was kept informed of what was going on and even managed to get some teaching.
The department is very relaxed and your experience depends on your own level of motivation. You get out what you put in! Luckily, there was an English Oleh who is a resident in the department so I spent much of my time with him. I really appreciated that he was there as I didn’t feel like it was a burden for him to translate what was going on or to teach me as is sometimes the case when asking someone to speak their second (or third!) language.
In Israel, Anaesthetics and Intensive Care aren’t as closely linked as in the UK, but nevertheless it is possible to split your time between both. In either case, the day starts at 8am and finishes at 3pm leaving enough time for a couple of hours on the beach, which is right next to the hospital. In ICU there is a teaching ward round each morning at 8.
I was fortunate enough to spend a day shadowing the on call doctor, which provided numerous opportunities to assist at crash calls and tricky intubations. I would recommend trying to spend a day like this as it allowed me to see parts of the hospital I otherwise wouldn’t have seen.
I found everyone to be really helpful and they allowed me to get involved from the start, I even managed to intubate a few patients! The medicine in Israel was the same standard as in the UK, but the way of doing things is very much Israeli. There are no induction rooms and so the patient, fully conscious, is wheeled into the OR whilst everyone else is still setting up and talking at each other! There is much less hierarchy so the doctors quickly felt more like friends and colleagues than teachers. Be prepared for things to be done very differently!
I think a career in Anaesthetics in Israel would be a great choice for British medical graduates. The training is great, with 6 months supernumerary, with one-on-one teaching and from what I was told getting a residency is much less competitive than in the UK.
I would be happy to chat if anyone has any questions – feel free to get in touch!
Thanks again to the JMA for the generous support.
Paediatrics Department, Royal Children’s Hospital, Melbourne, Australia
I spent four weeks on the neonatal intensive care unit (NICU) and the last two weeks with Ambulance Victoria’s Paediatric, Infant and Perinatal Emergency Retrieval (PIPER) team at the Royal Children’s Hospital in Melbourne, Australia.
On the very busy neonatal ICU I was quite self-directed with clinical opportunities as and when they presented themselves. I learnt how to cannulate neonates and take heel prick bloods and capillary blood gases, which the nurses taught me how to do on the wards and have since been incredibly useful skills for my foundation jobs.
Typically my day was around 8am-4pm. I attended handover and ward rounds in the morning and then helped the junior doctors with their jobs. I was able to sit in on family meetings and interesting psychosocial meetings with social workers, music therapists, physiotherapists and OTs. I also joined the teaching day for the junior doctors, participating in SIM sessions and physiology teaching. There was also a fascinating NICU specialist ethicist who I observed for a little bit. On NICU there were also bedside surgeries (e.g. exploratory laparotomies) as RCH is the main centre for Paediatric Surgery in Melbourne which I was able to observe. The hospital also hosts regular lunchtime lectures and Grand Rounds for anyone to attend which were interesting and useful for those interested in Paediatrics.
Early on I was offered opportunities to get involved with academic research. I completed an audit as part of a wider research project at the RCH looking at the long-term neurodevelopmental outcomes at 2, 5 and 8 years of neonates born with features of VACTERL association which I really enjoyed and found very interesting; in particular I looked at the incidence of multiple VACTERL association in neonates admitted to NICU with tracheo-oesophageal fistula or oesophageal atresia over a ten year period. I have since presented this audit as a poster at a conference at the John Radcliffe Hospital, Oxford which was very well recieved.
For my last two weeks I joined the Neonate Emergency Transport service, which retrieves unwell neonates from all over Victoria (and sometimes beyond) and brings them to tertiary centres for further investigation and management and/or surgery. This was an incredible experience as I got to join the team on trips to other hospitals in the city and outskirts as well as on aeroplane trips to hospitals further away from Melbourne in Victoria to collect patients. From a learning perspective it was a bit different from the skills-based experience on NICU as it was more acute and more case-based around the babies we were retrieving. My NETS experience was not part of my original elective plan, however I asked if I could spend some time with the team after observing their handover of their patients to the NICU and I enjoyed my first day with them so much I spent another two weeks there!
I applied for this elective placement at the Royal Children’s Hospital (RCH) through the University of Melbourne external students’ elective programme and I would highly recommend it to anyone interested in pursuing a career in Paediatrics.
Ophthalmology department, Prince of Wales Hospital, Sydney
From April to May 2016 I spent six weeks at the Prince of Wales hospital in Randwick, Sydney, in their adult and paediatric ophthalmology department. The Prince of Wales is a large hospital in central Sydney with both a public and a private hospital on the same site, and it serves diverse population.
Ophthalmology theatres for the hospital were situated in the nearby Sydney Eye Hospital.
During my elective I spent time in theatre, in outpatient clinics and occasionally on the wards. In adult and paediatric theatre I had the opportunity to observe a variety of surgeries that I had not previously been exposed to.
I also sat in many adult and paediatric outpatient clinics where I learnt valuable practical skills. I have become much better at using a slit lamp with lenses, and the indirect ophthalmoscope to visualize the retina clearly and detect retinal pathology. I was able to observe many procedures during clinic time, such as anti-VEGF injections, laser such as the Yag and laser for diabetic retinopathy. I was also exposed to paediatric ophthalmology for the first time – where I saw a completely different range of pathology and I was able to appreciate the different aims of treatment when treating children vs adults (for example patching to improve eyesight).
I felt that doing my elective in an area that I saw much less of in medical school gave me an opportunity to learn a lot of new skills and to broaden my knowledge in a way I would not have other wise done.
I found the Sydney Jewish community incredibly warm and welcoming whilst I was there and this really enhanced my experience.
I am very grateful to the association for their generous contribution towards my elective.
Trauma and Intensive Care Units, Royal Melbourne Hospital, Melbourne
I undertook my elective at the Royal Melbourne Hospital (RMH), Australia. During this time, I rotated through endocrinology and ICU.
My motivation for choosing Australia was two-fold: it constituted an opportunity to experience a different healthcare system whilst working in an environment not too dissimilar to the NHS. I hoped to transfer knowledge and skills learnt during my elective to practice back in the UK. A further attraction was the absence of a language barrier, which would allow me to learn quickly and effectively. Given the current state of the NHS and the proposed introduction of the new junior doctor contract, my awareness was heightened to claims of greater job satisfaction in Australia. In other words, I was going to see for myself whether the grass really was greener on the other side!
THE ROYAL MELBOURNE HOSPITAL
I chose the Royal Melbourne Hospital (RMH) because of it’s central location and reputation as a Level 1 trauma centre1. I have always been interested in acute and critical care, something which was enhanced by my 4th year ACC placement. For this, I was placed in a DGH (District General Hospital) and whilst a useful teaching opportunity, I felt it lacked the excitement and drama of a regional trauma centre – an experience many of my colleagues enthused about. By contrast, RMH is a tertiary level referral centre with highly specialised critical care facilities1,2. It is one of the largest hospitals in Melbourne with a capacity of 1400 beds1 and is located in the centre of the central business district. Melbourne has a varied demographic, and as such the Royal Melbourne is responsible for treating a diverse cross-section of patients3. This includes the local aboriginal community as well as a large migrant patient population, for whom language and differences in culture pose a significant barrier to healthcare access4.
Within Australia, much like the UK, there is a defined public and private sector. RMH is based within the public sector and whilst services were rationed based on clinical need, the strain appeared far less than in the NHS. Healthcare is delivered primarily by Medicare, a state funded healthcare system which is free at the point of delivery5. Although a government-led service, there is variation in policy between individual states5. Despite this service, many Australians, choose to pay for private healthcare insurance, which in turn alleviates pressure of demand on the public sector.
AIMS & OBJECTIVES:
My primary aims were:
- To develop skills and knowledge transferable to my future practice as a junior doctor, whilst at the same time gaining experience of a healthcare system with different cultural groups to that of the UK.
- To gain first-hand experience of the Australian healthcare system and working environment, to see if this would be a country in which I would like to work in the future.
- To gain greater clinical experience in acute and critical care. Develop confidence in managing the critically ill patient, building upon the skills and knowledge gained in the RRAPID element of the Leeds MBCHB course.
- After having spent a year gaining specialist knowledge, I wanted to refresh my general medical knowledge ahead of 5th year. In particular, to extend my skills in history taking and clinical examination.
During my time at RMH, I participated in ward rounds, attended clinics and was involved in educational activities such as teaching and simulation. I had the opportunity to lead handovers and perform many of the roles expected of an FY1 doctor; as such it was extremely useful preparation for 5th year as well as my future clinical practice.
On endocrinology, I spent most mornings with the “residents”, equivalent to UK foundation doctors. Here, I was able to consolidate clinical history and examination skills as well as basic skills such as venepuncture and cannulation. The remaining time was spent in clinics, where I was encouraged to conduct my own clinic lists and with supervision, formulate management plans. On ICU, I had the opportunity to participate in procedures such as central lines and intubation. This was in addition to ward rounds, where I was encouraged to present complex patient histories.
On reflection, I experienced a number of notable cases during my time at RMH. However, there is one case in particular, which I feel warrants further discussion: a patient with whom I had contact with during both my endocrinology and ICU rotation. The patient concerned was a 39 year-old aboriginal man (Mr. X), who presented in type 2 respiratory failure secondary to severe bronchospasm. He presented with worsening dyspnoea following a 2-week history of coryzal type symptoms including dry cough and intermittent fevers, for which he received no medical care. Initially, treated with nebulised salbutamol and oral prednisolone, Mr. X’s condition deteriorated and ultimately required intubation and transfer to ICU.
A type 1 diabetic (T1DM), the physiological stress induced by the bronchospasm triggered a diabeteic ketoacidosis (DKA) (blood gas pH 7.1, blood glucose of 38mmol/l and blood ketones 5mmol/l). Blood gas results revealed a mixed respiratory and metabolic acidosis; requiring both endocrine and intensivist input. Management of his DKA involved rehydration with crystalloid fluids and an insulin/potassium infusion.
Medical records revealed extensive alcohol and drug history as well as a long-standing history of T1DM with poor compliance. This was further suggested by a right transmetatarsal amputation for complications of peripheral neuropathy. There was also note of previous criminal convictions.
Examination findings were as follows: Mr X was intubated, sedated and paralysed.
A: The patient was intubated with an endotracheal tube measuring 7.5mm and 23cm at the lips.
B: Oxygen Saturations were 97% on FiO2 100%, ventilatory support (SIMV – synchronised intermittent mechanical ventilation). Air entry was equal and bilateral with symmetrical chest wall movement. A prolonged expiratory phase with wheeze heard on auscultation.
C:BP 84/50, MAP 58, HR 82, peripherally cool with a delayed capillary refill time of 4 seconds. No audible murmur. Mr X required boluses of matrimonial to maintain SBP > 80 and a MAP > 55
D: Afebrile. GCS 3 (E1, Vt, M1) – patient was intubated, sedated and paralysed. BSL 35mmol/l
E: Abdomen soft and non-tender.
(1) CVC (Central Venous Catheter) inserted and position in subclavian confirmed by CXR and blood gas aspirates.
(2) Right radial arterial line in situ
(3) Bladder catheter in situ
After three days in ICU, Mr X was successfully extubated and we were able to take a more detailed history. It became evident that Mr X was socially isolated having previously resisted all medical and social intervention. The formal organisation of western society i.e. our norms, rules and customs are antithetical to the Aboriginal way of life4,5. This manifested itself as a barrier for Mr X resulting in his previous failure to access appropriate care. Although, staff members maintained professional throughout treating Mr X, I observed that they lacked the empathy so clearly demonstrated to other patients. There was an unsaid disapproval that his medical deterioration was self-inflicted, which in turn contributed to a paternalistic approach towards him. I saw how this approach created a viscous cycle resulting in Mr X withdrawing further from medical advice, such that three weeks later he was readmitted with a further episode of DKA. I was advised that this pattern was not untypical for patients from an aboriginal background4,5. I was shocked by the degree of cultural insensitivity and the importance of appreciating cultural differences so as to remain non-judgmental.
I found many aspects of Australian public healthcare to be similar to the NHS, namely the standard and quality of medical care. However, there were definite differences between the two, mostly due to the varying cultural groups that exist within Australia. For example, there is a huge disparity between aboriginal and non-aboriginal communities, with members of the indigenous population inherently disadvantaged. I observed a definite paternalistic attitude towards such patients and in my opinion a shameful disregard for their autonomy. This disparity is highlighted in the above case where Mr X’s physical and social neglect was such that he was at a point of absolute desperation. The paternalistic and controlling approach employed by previous medical staff had alienated Mr X such that he had come to avoid seeking medical attention. To me, the economic and cultural divisions seemed far more pronounced in Australia than in the NHS.
Above all, I have taken away the importance of holistic and patient-centred care, and seen how the attitude of “the doctor knows best” can be to the detriment of the patient. There did not appear to be the same emphasis on communication or patient choice, as I have experienced in the UK. It was on these occasions, I felt proud to be training in a system where doctors are encouraged to seek out their patient’s concerns, allowing for shared decision-making.
Overall, I had an absolutely fantastic elective experience, both medically and culturally and on reflection, I do feel that I have satisfied my aims and objectives. I have gained knowledge and enhanced skills, which I will ultimately be able to transfer to my working practice. Through attending simulation training on airway management and being actively involved in a patient’s resuscitation, I do feel more confident in managing a critically ill patient; something, which will be invaluable to my future working practice. During my time at RMH, I also gained experience in managing emergency conditions such as DKA, something with which I am expected to be familiar as a foundation doctor.
And so, in answer to whether the grass is greener on the other side, I would say that there are certain attractions, which would undoubtedly appeal to any doctor looking for a change in working environment, not least the weather and less strained resources! However, as I prepare myself for life as a junior doctor working in the NHS, I can be satisfied with the quality of care that is provided and which hopefully, I will help to deliver.
(1) The Royal Melbourne Hospital. About RMH. 2016. Available at: https://www.thermh.org.au/about/about-rmh (Accessed 13/09/16)
(2) The Royal Melbourne Hospital. Intensive Care Unit. 2016. Available at: https://www.thermh.org.au/health-professionals/clinical-services/intensive-care-unit (Accessed 13/09/16)
(3) Australian Government: Australian Bureau of Statistics. 2016. Available fromhttp://www.abs.gov.au/ausstats/abs@.nsf/mf/3101.0 (Accessed 13/09/16)
(4) Australian Government: Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people an overview. 2011. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737418955 (Accessed 13/09/16)
(5) Australian Government: Institute of Health and Welfare. 2014. Available at: http://www.aihw.gov.au/australias-health/2014/health-system/ (Accessed 13/09/16)
Adult Learning Disabilities, Sheba Medical Centre, Tel-Aviv
- I aim to develop an understanding of healthcare in Israel and appreciate differences in their health and welfare system.
- I will gain an overview of the care of people with intellectual disabilities, including psychological aspects, physical aspects and social care.
- My experience of psychiatry will be enhanced, with particular emphasis on the impact of culture on mental health diagnoses.
- I hope to work on an audit or research project during my time in Tel Aviv.
- I will learn some basic Hebrew and discover the culture of Israel.
Throughout my time at medical school and previously, I have had an interest in the care of people with Intellectual and Developmental Disabilities. I have been able to explore this through an SSC with the paediatric neurodisability service at Ryegate Children’s Centre, Sheffield, through volunteering with Sense and Teddy Bear Hospital and through my part-time employment at Step Up Support currently. However, I wanted to use my elective period to fill a gap in my experience in the medical care of adults with Intellectual Disabilities (ID). Through contacts at the medical school and beyond, I was able to arrange an elective with the Intellectual Disability Psychiatry team at the Chaim Sheba Medical Center, Tel Aviv in Israel.
I aim to develop an understanding of healthcare in Israel and appreciate differences in their health and welfare system.
Israel’s National Health Insurance Law requires all citizens to register with one of the four Health Maintenance Organisations (HMOs), the largest of which is Clalit (כללית). I was able to see during my placement that Clalit serves a significant proportion of the underprivileged, including people with disabilities (Balicer, et al., 2011). As far as I witnessed, health funds seemed to fulfil the principles of “justice, equality and mutual assistance” (State of Israel: Ministry of Health, n.d.) upon which they were based. While they have their differences, both Israel and the UK have universal health coverage.
I will gain an overview of the care of people with intellectual disabilities, including psychological aspects, physical aspects and social care.
While describing in depth the health policy and welfare systems in place for people with ID in Israel may be instructive for the reader, I have the advantage of being able to refer to authors I met in the country for this information (Halperin, et al., 2005). I have gained a good understanding of health service commissioning in Israel for people with ID through discussions with two of the authors of the above, as well as with professionals I met on placement and during the interview stage of my research project.
I have been able to see many aspects of care for people with ID. I have met doctors, nurses, psychologists, behavioural therapists, speech and language therapists, teachers and researchers. However, time constraints did not allow me to visit other specialist services, such as a dental service specifically for people with ID. More planning of activities before my arrival to Israel would have allowed me to organise this more effectively, although my time was more than filled adequately.
My experience of psychiatry will be enhanced, with particular emphasis on the impact of culture on mental health diagnoses.
The Bnei Brak clinic is specifically for the Jewish Orthodox population. However, in all of the clinics I was in I was able to see how culture influenced the relationship between doctor and patient, the acceptance of treatment and the role of the family in the process.
In terms of differences in psychiatric care in Israel, there is one issue which stood out for me. I saw that challenging behaviour was not an uncommon indication for prescribing antipsychotic medication. This is not an indication I have seen here in the UK, and I need to do further research to find if it is common practice. As a result of my hands-on experience, I am inclined to promote non-medical management for challenging behaviours, and I am not convinced of the ethics of this method of ‘chemical restraint’ when experience has shown me how behaviours are usually a response to the environment.
I hope to work on an audit or research project during my time in Tel Aviv.
The title of my research project was: ‘Stakeholder perceptions of guardianship and supported decision making for people with intellectual disabilities in Israel.’
Recent research has promoted the use of supported decision making, in contrast to historical methods of substitute decision making when working with people with intellectual disabilities. In Israel, people with disabilities are protected by the Legal Capacity and Guardianship Law of 1962, which was amended in 2016. This research considers how these recent changes are perceived by professionals in Israel.
Professionals with experience in policy making, law, social work and with direct experience working with people with intellectual disabilities (ID) were interviewed using semi-structured interviews and one focus group. Interviews were recorded and subsequently coded and analysed qualitatively.
Two major themes were identified. These were: The Law and its Phrasing, and Changing Culture. Findings highlight the process of change within guardianship law and practice and the challenges in implementation encountered so far and anticipated in the future.
Results from this study support those that have been found in previous studies from other parts of the world. More evidence is required to identify the most effective way to manage capacity and guardianship issues for people with ID.
My project is now complete, and we are in the process of submitting the final report for publication.
I will learn some basic Hebrew and discover the culture of Israel.
I had hoped to find a class (Ulpan) to be learn some Hebrew while in Israel, but this was not possible for various reasons. This is another part of the trip which would have benefitted from more preparation. However, after some time in the country I was able to understand much more of the language.
During consultations I was surprised how much I could understand from expression and the little I had picked up of the language. I was also able to assess the majority of a mental state examination through only observation, and I certainly feel more competent with this.
My choice of Israel was a surprise to many of the people I met there, as I am not particularly religious. I was raised Catholic, and Israel is predominantly a Jewish state. However, the country held an interest for me as a place steeped in history and political controversy. Security threats were a minor concern: I reasoned that in light of recent attacks throughout the rest of the world, the danger for me in Israel was not much more than my colleagues in other parts of the world if I followed government advice. Whilst in Tel Aviv, I was surprised and comforted by the level of security displayed. My bag was searched at hospitals, bus stations, supermarkets and train stations and on some occasions I was asked to show my passport. On further reflection, I can see that while this increased security was a new phenomenon for me, the experience may have been less unpleasant as suspicion towards me as a white British female is relatively low.
On my first day at Sheba Medical Center, I met with Joav Merrick who explained much of the information contained in the referenced article on health policy (Halperin, et al., 2005), as well as directing me to spend time with many of his colleagues. One of these was Mohammed Morad, another of the authors, who welcomed me with true Middle Eastern generosity into his town of Beer Sheva a few weeks later.
In one morning at his clinic, I encountered a traditional Jewish Israeli man, an orthodox Jewish lady, a Russian lady and an Ethiopian man. I understood that the clinic and its branches also serve the Bedouin community in the area. It is an incredible example of Jewish and Muslim living harmoniously: the doctor I met with was Muslim, his partner at the centre was Jewish. They talked to me for a long time about how they formed a group years ago to highlight the importance of doctors acting ethically and not be influenced by race, religion, politics or any other factor. In my position as a privileged and open-minded person, I have never considered allowing those things to alter the care I provide. However, it was clear that driven by propaganda, fear sets communities in this continent apart. As educated professionals, I hope, as they do, that we can set an example around the world of how to transcend these differences.
My interest in the care of adults and children with Intellectual and Developmental Disabilities has not changed as a result of this trip. I am still passionate about this population. However, what I have found is that my career interests lie primarily in the diagnosis of children with developmental disability, and the behaviours they present with. As I am approaching foundation programme applications, I will be considering training pathways in more detail.
I am also finalising my research report and I am in constant contact with my supervisors to continue progress towards publication. I hope to do more research in this area.
I have been able to network abroad and attend conferences. I plan to attend the next conference at Beit Issie Shapeiro and I am looking at further conferences closer to home.
Paediatric Surgery, Sourasky Medical Centre, Tel Aviv
For my elective I spent four weeks in the paediatric general surgery department of the Sourasky medical centre in Tel Aviv. The hospital is a large tertiary referral centre as well as a teaching hospital of Tel Aviv university. Paediatric surgery is split up into sub- specialty teams: Paediatric orthopaedics, plastics, urology, neurosurgery and general surgery, which are independent departments.
Every morning I joined the departmental handover meeting, followed by the ward round. Elective theatres took place on 3 days of the week, and emergency theatre as needed. I usually went to theatre when my department had a list. Towards the end of my attachment I usually was scrubbed to assist in small cases and was allowed to close the skin if it needed suturing. I usually observed the larger cases and any laparoscopic surgery. When there was no theatre, I joined clinic or went to the A&E department to see patients that had been referred to our team. When theatre or clinic was finished I was given the choice to stay on the ward or go explore Tel Aviv. Wednesday mornings were reserved for journal club. I contributed by presenting a paper describing a new approach to treating pilonidal sinuses.
My department consisted of three doctors in training, three senior specialist doctors and the chief of department. All doctors were very welcoming and translated, explained what was happening and answered all my questions, even if their English was not entirely fluent.
The working language of the department is Hebrew, even though most doctors were able to speak Russian or Arabic as well. I tried to learn some basic Hebrew prior to my attachment and picked up surprisingly much throughout my time in the department. Of course this was not sufficient to be able to understand conversations within the team, with patients and also patient notes. This certainly limited me in my understanding of handover, in clinic or on ward rounds. However I was surprised that I usually had a rough idea of what was going on. Many medical words are the same or similar to English, and I could understand the non-verbal communication (e.g. pointing of the patient) or was able to pick out the Hebrew words I did know. Fortunately the doctors filled the gap in my understanding by summarizing the discussion or case afterwards. I knew that I would be facing a language barrier previous to starting my elective, so I expected to struggle to understand. This meant that I was neither surprised nor frustrated by the limitation. Quite on the contrary, it was a very rewarding experience as I have never previously been so immersed in a foreign culture and language and I was impressed by the speed I managed to pick up new words.
There are a lot of paediatric surgery departments in Israel and there is no system of centralizing care to specialist centres as there is in the UK: rare and complicated conditions are not collected in one hospital but are treated in the local hospital. This meant that during my time in the department I saw many short and common surgical cases such as hernias, undescended testis, line insertions and biopsies. I also learned about Hirsprung’s disease and saw all steps of management: I observed the biopsy to diagnose it, rectal irrigation, surgery and the patient follow up post-OP. Amongst the larger surgical cases I observed bowel resections and there was a patient on the ward with a complicated recovery after a tracheo-oesophageal fistula.
Tel Aviv is one of the most vibrant, cool, young and diverse cities I’ve come across. There is a very good restaurant and food scene, interesting museums and cultural
opportunities and of course the beach! It is certainly a city I could easily spend more time in. There are also some other electives students in the hospital, and the doctors have a very international background too, which led to new friendships and stories from medical school and medicine in different countries.
I thoroughly enjoyed my time in the paediatric surgery department and could not have wished for a better elective! The Sourasky medical centre would be an excellent option for doing a fellowship later in my career. I would like to thank the Jewish Medical Association for their support.
To organize my placement I applied via the online electives portal of Tel Aviv University. The exchange office staff were very friendly and quick to respond. Thus I managed to arrange a placement despite applying much later than the recommended timeframe. University fees for electives are 50 Euros per week. The hospital provided me with scrubs and white coats and there is a staff canteen with amazing and very affordable lunch. I did not live in hospital accommodation but stayed with friends who lived close to the hospital. Hospital accommodation can be quite far away however there are a lot of flat-share opportunities in Tel Aviv so it should be easy to find a room (my recommendation). My friends and family were concerned about my safety, but it is likely to be more safe walking the street by myself at night in Tel Aviv than in London.
Medicine and Cardiology Departments, St Boniface Hospital, University of Manitoba, Winnipeg/ Montreal General Hospital, Montreal
Choosing my elective specialty was the easy part; I have always had a particular interest in cardiology and want to pursue it as a career. However, location was more tricky; I wanted a large English speaking country, and, having done a previous placement in the US (which I enjoyed tremendously), I settled on Canada. More specifically, Montreal.
My elective experience can be divided into three broad sections: the cardiology, the healthcare system, and the country.
I was lucky enough to be allocated time in each of the three main hospitals in Montreal (Montreal General, Royal Victoria, and Jewish General), and spent time in many different areas of cardiology: coronary care unit, ward and emergency consultations, echocardiology, electrophysiology, and clinics. Without the pressures of upcoming exams, I applied myself as much as possible, and was rewarded with ever-increasing responsibilities as the team saw my capabilities. The basics of cardiology, as with much of modern medicine, are a universal language for doctors. Hence, I tried my best to notice the subtle differences, such as different scoring systems (eg TIMI as opposed to GRACE) and drug regimes, in an effort to understand their benefits and drawbacks. Communicating with patients for whom English was a second language was also challenging at times, especially when trying to elicit symptoms with more nuanced vocabulary; towards the end I felt as though my more detailed questioning was certainly improving.
Montreal’s hospitals all fall under Quebec’s nationalised healthcare system, in which private healthcare is illegal. On reflection, this has many benefits, not least that all clinicians dedicate all their clinical time to all patients, rich or poor. However, drawbacks such as extensive waiting times for basic scans and operations are certainly an issue. Moreover, the fact that “staff” doctors (equivalent to consultants) are almost exclusively paid per patient within the hospitals, has distinct positives, such as an emphasis on working efficiently to maximise income, but brings the possibility of abusing the system and not providing the best possible care for each patient, in the interests of time.
Lastly, spending my time in Quebec, Canada’s largest province, has been an unforgettable experience. Montreal is a unique city in North America, with both a European and North American flavour, and has an overall atmosphere somewhere in between Paris and New York. Although there are tensions between the French-speaking Quebecois population and English speakers, the people I interacted with from both sides of the debate were immensely welcoming. Touring around the historical sectors of Montreal, Quebec City, and Ottawa, visiting museums and national landmarks, and viewing some areas of outstanding natural beauty have helped me to understand the richness of Canada’s history, and Quebec’s place within it. Not to mention, the food was delicious, and Quebec’s favourite dish, the poutine (chips, cheese and (parev) gravy) made me certain of one thing – I’ll be back for more!
I have thoroughly enjoyed my elective experience, and am thankful to the Jewish Medical Association for their financial assistance in this endeavor.
Ichilov-Sourasky Medical Centre/ Tel-Aviv University Medical School, Tel-Aviv
I undertook my 5-week medical elective at the Tel-Aviv Sourasky Medical Center where I was placed in an Internal Medicine department at Ichilov General Hospital. I decided to go to Israel because I wanted to spend my elective in a high-income health care setting with working conditions similar to those that I am likely to encounter as a junior doctor.
The Tel-Aviv Sourasky Medical Center is the second largest and one of the most full-service healthcare treatment and research institutions in Israel. It serves as a national referral center for many primary and specialty care services, and features four main hospitals. Over 1.5 million patients are seen per year at the Medical Center, which employs 6400 staff. The facility also serves as the affiliate lecture and research center for both the Sackler Faculty of Medicine and the Sheinborn Nursing School of the University of Tel Aviv.
Before leaving on elective I mapped out the aims I wanted to achieve along the General Medical Council’s Outcomes for Graduates with the view that I wanted to use it as an opportunity to prepare for the Foundation Programme. Broadly speaking, I wanted to apply the knowledge I had gained from my Pathology curriculum to the process of diagnosis and management required in clinical practice, learn to function more autonomously in an unfamiliar environment, and improve my communication skills with patients and colleagues from different backgrounds.
The Internal Medicine ward I based at was similar to a General Medicine ward in the UK and had around 40 patients. Most of them had come through the hospital’s Emergency Department, although some had been transferred from the Intensive Care Unit or another Internal Medicine ward in the hospital. The ward’s weekly routines included a ward round on Sundays with all of the doctors and the weekend on-call person to see new admissions or more complex patients, an afternoon meeting with the Microbiology team every Wednesday, and a Radiology meeting on Thursday morning.
The doctors on my ward were split into a red and a blue team. Within each team, the doctors would then divide up the patients to see amongst themselves, and if a doctor had seen the patient the day before they would try to put them on their list again the following day. The idea of this system was to ensure the continuity of patient care. Each team was responsible for about 20 patients and was composed of 3 senior physicians (Consultants or Registrars) who would pair up with an Intern (FY1 equivalent). It seemed like this set-up actively tried to break down barriers between junior and senior staff, and encouraged newly qualified doctors to ask more experienced doctors for help.
In the morning, I would arrive at my ward for 8.30 or 9.00am to join a Consultant and an Intern on their ward round. We usually saw between 6 and 8 patients together. The patient consultation and most of the patient notes and reports on the electronic system were in Hebrew, but somebody would always talk me through the key lab results and the important points in the patient’s history. I was then asked to examine the patient and document my findings. I would also be asked questions related to the patient’s conditions. Were there any further investigations I wanted to order? Would I start/stop any medications? Should the patient be seen by any of the specialists?
It took me a while to become familiar with patients’ medications, as Israeli doctors tend to favour using brand names over the generic nomenclature. The protocols on best practice and management for a given condition also differed. In the UK, the NICE guidelines tend to be used whereas in Israel doctors often referred to the UpToDate database to inform their clinical decisions.
Overall, the patient population I encountered during my time in Israel was similar to the UK but I felt that on a day-to-day basis I saw a higher number of patients with more severe complications, such as hepatic encephalopathy due to advanced liver cirrhosis or a bloody pleural effusion secondary to widely disseminated breast cancer. One of the rooms on the ward served as a High Dependency Unit and mostly had patients who were intubated or had a tracheostomy. Thus, I had the opportunity to learn about what support these patients needed and the different types of ventilators that were used.
I also decided to spend a week in the Intensive Cardiology Care Unit where I saw PCIs and exercise stress tests being performed, and gained more experience in interpreting complex ECGs and how patients with recent MIs are managed. I was even allowed to cardiovert a patient under the supervision of the Cardiology and an Anaesthetist Consultants, which was definitely one of the highlights of my elective!
Absolutely! Being on an Internal Medicine ward meant that the conditions I saw were quite varied and allowed me to apply the Pathology I had previously learned, which had been one of the goals of my elective. The doctors I shadowed all learnt my name, were approachable when I had questions and gave me excellent one-on-one teaching. Their willingness to let me be involved really motivated me to engage on ward rounds and was a welcome change from some of the placements I’ve had in the UK where the doctors on the ward sometimes haven’t even acknowledged the presence of students. My elective experience has also shaped my view on my future career ambitions by giving me a flavour of what it would be like look after patients who require intensive care.
I would like to thank the Jewish Medical Association UK for their generous grant that helped fund my elective.
Paediatric Oncology, Tata Medical Centre, Kolkata, India
I spent my elective working on a paediatric oncology ward at Tata Medical Centre (TMC), a specialist cancer hospital on the outskirts of Kolkata, India. TMC is a charity hospital where the cost of treatment is subsidised with donations from philanthropists. India’s public healthcare system has many financial restrictions and when state hospitals cannot provide patients will often turn to the private sector. However, this alternative is beyond the means of many in India and charity hospitals provide high quality medical care to those who would otherwise not be able to afford it. This is important in oncology, as cancer treatment is expensive, but even more so in paediatric oncology, as the parents of young children are typically young themselves without the savings to support medical treatment.
Working at TMC was an eye-opening experience. Children’s cancer is one of the most difficult areas of medicine to work in, but it is also one of the most rewarding. Many cancers in paediatric oncology do respond well to therapy but even in these cases the treatment programmes are prolonged and arduous, and demand great courage from the patients and their parents. Many children are too young to understand importance of treatment, which makes the process even harder. However, despite all of this I found that the children continued to confound my expectations, from their powers of recovery to their positive outlook on life. There is also a lot of support that patients can give each other. Accommodation was provided nearby for families to stay during treatment, and meeting others going through similar ordeals was helpful for both the children and their parents.
Medical care at Tata Medical Centre is not fully subsidised and patients contribute to the costs of treatment, especially at the start of therapy while paperwork is being processed. Because of this, even with financial aid families with low incomes still face limitations on what treatments they can afford. It is a frustrating experience as a medic to know what treatment a child needs but be unable to give it. Additionally, the intersection between illness and poverty can lead to painful decisions for the parents. Cancer treatment can bankrupt a family, and they must take into account factors such as how many other children are at home to support, or how likely the cancer is to be cured. Sometimes cost dictates the ceiling of care that can be offered. Certain cancers can only be cured with a bone marrow transplant, but their cost is beyond the reach of most patients at the centre. It is difficult to see children with cancers that might have been treated successfully if they had been born in the UK, or if their families were more prosperous. In other cases cheaper drugs have to be used despite the increased risk to the patient’s health. Cheaper antifungal drugs can inhibit the breakdown of chemotherapy and increase the risk of side effects, such as permanent liver or nerve damage. The antifungals that do not interact with chemotherapy are unaffordable for many, and so patients are forced to use cheaper antifungal cover that carries a greater risk for their health.
There are aspects of the Indian healthcare system that the UK could learn from. Patients were asked to buy certain medical supplies themselves, such as lumbar puncture needles. The result was a relatively small financial burden on each patient but a significant saving on the part of the hospital. In the context of an underfunded NHS, minor or nominal payments from each patient could lead to greater savings overall while minimising the impact on the population. Similarly, the centre chose not to fully subsidise their medical treatment. This was primarily to make their funds go further, but some also argued that financial contributions lead to patients taking more responsibility over their own health. These approaches to medical care are not commonly discussed in the UK. However, the use of financial contributions to influence personal behaviour, as has been seen in the recent charges for plastic bags, is likely to gain greater prominence in public debate in the future.
The most I learnt at TMC was by observing the teamwork in the paediatric unit. The unit had a sense of equality that is unusual to find in medicine, where the consultants encouraged their juniors to challenge their decisions and would consider them seriously. This lead to constructive discussions about the patients to which anyone could contribute, rather than the head of the team dispensing a string of instructions. The patients benefited from the closer attention to detail; the fellows benefited from being pushed; and the consultants benefited from the contributions of the whole team. It is an atmosphere that I would like to replicate myself in the future, but one that is easily squeezed out by the everyday pressures of hospital wards: too many patients with too little time.
Whilst in Kolkata I also worked a state hospital to compare the delivery of care between the two systems. The clearest difference was the sheer volume of people that the state hospitals treated, with crowds filling up the courtyards and corridors every morning. There were limited beds on the wards and so most were deferred to overflowing outpatient clinics. Personnel were a major cost, leading to single nurse for each ward. Much of the traditional role of the nurse was replaced by families looking after their relatives and I met one young girl with leukaemia who would assist the junior doctor with his procedures on the ward.
I found the state hospital full of passionate doctors struggling to work within the confines of a poor system. They had limited resources, but the resources they did have were not being used efficiently. My ward would turn patients away for lack of space even though there were empty beds in the ward next door, because the hospital management wouldn’t allow them to use other beds. Other challenges lay in government mismanagement. During my stay the state of West Bengal was holding elections, which occur district by district over a month. Rather than giving hospitals funds for medical supplies, the West Bengal government buys them in bulk and delivers them to the hospitals. This means that medical deliveries are dependent on government bureaucracy and during elections that bureaucracy grinds to a halt. While politicians were insisting publicly that their hospitals were well stocked, on the ground resources were running short and it was estimated that the shortages could continue for months after the election. It was not just drugs that were in short supply. Many blood donation centres closed down during the election leading to a shortage of blood products. None of these problems were due to funding – they were problems rooted in a system that was failing to utilise its resources effectively.
I was in India over Pesach and I joined the Jewish community for their communal Seder. The community used to number over 6000 before World War II but has dwindled today to less than 30. They have a fascinating mix of traditions – some Sephardi traditions, a scattering of European tunes, and an Israeli pronunciation of Hebrew. This was the first year they were running a communal Seder and it was held in the Kolkata Jewish Girls School, which has a British-style school hall with wooden plaques listing the accolades of past students. Two young Chabad students had come out from New Jersey to help run it, and I had not appreciated before the impact they can have visiting small communities across the world. The Seder meant a lot to the locals and it was heart-warming to see the strength of their Jewish connection. It was an amazing experience to sit down in one room with most of the Jews in the whole city, along with all our different languages, and take part in a ceremony that Jews have been performing together for millennia.
Alongside Kolkata’s small Jewish community there are three large beautiful synagogues. Recent renovations have rendered the synagogues unrecognisable to how they appeared a decade before, with the smallest synagogue now being used regularly for Shabbat services. This synagogue had been used for years as storage for the merchants working on street below and the stall-keepers were very upset to discover that their free storage space was, in fact, a historic place of worship. One merchant, apparently no stranger to chutzpah, was still attempting to pursue legal action through the courts.
I travelled out to India to see the differences in the provision in care in a country with far greater financial limitations than where I trained. However rather than the differences between the two systems, what I found most striking were the similarities. The conversations with patients, the concerns that came to light, the discussions amongst medical teams and the factors weighed up in medical decisions were all the same. Despite the foreign language and cultural differences I found myself in a familiar environment. I feel that this is because the relationship between patients and their doctors remains unchanged regardless of where the medicine is practiced across the world, with its empathy, compassion and hope.
Paediatrics Department, Sydney Medical School, Sydney
My elective placement was in the paediatric department at Nepean Hospital. Nepean is a district general hospital on the outskirts of Sydney, in a town called Penrith. The immediate area around the hospital, Kingswood, is quite deprived. I spent most of my time during my elective either in the paediatric clinics (allergy, behavioural and developmental) or on the post-natal and paediatric wards. I also had formal teaching with the Nepean medical students.
Many of the clinics that I sat in during my elective revolved around allergy and atopy. As a developed country, Australia has relatively similar health problems to Britain. For the paediatric population, allergies and other features of atopy form a large part of secondary care.
One of the most important things that I have learnt that will influence my future practice as a doctor was that tests are not always helpful, and so they shouldn’t be carried out unnecessarily. During one allergy clinic, a consultant paediatrician was explaining to a 9 year old girl’s mother that although they could do a skin prick test to attempt to figure out exactly what was giving her a rash, but that it probably wasn’t the best idea. The patient’s mother had decided that the best way to avoid the rash was to test new products on the back of her hand first. The consultant explained that this is what they would recommend, and that a skin prick test was unlikely to change her management. Furthermore it would be a difficult test to carry out and horrible for the patient herself, and has the small risk of causing anaphylaxis. Therefore, in this case, the costs of the investigation would greatly outweigh benefits. This is something that can be applied to most areas of medicine, not just paediatrics.
During my time in the clinics, I was given time to see patients on my own, before presenting to the consultant and agreeing on a plan. Occasionally, I also typed up the letters from the clinic. This experience helped to build my communication skills, as well as being good practice for being a junior doctor. Furthermore, it enabled me to improve my ability to take a focused history and form differential diagnoses, as well as expanding my clinical knowledge of paediatrics. I particularly enjoyed the direct interaction with the patients and their families, as I was able to actually listen to their concerns myself and feel like I was doing something useful, rather than shadowing like we usually do in clinics at medical school. Whilst observing the ways in which other doctors practice is definitely a great way of learning, trying out those skills yourself in a real hospital setting really helps to build confidence, knowledge and communication skills.
Whilst on the wards I was able to take on the role of the junior doctor. Most of this involved perfecting baby checks and writing in the medical notes during paediatric ward rounds.
It was also interesting to see the differences between the healthcare systems and practices in Britain and Australia. While they were very similar in the public hospital that I was at, I was much more aware of the larger proportion of private healthcare in Australia, compared to that in the UK. A lot of patients got their radiological investigations done more quickly by having them privately, while only a small proportion of people do this in the UK.
Additionally, when patients came to clinic, they had to have their Medicare card with them, showing that they are entitled to treatment. Medicare helps all Australians to access healthcare, similarly to the UK. However, sometimes they will have to pay for certain services, and then they will be reimbursed partly (for subsidized treatments) or completely. Therefore, while Australia’s healthcare system is similar to that of the UK, there is a greater proportion of private work, and they use Medicare to ensure that everyone has access to affordable healthcare, even if it is not always free.
The Impact of Allergies
One of the paediatric consultants that I worked with has a special interest in allergies. This encompasses all of the features of atopy, so he mostly saw children with allergies, asthma, hayfever and eczema in his clinic. Despite being aware of allergies and atopy before, it was in this clinic where I realised how big of an impact an allergy (and associated problems) can be on someone’s life, and the variety of ways in which it can affect them.
For most people, food allergies are a relatively minor concern. They might get a bit of a tummy ache or a rash when they ingest the allergen, but the reaction won’t usually be severe, let alone life threatening. However, for some children, eating the wrong food can be disastrous, and this leads to knock-on effects on their health, psychology and even their education and future prospects.
The most pressing concern is anaphylaxis. Anaphylaxis still kills people, despite the increased awareness of allergies and the advent of medication that should save them. Children and adults alike do not always carry their EpiPens on them, and therefore, if they mistakenly eat something that they shouldn’t and don’t get to hospital in time, it becomes a fatal error. Deaths due to anaphylactic shock are, luckily, very rare in Australia (112 deaths from 1995-2007, (only 6% of which were due to food allergy).
However, anaphylaxis is not the only way in which allergies can affect a child’s health. Babies who have allergies to, for example, cows milk protein, may develop chronic diarrhoea, anaemia, malabsorption and failure to thrive. This can impact their growth and development if it is not picked up and managed properly. Eczema can also cause failure to thrive when it leads to recurrent infections with bacteria and/or eczema herpeticum.
There is also a financial cost to allergies. This became clear when I saw a patient suffering from eczema, thought in her case to be due to a house dust mite allergy. The first line treatment includes conservative measures, such as buying protective bedding, getting rid of carpets and vacuuming every day. However, this can be very expensive and time-consuming. The protective bedding alone costs at least AU$300 (which needs to be repeatedly replaced), and if you don’t happen to live somewhere with wooden or tiled floors, ripping out the carpets, changing from fabric to leather sofas and from curtains to blinds is not only expensive, but also a great deal of work. Furthermore, while this does help most people with a suspected house dust mite allergy, it doesn’t always work. Most of the parents that I saw were happy to make these changes if it meant it would help with their child’s asthma or eczema. However, there was one family who became very distressed, because they couldn’t afford to buy the protective bedding (which did not seem to be covered by Medicare). They were also living in rented accommodation, and so they were unable to make all of the additional changes mentioned above. In the end, they agreed to move their child’s bedroom from an upstairs carpeted room, to a tiled room on a lower floor, and to clean and vacuum regularly, to see if that made any difference. The doctor hoped that this alone would improve the toddler’s symptoms.
Additionally, replacement foods and skin products are an extra cost. Milks, such as almond, rice and barley milk are much more expensive than regular cows milk. Formula milk for infants with a cow’s milk protein intolerance is also incredibly expensive, and although subsidized by the pharmaceutical benefits scheme from Medicare, parents must pay some of the cost.
It can also be difficult to find soaps and shampoos that don’t cause a reaction in a child with contact dermatitis. This may limit choice to more expensive brands, or buying multiple brands, before discovering one that can be tolerated by the child.
Therefore, allergies can become very expensive indeed. While it was manageable for the patients’ families from other areas of Penrith, those from the more deprived area of Kingswood were clearly finding it much more difficult, resulting in their children suffering more severely than they otherwise might have.
Having an allergy, particularly one that has caused anaphylaxis in the past, can cause anxiety in children and their families. Going into anaphylactic shock is terrifying for both adults and children. Furthermore, they have to constantly be vigilant, checking food labels and carrying their EpiPens. This can also weigh heavily on parents and siblings, who also need to be trained in how to use the EpiPens.
The family as a whole is also affected when it comes to cooking and food shopping. Where a child is allergic to food groups (e.g. dairy) or common foods such as eggs, or even both, cooking family meals can become very stressful. This can be particularly difficult for families with multiple young children with different allergies and/or tastes. If parents have to make multiple dishes, or are very limited in what they can make for a child, meal times are very hard. This can then go on to cause further health problems due to malnutrition.
Lastly, allergies can have profound effects on a child’s education. Studies have shown that children with allergic rhinitis have a poorer performance at school and in exams. This is believed to be due to both the disease itself affecting sleep quality, as well as the comorbidities associated with it and even some of the treatments. Whatever the reason, poorer school performance can impact greatly into later life, affecting future career paths and social class.
In conclusion, it is clear to see that an allergy is no small issue. The impact of allergies is not just a health concern, but can affect family life, the psychology of the child and even their future success.