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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.

What I learnt from my Elective Experience

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.

Health Concerns

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[1])).

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.

Financial Cost

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.

Psychological Impact

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.

 Social Issues

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[2].  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.

[1] http://www.allergy.org.au/health-professionals/hp-information/asthma-and-allergy/food-allergy-and-anaphylaxis-update-2014

[2] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345332/

Lauren Sandler
UCL

My elective was split between the UK and South Africa, working in Paediatric Infectious Diseases (ID). The Paediatric ID department at St. Mary’s is a tertiary care centre, receiving referrals from across the country, as is Tygerberg. However, it is there that the similarities end.  St. Marys’ is a ‘normal’ NHS, UK Hospital – wards are clean and organised, numerous nursing staff are a noticeable presence on the ward. When we arrived at Tygerberg, and (eventually) located the ward, we found a dirty ward with numerous beds, minimal nursing staff visible and little equipment to maintain a hygienic working environment. Doctors were walking around with long sleeves, hair down and scarves dangling over the patients. We had to search for hand sanitiser, and most staff members did not make use of it. There were no monitored bays, or any indication that these children were having their observations monitored. Patients at St Marys are representative of the make-up of the UK population, whereas the patient population in Tygerberg consists of only the financially disadvantaged, mainly Black and some Afrikaner members of society. When we had orientation in Tygerberg, we were told where the nearest private hospital is; it was very clear that as Caucasian, Western women, we would never be expected to utilise the hospital services here.

The paediatric department is huge, and spread across 10 floors. Despite its’ size, the system is clearly overburdened. However, there are no further services where children can be referred. This is the expert hospital. A senior registrar who had spent some time working in London, told us how the neonatal unit is lacking ventilators and equipment, and that many times they are unable to resuscitate premature babies, who would almost certainly survive in the UK system. Soon after, we encountered the backbone of the UK hospital system, the ward round. Firstly we were instructed to arrive at 10am, and when we did, were told that it wasn’t going to start until sometime after, although this time could not be specified! The ward round experience was astonishing – not due to the patients’ clinical state, but rather due to the absolute lack of organisation or structure. There was no patient list, or order in which to see the patient. No one wrote anything down in notes and there was no plan! Each distraction was embraced and I left feeling that nothing had been achieved.

From an ID perspective, South Africa is unfortunately a place to see a multitude of clinical presentations that are rare in the UK. The St Mary’s department is responsible for patients with HIV, TB and other infections. Most of the TB and HIV patients are outpatients, and a few patients are occasionally admitted to hospital with a severe complication of their disease. Furthermore, most of the TB infections are drug susceptible and identified early on in the disease process. When arriving in South Africa, we immediately encountered numerous patients hospitalised with TB, not simple drug susceptible TB, but multidrug resistant (MDR) as well as extensively drug resistant (XDR). There were numerous cases of TB meningitis as well as TB osteitis. These patients are being treated for 12-18 months, on second or third line medication and often as inpatients for the entire duration. The HIV population in South Africa is around 12% according to the UNAIDS report of 2007, with the highest number of infected people in any one country. Although HIV patients may need hospitalisation in the UK, the proportion of patients on the ward who were hospitalised with HIV related conditions was astounding. The children have an extremely high rate of maternal to fetal transmission, with many children not identified as HIV positive until a late stage. The anti-retrovirals available in South Africa are far more limited than those available in the UK, and until recently, patients only began treatment when their CD4 count was below a certain threshold, unlike the UK where treatment is initiated as soon as possible after diagnosis. It was extremely distressing to see this, as their condition is a preventable one – with good antiretroviral treatment, transmission could have been prevented, or the HIV supressed in the case of HIV already transmitted.

We also did visits to a specialist hospital, The Brooklyn Chest. The only way to describe the appearance of the building is like that of an old army barracks, with numerous small buildings. These were draughty with no heating and ventilated by simply opening the windows. Many children were wearing 3-4 jumpers, with doctors often wearing their coats indoors. The doctors were some of the finest I had ever encountered, not only from a knowledge perspective, but also from their patient manner and the obvious devotion for their young patients. I was entirely out of my depth clinically, as I had no idea about some of the drugs that were used. I asked about the adverse effect that prolonged hospitalisation would have on a child’s development, and was told that the care they receive, regular meals and intellectual stimulation from the other children and staff is superior to that where they live.

We had the opportunity to visit a healthcare clinic in Mfuleni, a nearby township. This experience was difficult in so many ways. I had never seen poverty like this, with people living in shacks, with no running water or indoor toilet. Animals and flies roamed freely inside the homes, and many patients couldn’t afford the fare to the hospital. We were educating an obese woman about a good diet, and she simply stated that she could not afford anything other than bread. We had to teach a boy with numerous cavities how to brush his teeth with a piece of cloth as he couldn’t afford a toothbrush.

The experience was informative in so many ways – exposure to new conditions as well as exposure to a different healthcare system.

I left extremely proud of the NHS, and disheartened to find that despite democracy, many inequalities remain within South Africa. There is so much to be done to correct this, much of which is far deeper than simply providing “better healthcare”. I realised that this is a beautiful but complicated country in so many ways. Despite the fall of apartheid, there is still an enormous divide between white and black. Segregation in living areas, although not legally enforced still remains. The white population is centred in Cape Town itself, with the black population on the Cape Flats.  Young children beg on the side of the motorway, and there were so many basic need that people in the townships were lacking. When you observe this, there is an immediate and overwhelming desire to help. However, you have to stop and think. Sometimes, handing out money or simply buying an item for someone does not help. This encourages children not to attend school, and it is ultimately education that is going to break the poverty cycle, and provides no sustainable income for the beneficiaries. In the township, I saw abject poverty which was nothing short of devastating. This was emphasised when there were numerous generations living in poverty, as the system has failed them and not equipped them to rise from where they were born.

I felt that in the UK, the difference between socialised and private healthcare is minimal. Although the private hospital may be more aesthetically appealing and waiting times for a routine procedure or appointment shorter, ultimately, it is the same medicine being practiced with the same regulations. I got the sense that this is vastly untrue in South Africa. From what I was told, the private hospitals resemble Western institutions and the State run hospitals are entirely different, with significantly lower standards of care.

I felt that the students and junior doctors in South Africa were often superior in their clinical skills. The amount of information that they were able to glean from a simple chest x-ray was far beyond anything I could have noticed! In the UK, we would simply order a CT if there was a suspicious or unclear area, but these are in limited supply and therefore they have to take more from a plain chest x-ray. However, the inefficiency (which I am told from other students is not limited to the paediatric department) provides such a hindrance to delivery of care.

Despite large amounts of misery and poverty, some of the staff and services are truly inspiring. The healthcare they provide no doubt saves lives, and they are beginning to give people the opportunity to live healthy lives and remedy the inequalities that remain until today. I really feel that the change needs to happen on a deep, societal level. It is not a ‘quick fix’ or simply a case of giving money to disadvantaged people. Ultimately, the current healthcare provisions are better than what was available 30 years ago, and hopefully positive changes will continue to happen.

Ashira Rabinowitz
UCL

Background – Where I went and why

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.

Learning Objectives – What I planned to do and what I actually did

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.

Evaluation – What experience I gained from my elective

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!

Reflection – Did my elective meet my expectations?

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.

Acknowledgements

I would like to thank the Jewish Medical Association UK for their generous grant that helped fund my elective.

Gillian McKenna
Cambridge 

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.

Talya Finke
Kings College London

 

 

Overview

I spent four weeks at the Western Galilee Medical Centre (WGMC), mostly in the Emergency Department (ED) but also in paediatric emergency, oncology, internal medicine and theatre. The elective allowed me to improve on basic skills of history-taking, examining in a focused way and presenting patients, and gave me a chance to think about what the responsibilites of an emergency physician are. I spent a lot of time learning medical and general Hebrew vocabulary and tried to speak to patients and staff. There were also a few totally new experiences, which I highlight below. Outside of the hospital, I explored the coastal area and reunited with  friends and relatives.

Patients

Despite knowing that the population served by the hospital was varied I nonethless found my preconceptions challenged. Most of patients that I saw did not speak Hebrew as a first language, but rather Arabic or Russian. In many cases Hebrew was poor or absent. This did make me even more hesitant to take patient histories, although thankfully Fadi, my excellent stagaire partner, was encouraging and made sure to involve me in any clerking he did by translating and discussing. He would often ask me to examine the patient after he had taken the history.

Typical cases I saw included road-traffic accidents, COPD exacerbations or chest infections, cerebrovascular accidents, coronary heart disease and elderly ‘off-legs’ patients. I would judge the patient mix to be similar to the mix seen in London, with the notable relative paucity of alcohol-related admissions, such as acute intoxication, alcohol-related injuries and alcoholic liver disease.

Rarer cases that I saw included a case of a young American visitor with gastrointestinal and possibly biliary tapeworm infection and a young Syrian woman with shrapnel wounds, of which more later. I also had the opportunity to observe or participate in common procedures that I had never seen done before, such as coronary catheterisation, fixation of mid-shaft ulna and radius fractures in a child, and resection of  a lung mass.

The staff

Perhaps even more than was the case with the patients, I was surprised by the diversity of the ED team. Doctors of Russian descent, Druze, and Muslim or Christian Arab accounted for the majority, reflecting the diverse population in the region. The team seemed very friendly and cohesive. It was of course gratifying to see this and deepened my understanding of Israeli culture and society.

In comparing it with my experience of London a number of things stand out. Overall, there seemed to be more harmonious interaction between the different types of medical practitioner. The medical staff seemed to have a sense of ownership of the ED: often in the UK there is a sense of being a shift-worker managed by a non-medical line manager. The ‘perks’ are also much greater – kitchens stocked with simple food, where staff can take a few minutes to relax, refreshments brought round twice a day, meals provided free to those who stay late, free parking. The nursing staff seemed generally more competent than I had experienced, and I observed with interest the role played by physician assistants, who are highly experienced first-responders working in the ED. There is perhaps less referal to guidelines of management which are central to ED practice for all grades of British doctors, and which are a useful learning tool for newer doctors.  Overall, the workload seemed rather less here than a typical London A&E, though I was told that Nahariya has a relatively high rate of ED attendance. This discrepancy may be explained  by a better staff:patient ratio and/or by the observation that the the role of the ED doctor at WGMC involves less management (patients requiring treatment are often referred quickly to the wards).

Mass Casualty

I was lucky enough to observe a mass-casualty drill, something I had never seen in London. As the ‘event’ was announced, the ED was quickly cleared with all patients wheeled or walked into the paediatrics department. Numbered jackets were quickly distributed assigning a nurse, clerk and doctor to numbered bays. The doctors were from all parts of the hospital and the clerks were administrative staff who had been trained for this role. Equipment trolleys appeared by each bay. Then the ‘patients’ – soldiers with fake blood and stories around their necks – entered. There were not as many patients as I expected, but I suppose that the point is to test the adminstrative management and coordination between sections during such an event, rather than the skills of any particular team (who in a real event may become overwhelmed by a volume of patients assigned to their bay). Indeed, no patient ended up coming to our bay at all. Nonetheless it gave us an opportunity to remind ourselves of basic trauma management and to have a small sense of the adrenalin and confusion that would occur at such a time.

The hospital is also prepared for a direct strike by missile. The ED is reinforced with extremely thick walls and there is a huge basement warehouse where ward patients can be quickly moved if necessary.

Syrian patients

I was attracted to apply to the hospital in part because I had heard that Syrians were being treated here. It sounded exciting. I was curious as to how they reached this hospital, about 40 kilometres from the Syrian border, and what happened to them once they were here. I was told that up to 4 Syrians reached the hospital each day, brought to the hopsital from the border by Israeli army ambulance, across the border by the UN, and who knows what on the Syrian side. In the past they recovered on the open ward, but they now are largely confined to the basement hospital after a number of threats to their safety. I myself assisted in the treatment of one Syrian patient, a 25 year old woman with a one year old child who suffered shrapnel damage to her right leg from a bomb or grenade explosion. She had a large, open, putrid wound on her left lateral shin, as well as sprinklings of wounds up the front of that leg and on the medial aspect of her right leg. It was the first such injury that I have seen. From the distribution of the wounds on her leg it was possible to plot where the bomb exploded and possibly even how far away – which led the surgeon to wonder how she had got away so lightly. I wondered what it was like for her to be in Israel, in an Israeli hospital, with an over-eager, oversized medical student from England trying to ask her questions with Google translate. But that is a question I never asked.

Gabriel Doctor
Barts and the London

I chose to go to Ethiopia on my elective because of a novel, a coffee shop on a summer’s day and a traveller’s tale. Years ago I read ‘Cutting for Stone’ by Abraham Verghese – a richly descriptive story set around a hospital in Addis Ababa in the 1950s –  and the evocation of the city, its food and music captured me.  A few years’ later, as a 4^th year medical student, I sat at ‘Kaffa Coffee’ in Dalston with a strong espresso and a plate of injera covered with richly coloured pickles and vegetable stews, listening to Ethiopian piano jazz rolling out like a wave across Gillard Square. Then a conversation with a friend who said: “The Addis Sheraton is like that bar scene in Stars Wars. It’s the greatest people-watching place in the world. Plus their calendar is 6 years behind and their clock runs six hours ahead.”

After trying and failing to arrange an elective through the Tikur Anbessa (Black Lion) teaching hospital, a friendly professor who had seen a documentary about him suggested that I contact Dr Rick Hodes. Rick Hodes is Brooklyn in Addis. He first went to Ethiopia in the 1980s to teach medical students. He returned in the early 1990s with the Jewish Joint Distribution Committee (the JDC) to be a public health doctor in the refugee camps for Ethiopians who were waiting to be airlifted to Israel. He stayed in Addis, later working at the Mother Teresa Mission centre. It was here that he met a child with terrible – but theoretically treatable – spinal deformities. Just like any of us would do, he adopted him so that he could add the child to his American health insurance policy. The child duly flew to the States for life-transforming surgery. Rick went on to adopt a further four children in this manner, who also duly flew to the States for surgery – and this is his family today. Rick developed a reputation for being able to treat these cases and decided to develop a more robust programme.

Nowadays Rick runs the JDC’s Ethiopia Hearts and Spines programme, officially, and unofficially runs a boarding house for some of the children he is treating or has treated.

The Hearts and Spines programme is a gateway clinic, run by Rick and a small team, for the management of heart and spine disease which is life-threatening but treatable by surgery. Patients come through word of mouth, after being spotted on the street in Addis Ababa, or via referral from medical professionals. He sees about 400 new spine patients in a year about 100 new heart patients, in addition to follow ups and people who don’t fit into the programme. Only about 10% of those attending with documented spinal disease can currently be funded for surgery. Rick triages patients according severity, likelihood of sudden deterioration and the likely success of treatment. He arranges surgery, usually conducted at the FOCOS Hospital in Ghana by Dr Oheneba Boachie-Adjei, but occasionally in Texas (at the Texas Back Institute by Dr Ted Belanger) and sometimes in Addis Ababa by visiting teams.

‘Surgery’ in Ghana, where the most serious cases go, is a process lasting eight months in which the patients – usually children between the ages of 7-18 – undergo six months of 23-hour per day traction, prior to the actual surgery which usually involves remodelling or removing vertebrae, and then inserting titanium rods to support the spine in its new shape. Back in Ethiopia, Rick follows the patients up his clinic and manages complications. None of the patients can afford the cost of surgery which runs close to $20,000 per patient including ongoing care and the programme at the moment receives little Ethiopian government funding, so relies on charitable funding from abroad.

There are cardiac centres in Addis Ababa and in Jimma, but these generally operate only on simpler single valve defects. As of 2016, there are no paediatric cardiac surgeons in Ethiopia. Rick generally sends his patients with these more complicated problems to the Amrita Hospital in Cochin, India and occasionally to Israel.

During my elective I sat as an observer in the clinic which happens 3 days per week, helped with administration and interviewed patients and their relatives. The clinics were fascinating, both for the people and the pathology. Patients were mostly children or young adults, usually attending with family members, from all over Ethiopia. The waiting room was a melting pot of people from different regions, religions and ethnic groups. While most patients had deforming spinal disease or unseen but equally devastating cardiac disease, there were a significant number with neither but who nonetheless had heard of Rick as a great doctor. Cases include scoliosis, kyphosis, lordosis as well as more bizarre Z-shaped deformities and combinations of the above. I saw several spinal curvatures greater than 180˚. In addition to the common congenital, rheumatological, traumatic, infectious causes of spinal deformity, I saw Rick diagnose a six year old girl with one of the rarest described conditions in the world, fibrodysplasia ossificans progressiva, in which a person’s muscles transform into a bony cage around the body. Rick could offer her nothing – indeed there is no known treatment – except to add her to an international registry of such people.

Life outside the clinic was fascinating. Addis is a fun city with bars, live music, great food  – a mix of Ethiopian, Italian and Arabic – and interesting museums and cultural attractions. I explored these with people I met at my guesthouse, other visitors to Rick’s clinic and one of the kids living at Rick’s house. I visited Lalibela, whose 900 year old rock temples are among the wonders of the world. The most unusual experience I had was Shabbat dinner on Friday nights at Rick’s house. Every week, the resident kids and a smattering of local and out of towners gather in his hard-used living room. The other guests are doctors, students, anthropologists, musicologists, engineers, funders, politicians.  Rick hands out novelty hats to everyone and we gather in a big circle, hold hands, and sing the protest song ‘If I had a hammer’ by Pete Seeger, followed by Shalom Aleichem, and then he makes Kiddush. Rick reappears a bit later with his aluminium camping mug, out of which he eats most of his meals – this is a signal that food is ready in the kitchen. Injera, Shiro Wat, pickles vegetables, pasta fill my plate.

My elective in Ethiopia was great. I got to eat the food, live in the city and listen to the music just as I’d hoped. I got to explore a culture which is like a parallel reality to our own –“What if the Ark of the Covenant was secretly ferreted out of Solomon’s Temple?”. I saw fascinating medical cases and helped in a small way. The trip broadened my horizons of what one can do with a medical degree and indeed how a person can choose to live. And I did make it to the Sheraton Addis Ababa – if only because Rick likes to use the toilets there after a long hard day in clinic.

Thanks to the JMA for its financial help. Do get in touch if you are thinking about an elective in Addis or want to get in touch with Rick.

Gabriel Doctor
Barts and the London

Whilst planning my elective, I managed to distil my aims down to three fundamental themes: immersion in neurosurgery; exposure to a different health system; and the exploration of Israel. With my feet back on English soil I have come to realise how insightful my elective was and the privilege I was granted in being able to undertake it.

Excitement aside, my arrival in Ben Gurion airport was shrouded in apprehension. I was to spend four weeks in neurosurgical unit of the world-renowned Hadassah Medical Centre, equipped with little more than a guidebook and an undergraduate grasp of neuro-anatomy.  Fortunately, my first few days in Jerusalem were some of acclimatization allowing me to settle in before the placement-proper began. From my hostel in Davidka Square I ventured out, only to be overwhelmed by the vivacity and variety the city had to offer. I passed from the westernised new city under Jaffa Gate, to be greeted by the rich tangle of streets and alleyways which make up the old city.  The Via Dolorosa, Holy Sepulchre, Damascus Gate… The venerable renown of these timeless places seemed so at odds with the modern-day souvenir stalls and falafel stands. I arrived at the Western Wall plaza just as the city prepared to welcome Shabbat, and was in awe at the holy fervour which built as the sun set. Jerusalem, in all her antiquity and modernity, was like no place I had ever seen, and I was fascinated.

My first impressions of Hadassah Ein Kerem were dominated by the site’s enormity. The gleaming building, equipped with its own shopping mall, was somewhat dissimilar to the worn-down buildings of my own university hospital. The open-plan reception hall would seem more at home in a museum than a health centre, though given the organisation’s historic status, and its stunning Synagogue, perhaps this was only appropriate. I was taken to the crisp neurosurgical ward on the hospital’s top floor and introduced to Professor Shoshan, the unit’s director. Two things became immediately apparent: the team was extremely welcoming, and extremely busy.

At the morning residents meeting I met the ten-or-so neurosurgical residents who I would get to know over the coming month. The group were not dissimilar to the NHS registrars I have met (not least in work ethic and dark humour), yet they were far more varied in background. Many residents had come Israel specially to train, having started their medical careers in South America, whilst others had entered medicine having completed their national service in Israel. Such diversity extended to the consultant body, with one surgeon coming from London, and several others from North America. Understandably, Hebrew was the lingua franca in this assorted group, but the team never-the-less slipped effortlessly into English whenever they noted my presence. It was fascinating to hear the stories of these doctors, many of whom had made significant sacrifices to come and benefit from training at Hadassah.

I spent much of my time in the operating theatre, not only because surgery is something of a universal language, but also because of the sheer variety of procedures taking place. I finally had the opportunity to observe many of the textbook pathologies and procedures I had only ever had chance to read about: the trans-sphenoidal excision of a pituitary macroadenoma; excision of a para-sagittal meningioma; the removal of a cerebello-pontine angle tumour… I also benefitted from observing more esoteric procedures performed by the skull base surgeon, Professor Spektor. As I watched this surgeon make his carefully calculated approach, revealing intricate anatomy layer by layer, I was left in little doubt that I wanted to be a neurosurgeon. I will not soon forget my first glimpse of brainstem as the surgeon approached a deep lying cyst; nor will I forget the guttural apprehension I experienced when watching him painstakingly separate a tumour from a patient’s optic nerve. To say that my experience of Hadassah operating theatres was inspirational would be insufficient; it was motivational.

As well as observing procedures, I had the privilege of assisting in several surgeries. Most of these were spinal laminectomies, and I relished the physicality of such surgery. I was also invited to scrub for the insertion of an external ventricular drain, a common-place trainee-level procedure. During this operation I was able to make my first skin incision and operate the skull drill. Whilst very straight-forward, completing these small tasks whetted my appetite for surgery in a way previously unknown.

When not in theatre, I would join rounds on the ward or in neuro-Intensive Care Unit (ICU). I found the ICU rounds particularly useful as it demonstrated the non-operative aspect of neurosurgery, namely managing pathologies such as subarachnoid haemorrhage, as well as showing me the significant impact that neurosurgery can have on patients. By watching residents, I came to better understand how to evaluate the neurological status of unconscious patients, and enjoyed the evidence-based discussions led by the neuro-intensivist.

Whilst the above accounted for most of my clinical time, over the four weeks I was exposed to other aspects of neurosurgical care on a less regular basis. I enjoyed the weekly neurosurgical unit meeting at which residents presented interesting cases from the week, as well as the neuroradiology multidisciplinary team (MDT), during which particularly tricky cases were discussed with radiologists. One afternoon I accompanied a biopsy sample to the pathology lab and had some impromptu teaching on CNS lymphoma, whilst another afternoon I went to the interventional radiology suite to watch the coiling of a subarachnoid aneurysm. These experiences were also valuable, and fleshed out my understanding of service’s work.

Within a week I felt at home in Hadassah. I had familiarised myself with the mundane (working the scrub dispenser, negotiating bus routes…), and had become very accustomed to the fantastic lunches served in the hospital canteen. I also came to understand a little more about the hospital’s organisation. Elective patients being treated under compulsory health insurance would be operated upon in the morning, whilst private patients were taken to theatre after lunch. I learned with interest that residents assisting in the afternoon received an extra pay packet, an arrangement which surely would be welcomed by NHS trainees! The compulsory and accessible nature of health insurance in Israel also meant that the patient profile was varied; on several occasions the patient had been transferred from smaller hospitals in the Palestinian territories, the smaller hospital not being equipped to manage that particular pathology. This diversity of patients, as well as of staff, was a welcome balance to the picture of Israel often painted in the media.

Becoming more comfortable with the weekly routine meant that I had energy at the weekends to explore some of Israel. I ventured to Masada for sunrise, as well as to Ein Bokek to benefit from the salty water of the Dead Sea. I managed to explore some of Galilee, and visit the cities of Ramallah and Bethlehem. I remain astounded at the geographical and cultural variety offered by Israel, and most certainly hope to return in the near future.

Whilst I was disappointed when the placement ended, I was, and am, aware of just how much I have gained from it. I now have a much clearer idea of what day-to-day life in neurosurgery is like, as well as just how intense and immensely rewarding a career in this field could be. I have seen how Hadassah provides high-quality care to those in need, regardless of ethnicity or politics, and how the Israeli system of health insurance does seem to deliver to all members of society. I have been inspired by the commitment of neurosurgical trainees, as well as by the skill of their mentors, and remain stunned by the diverse beauty of what is simultaneously an ancient and very young country.

I am immensely grateful to the Jewish Medical Association who, through their generous gift, supported me in undertaking this most fruitful experience.

Dominic Ballard
Oxford

My elective was in Ophthalmology at the Royal Victorian Eye and Ear Hospital in Melbourne, Australia. This is a tertiary referral centre for ENT and Ophthalmology in Australia with specialist clinics and a 24-hour emergency service for the State of Victoria.

My elective experience was a unique opportunity for me to learn about the clinical skills and expertise necessary to perform as a doctor. An integral skill in being a doctor is communication. Throughout my time at the Royal Victorian Eye and Ear Hospital I met people from many cultures and nationalities.

About 30% of consultations were not in English so it was crucial for me to learn how to communicate with an interpreter present in the consultation. I drastically improved upon my non-verbal communication such as drawing simple diagrams to help patients understand their disease. I believe a patient should always be given the opportunity to understand what their disease is as this helps when the patient has to decide what treatment options should be chosen. When I am a doctor in the UK, I will always try my hardest to inform patients about their disease, even if it is difficult to communicate this.

Another important thing to learn was the clinical examination of ophthalmology. I slowly built up my examination skills using the slit lamp. Through determination and a very supportive network of colleagues at the hospital I was finally able to examine the anterior chamber of the eye. Not only this, I was also able to use lenses to visualise the retina, which is an advanced skill. This progress really emphasised to me the important values of teaching and teamwork. I felt like an integral member of the team and was shown respect and belonging. This made me feel determined to improve upon my skills and achieve to the best of my ability.

It was also important for me to learn how to diagnose ophthalmological disease by logically working from a focused selection of symptoms and signs attained from the history and examination. I was in fact running my own clinics in the Emergency Department, which was an amazing experience.  Yet the most important thing I learnt was not the fascinating diseases or patients that came through my door; it was learning when to say ‘I don’t know’. There were many times when I did not know the answer or felt thrown into the deep end. Fortunately, I was supported by a network of colleagues and was not scared to say ‘I don’t know’. There will always be a time when one will not know the answer to the diagnosis or cause of a disease. What is important is to know one’s own clinical limitations and to ask for help when this occurs. It also emphasised to me the role of teamwork and how crucial it is to learn from your peers. In fact ‘I don’t know’ taught me more medicine than any other phrase on my elective!

One aspect that drew me to Australia was to explore how the cultural and social perspectives of eye health differ in Australia compared to the UK. I was particularly interested in the noticeable healthcare discrepancy between the Indigenous (Aboriginal and Torres Strait Islander) and non-Indigenous people of Australia.

Indigenous people are six times more likely to be blind compared to non-Indigenous people. Extraordinary, Australia is the only developed country where the rare tropical eye disease Trachoma has not been eradicated. The Indigenous people suffer the brunt of this disease with some populations showing infection rates of up to 25% in Central Australia. This is a hugely interesting phenomenon and I wanted to investigate how this can be the case in a country that rates the second highest in the Human Development Index in the world.

I learnt that socially, the Indigenous population have been discriminated against since the Europeans colonised Australia. Many atrocities occurred with the Indigenous population being killed and forced to give up their land. Even up to the 1970s the Australian government took Aboriginal children from their original families and moved them to white households for assimilation. These children have been named by the Indigenous as the ‘stolen generation’.  An official apology from the Australian government was only issued in 2007. Naturally there is a great deal of mistrust between the Indigenous population and the Australian government – which is a plausible factor as to why Aboriginals have a poorer access to healthcare.

In response to this, the Australian government in conjunction with the University of Melbourne initiated a programme called ‘Closing the Gap for Vision’ in 2008. The aim of this programme was to eliminate this discrepancy by 2020. This was to be achieved through outreach clinics, education programmes and service changes to increase Indigenous healthcare access.

Locally at the Royal Victorian Eye and Ear Hospital there is a drive to make sure services are accessible to the Aboriginal population. I had a meeting with the Aboriginal Health Liaison Officer at my hospital to understand the protocol at the hospital. He explained if a patient identified as Aboriginal they are put on a separate pathway in the hospital system. For example, they would be assigned a personal Aboriginal Heath Liaison Officer who is of Aboriginal status themselves. These officers will contact the patient a couple of days before the appointment to make sure these patients attend and don’t get lost in the system.

In addition, Aboriginal patients have access to free transport to and from the hospital as many Aboriginal patients can live over 100km away. Because Aboriginals have a lower outcome than their European counterparts, they are seen as a priority for surgery. The normal waiting time for cataract surgery is 13 months. If one identifies as Aboriginal the surgery will be performed within 30 days. Therefore it is very important to identify Indigenous patients at the beginning of their treatment.

I was able to meet many Aboriginal patients and interviewed them on their thoughts on hospital access and healthcare. When speaking to patient JM, she explained to me the awful conditions her family grew up in the Northern Territory. She was pulled out of school at 12 and forced to work on the farms by the government. She resented the government and how they mistreated her. She found it very difficult to socially interact with ‘whites’ and it was very eye-opening to understand the level of poverty she had been through – with 8 children all sharing the same room. It made me realise that poverty is a major factor that contributes to poorer access of healthcare. When I am a doctor in the UK, I will never forget how poverty can affect my patients and will always try to help increase their access to healthcare to the best of my ability.

I wanted to get involved further in the eye health of the Indigenous people and managed to organise a small project in improving the local service. A national strategy had been adopted 2 years ago by the hospital that all patients would be asked if they identify as Indigenous before every appointment. This was because it was so important to identify those who are Aboriginal to get them onto the priority service.

A recent audit showed that receptionists were only asking Indigenous status to 3% of patients coming in for an appointment. This is obviously extremely low against the national standards. I was therefore asked to commission a survey to be sent to all receptionists in the hospital as to why ‘The Question’ was not being asked and to help tailor a training module for staff to correctly identify Indigenous patients.

In this survey I asked when administrators believed they should ask a patient about their Indigenous status. Then I also asked why they wouldn’t ask a patient about their status. The results showed that there were multiple reasons why staff did not ask ‘The Question’. The most common was that a patient’s nationality made them unlikely to be Aboriginal which can be seen as valid as a patient from China is unlikely to identify as Aboriginal. However, other reasons included lack of time and being uncomfortable in asking ‘The Question’ due to ‘backlash’ from non-Indigenous patients. It is very important to address these reasons in a follow up training module for staff.

On reflection, the project really emphasised to me how much work needs to be done to identify who are Aboriginal patients. It is no good having a priority service if Aboriginals are not being identified at the very beginning. I have learnt that improving access to healthcare also involves the clerical staff. I understand what a crucial role these people have in a patient’s journey in the healthcare system and how important it is to keep clerical staff updated and informed about national and local guidelines. As a doctor in the UK, not only will I support my patients, I will also support my colleagues – in particular my non-medical colleagues who perform an equally crucial role in the hospital.

Overall, I have learnt so much from my elective and I thank the Royal Victorian Eye and Ear Hospital, UCL and the Jewish Medical Association for giving me this fantastic opportunity.

Sam Myers
UCL

I was fortunate enough to spend 6 weeks undertaking an elective within the Trauma Department at Groote Schuur Hospital in Cape Town, South Africa. This was a fascinating experience where my practical skills were tested and constantly improved. I set myself the following four objectives for this elective.

Objective 1 – To understand the pattern and burden of Traumatic injuries and presentations to the Emergency Department in a main trauma centre in South Africa and how this compares to the UK and other more economically developed countries.

Trauma, relating to penetrating or blunt mechanical injury, statistics in South Africa are staggering and increasing. With over 60,000 trauma related deaths a year, many have labelled Trauma as one of South Africa’s main epidemics. In 2000, it was estimated that 12% of deaths in S.Africa were injury related. Compared with global rates, the injury related mortality rate is 6x higher and road traffic injury rates are double. There are over 1200 deaths a month on South Africa’s roads with PVAs (pedestrian vehicle accidents) accounting for over half of road related fatalities in comparison to MVAs (motor vehicle accidents). MVAs and PVAs account for 25% of trauma related deaths when combined. Homicide figures are 8x the global rates and account for around a third of trauma related deaths – there were 18,673 murders in 12 months between March 2015 and 2016. The Western Cape (the district which contains Cape Town) has the second highest murder rate in S. Africa at 52 per 100,000 of the population. In the UK, the homicide rate is 10 per million per annum (600 per year), which equates to around 35x below the rates in South Africa. It is difficult to appreciate how staggering raw statistics like these above are, however after a single shift in the C14 Trauma unit at Groote Schuur Hospital (GSH), it became apparent. In 4 weeks of Emergency Medicine and 6 weeks in Anaesthetics during Medical School in London I had not seen a single stab or gunshot wound. On my first shift, I saw 8 patients with penetrating gun shots and over 15 with stabbing injuries. For every trauma related death there are many trauma related injuries. It is estimated 40% of emergency admissions to hospitals in S. Africa are trauma related with over 3.5 million patients seeking care for trauma related injuries. Trauma itself is a product of many personal and societal factors including unemployment, poverty, drugs, alcohol, policing standards and the widespread practice of community assault. Community assault was a concept I had not previously encountered. What is essentially vigilantism is widespread in S.Africa and many of the patients I saw were victims of this. Whilst gunshots and stabbings are rare in the UK, community assaults are non-existent.

Objective 2 – To understand how a Trauma department in South Africa functions in comparison to the UK in terms of streamlining, organisation and facilities and to understand differences in pre-hospital emergency care provision between the UK and South Africa.

Groote Schuur Hospital (GSH) is one of two tertiary referral centres for Trauma in Cape Town therefore in addition to receiving trauma patients primarily it also accepts many referrals from other hospitals and day clinics which lack access to CT scanners. One primary difference between GSH and hospitals in the UK is the splitting of traumatic and medical emergencies into two separate departments. The newer district hospitals such as Khayelitsha and Mitchells Plain lack such streamlining and have tended towards Emergency departments like the UK. Within the trauma unit at GSH, patients are organised into 3 regions – Green, Yellow and Red (Resuscitation) which were staffed by 2 Medical Officers / Registrars, an intern (occasionally), one or two elective students with 5th year UCT students sometimes present in the evenings and weekends. These staffing levels differs significantly from the UK and become polarised in resuscitation situations. In GSH a red patient would be received by a single registrar with help from sisters and students however in the UK for critically ill resuscitation patients the ambulance or HEMS (helicopter emergency medical services) would pre-alert the department of an inbound patient. The department would then prepare for their arrival with the necessary equipment and staff which would include an Anaesthetic trainee, emergency medicine physicians, nurses and surgical specialties if necessary. In some very severe HEMS cases, patients might be transferred direct to CT before arrival in the resuscitation department. Furthermore, the quality of CPR I observed in GSH appeared poor in comparison to the UK. There is no 2222 related call system which in the UK provides resuscitation officers, staff members to document, keep time, anaesthetic trainees to manage the airway and sisters. Unfortunately, at GSH, CPR situations highlighted the staffing shortages. Added to this, trauma patients have reversible causes of cardiac arrest, are young and lacking medical problems and could often have good resuscitation outcomes. The facilities at GSH were dated and the department was often under stocked. I felt much time each shift was searching for necessary equipment. Much like in the UK there were bureaucratic issues which often slowed patient care – for example waiting for a folder and sticker for patients to allow them to have blood tests and further imaging investigations. On the other hand, the quality of the doctors in the department was incredible and it was a privilege to observe and learn from them. They cover many roles, work with time pressures and patient volumes which we don’t see in the UK, demonstrating incredible levels of practical skill. Pre-hospital care provision in S. Africa has a private and public component which differs from the UK and the quality of paramedics was variable. We often had paramedic students training in the department who spoke of the skill level they are hoping to achieve including emergency surgical airways which would not be performed by paramedics in the UK other than pre-hospital anaesthetists as part of HEMS team.

Objective 3 – To understand differences in the structure of the South African health care system and the NHS and to appreciate how this is influenced by poverty.

Statistics South Africa defines poverty in 3 categories; i) Food poverty line (people can’t afford food that meets the basic calorie needs), ii) Lower bound poverty line and iii) Upper bound poverty line. 27 million people (52% of the population) live below the upper bound on less than R779 per person per month (£47). Of these 18.6 million (36%) live below the lower bound on less than R501 per person per month (£30). 10.7 million (20.5%) live below the food poverty line on less than R335 per person per month (£20) and are therefore going hungry. These are extreme levels of poverty in a country with a phenomenal rich poor divide that is evident only by driving 10 minutes around Cape Town. These extreme levels of poverty influence accessing healthcare and healthcare provisions and poverty itself has been widely associated with poor health outcomes. The UK and South Africa both have governmental and private heath institutions however the government institutions are reportedly chronically understaffed and under resourced. In light of this, the wealthiest members of the South African population have private health insurance (medical aid) at great cost – around 18 million people (33% of the population) creating a two-tiered health system divided along the socioeconomic line of poverty. In 2013 the Total Health Expenditure in S. Africa was 8.9% of its GDP of which 48.4% was government funded to deliver services for around 70% of the population. The majority (51.6%) of the Total Health Expenditure was funded by 83 private medical aid schemes for the subset of population with medical aid. In the UK, the spend was 9.1% of which 84% was public government funded. These statistics highlight the funding disparity between the public systems in the UK and SA. Further evidence of funding differences is highlighted by the fact that the UK has 2.8 practicing physicians per 1000 population compared with 0.7 physicians per 1000 population in S.Africa. On the ground the structures of the public healthcare systems in SA and the UK are similar with primary healthcare facilities, district hospitals and specialised tertiary centres for advanced diagnostic procedures and treatments.

Objective 4 -To integrate into a team of healthcare professionals and contribute efficiently in a department where resources may be lacking compared to the UK. To improve my clinical skills including practical skills, clerking patients, communication skills and management of acute presentations to the Trauma unit / Emergency department for preparation as a Foundation year 1 doctor in the UK.

I was excited at the prospect of an elective in Trauma at GSH as I knew my skill level would be tested and constantly improved. I was initially taken aback at the sheer volume and type of trauma, lack of sedation and analgesia in use and that patients waited for well over 8 hours to be seen in some cases without any complaints. I was also initially surprised at the paternalistic nature of medical practice in the department due to the conditions in which the staff had to work. Ultimately though, this elective resulted in my best placement during my 5 years of medical school. There were between 7 and 10 elective students in the department during my 6 weeks at GSH and we divided up the week into 14 shifts which we were expected to cover. Day shifts were 8am to 6pm and nights from 6pm to 8am. As the weeks went by and the shifts came and went I grew in confidence with regards to my practical skills including suturing, ICDs (chest drains), airway management, taking bloods and cannulation, femoral stabs and ABGs as well as identifying critically ill patients. I was able to clerk patients in the green and yellow areas of the department, formulating investigation and management plans to present to the registrars for approval and confirmation. I was also encouraged to present patients at the post shift ward rounds. Overall this was a very rewarding, yet intense elective with incredible learning opportunities from some very skilled clinicians and if I had the chance to I would repeat it again.

Non-Medical Activities

Cape Town is a fantastic city with activities and a vibrant night life. From mountainous hikes, to wine tasting we were well entertained. There is also a vibrant Jewish Community based in Seapoint and in the some of the outer suburbs. It was a pleasure to integrate into the Gardens Jewish Community for Shabbat and Pesach services and to meet many local Jews. I was privileged to take my non-Jewish colleagues to the Cape Town Jewish Museum and Holocaust memorial. They all commented that it was an eye opening worthwhile experience.

We also had the opportunity to spend 3 weeks travelling across South Africa. As a group, we decided to drive from the East to the West Coast and experience some of South Africa’s finest sights including the Garden Route, Bloukrans Bungee Jump, Coffee Bay, Imfolozi Safari Park, Addo National Park as well as big cities like Durban and Joburg.

I am grateful for the funding I received for this once in a lifetime elective and I would strongly recommend Cape Town as an all-encompassing elective destination for future students.

Alan Greenstein
QMUL

INTRODUCTION

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 facilities^1,2. 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:

1. 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.
2. 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.
3. 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.
4. After having spent a year gaining specialist knowledge, I wanted to refresh my general medical knowledge ahead of 5^th year. In particular, to extend my skills in history taking and clinical examination.

ELECTIVE ACTIVITIES

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 5^th 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.

CASE DISCUSSION

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.

Lines:

(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 life^4,5. 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 background^4,5. I was shocked by the degree of cultural insensitivity and the importance of appreciating cultural differences so as to remain non-judgmental.

OVERALL REFLECTION

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.

REFERENCES

(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)

 

Sophie Ellis
Leeds