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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

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