Category: Uncategorised

Introduction:

From July to September 2018, I undertook a six week elective in the trauma and emergency medicine departments at Tygerberg Hospital, South Africa. This tertiary hospital is situated about 20 minutes drive from central Cape Town. Opened in 1976, it is the largest hospital in the Western Cape with 1899 beds and is state-funded by the National Department of Health. It serves as a teaching hospital for students from Stellenbosch University’s Health Science Faculty and manages a population of over 3 million people (South Africa has a total population of around 55 million).

In terms of hospital resources, my visit to Cape Town coincided with the end of a severe drought which had lasted almost three years. There had been concern that in the months running up to the start of my elective the city’s water supply would dry up, an event referred to as ‘Day Zero’. At this point water taps would cease to function and Capetonians would have been forced to collect water from local municipality spots throughout the city. Hospitals themselves wouldn’t have their water supply revoked, however a spike in admissions was still predicted due to the acute effects of the supply ban in the community. Fortunately sufficient rain throughout July and the rapid construction of desalination plants had removed this acute threat, however water was still used sparingly in the hospital. There was a scarcity of other resources too due to chronic underfunding from the Department of Health which limited access to investigations such as blood tests and imaging. A positive consequence of such shortages was that doctors were diligent at relying on signs and symptoms to form diagnoses.

Departments and Ambulance Work:

Unlike hospitals in the UK, Tygerberg Hospital has separate emergency and trauma departments. The emergency department handles similar cases to Accident and Emergency departments in the UK. The vast majority of cases presenting to the trauma department were shootings and stabbings of young males from the multitude of townships surrounding the hospital. Many of these patients were involved in the Number’s Gangs:a collection of rival gangs which is prevalent in Cape Town prisons. Former inmates often remain associated with their respective gangs even after release where they are known to impose tyrannical control over township communities. I had the opportunity to see first hand the violence in these townships whilst joining the ambulance crew who often had to venture into the townships under police escort. On some occasions, the police refused to escort ambulances into the most dangerous townships, so-called ‘red zones’. In these situations, the patient would have to rely on self-admission to hospital which  would have worse prognoses. Aside from ambulance shifts, I had the option each day to work either in the trauma or emergency departments. The trauma department was generally busier during weekend night shifts and busiest on a payday weekend, with alcohol-fuelled violence causing a surge in trauma admissions.

A typical shift:

Shifts would last up to 12 hours, although it was not uncommon to be working with doctors on 24 hour shifts. A typical shift in the trauma department would involve shadowing a junior doctor or clerking my own patients as part of triage, performing a variety of clinical skills including venepuncture, arterial blood gases and catheterisation. I had learnt the foundations of sutering from courses with the Cutting Edge Surgical Society and I was very keen to develop these skills in the trauma unit. Following teaching at the skills lab at Tygerberg and ward teaching from the junior doctors, I was able to suture some of the patients that were admitted with sharp trauma, for example knife attacks. With the clinical skills I was performing, I received constructive feedback which I believe improved my clinical performance. After a few shifts I was inserting chest drains for haemothoraxes secondary to sharp chest traumas, and performing lumbar punctures (all under close supervision!). As with my experience in the UK, it was incredibly useful for my learning to follow patients from their admission to discharge and understand the reasoning behind each clinical decision in the patient’s management plan.

 

Unlike the trauma department, I would normally attend day shifts at the emergency department, mainly so I could attend the morning ward round which may have involved up to 15 medical professionals from different specialities. The ward round would take around three hours and involve reviewing up to 70 patients. Despite the number of patients, the consultant leading the ward round would consistently provide teaching to the medical students. My key observations from the emergency department were: firstly, the late presentation of so many patients – this could be put down to multiple factors including poor health education meaning patients are far less aware of urgent symptoms, socio-economic factors affecting their ability to transport themselves to hospital and the lack of screening programmes to enable early disease identification; and secondly the prevalence of HIV and TB.

Public health concerns: HIV and TB

Nineteen percent of South Africans are believed to have HIV, making it the country with the largest population of HIV patients. However antiretroviral drugs, health education programmes and increased condom usage (amongst other factors) have contributed to a reduced incidence of HIV by up to 44% from 2010-2016.This comes after a period of ‘AIDS denialism’ when Thabo Mbeki, the president of South Africa from 1999-2008 publicly denied that AIDS was caused by the HIV virus. This belief delayed public health authorities into commencing anti-retroviral (ARV) programmes. HIV remains a significant public health concern, however, and was accountable for a substantial number of immune-related hospital admissions that I witnessed. Furthermore, stigma towards HIV remains high which has reduced ARV compliance.

 

Aside from HIV, TB is a very common comorbidity with a co-infection rate of about 60%. Screening programmes have become more prevalent and public health authorities now believe that TB and HIV should be given the same attention. Previously undiagnosed late-stage TB was a common presenting complaint in the emergency department at Tygerberg. Whilst distressing to witness, it was beneficial to develop my chest x-ray interpretation skills and respiratory examinations during the management of these patients.

Conclusion and reflection:

I thoroughly enjoyed my elective in South Africa: I felt that my clinical skills improved and I became more confident in carrying them out competently and safely. I was also glad that I saw a wide range of admissions to the emergency department. Moving forward I would like to focus on the clinical skills and knowledge that I have obtained from my elective and put this into practice during my placements this year. I also feel more comfortable performing the types of jobs that will be expected if me as a foundation year doctor.

Noah Stanton

Leeds

As a part of my elective I chose to spend three weeks at a general practice in Israel.  As I am hoping to move to Israel after I qualify, and am interested in pursuing general practice, I thought I could use this as an opportunity to get more familiar with the Israeli medical system and determine whether I could be comfortable working in Israel.

I chose the practice based on good reviews from British students who had done electives there previously.  It also had the advantage of being in Netanya, where I had access to a flat so that accommodation was free!

The practice is located in the centre of Netanya and has four doctors and a nurse on site.  It is associated with the Maccabi Health Fund, but is not controlled by them, so that private patients are also seen.

The population in Netanya is very diverse and includes a mixture of Israeli born, English, French, Russians, South Africans, Germans and several others.  The four doctors spoke at least six languages fluently and the practice had become so well known for this in Netanya that several holiday-makers had come specifically to the practice and waited for hours to see the doctor that spoke their native language.

I spent most of my time sitting in with a South African doctor who was fluent in English and Hebrew.  Approximately 40% of the patients he saw were English speakers. As my Hebrew was not very good, this mix was advantageous as I could easily understand a lot of the consultations and could improve my medical understanding as well as working on my Hebrew. Unfortunately, my level of Hebrew prevented me from being able to clerk patients before they were seen by the doctor unless they were English speakers, but by the end of the placement I could understand most of the Hebrew conversations as well and was starting to be able to speak more confidently as well.

The multitude of languages in the practice led to a rather unique challenge for the doctors as it was important for them to know in which language to greet the patient.  The practice was so busy that they rarely had time to look at a patient’s notes before they came in and, if they were greeted in the wrong language, the patient would immediately know that the doctor did not remember them, thus creating a breach in their relationship.

During my placement, I was most struck by the computerised system the doctors used to document their notes.  The Maccabi health fund has an internet-based system that can be accessed by any other Maccabi-associated-doctor in the city.  This meant that the doctors could simply write their notes from the consultation on to the system and this would then be accessible instantly to another doctor in the city.  This removed the need for referral letters as the doctors would simply give the patient a form to make an appointment with a specialist who would be able to look at the reason for the referral on the system.  This saved an enormous amount of time and was much more efficient than the UK system.  It meant that the doctors could send a patient for blood tests and chest x-rays and see the report as soon as they were available, allowing them to act promptly where necessary.

It was also interesting to note that, because the population is almost completely Jewish, in the week preceding Yom Kippur the doctors had to be slightly more wary than usual in prescribing drugs such as antibiotics as they were aware that most people would be fasting and inclined to miss pills.

Overall the experience was extremely valuable and I gained a huge amount of medical knowledge as well as very valuable information about the way medicine works in Israel.  It has given me a lot more confidence to consider working in Israel in the future.

Miriam Burns

King’s College London

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Elliot Brown
Birmingham 

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

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

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

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

 

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.

Logistics:
To organise 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.

Julia Zimmermann
Imperial College London

Aims & Objectives

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

Why this elective?

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

Meeting my aims & objectives

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

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

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

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

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

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

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

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

Learn some basic Hebrew and discover the culture of Israel.

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

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

Reflections on my experiences

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

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

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

Looking to the future

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

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

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

Bibliography

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

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

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

Rebecca Davies
Sheffield