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From April to May 2016 I spent six weeks at the Prince of Wales hospital in Randwick, Sydney, in their adult and paediatric ophthalmology department.  The Prince of Wales is a large hospital in central Sydney with both a public and a private hospital on the same site, and it serves diverse population.

Ophthalmology theatres for the hospital were situated in the nearby Sydney Eye Hospital.

During my elective I spent time in theatre, in outpatient clinics and occasionally on the wards. In adult and paediatric theatre I had the opportunity to observe a variety of surgeries that I had not previously been exposed to.

I also sat in many adult and paediatric outpatient clinics where I learnt valuable practical skills. I have become much better at using a slit lamp with lenses, and the indirect ophthalmoscope to visualize the retina clearly and detect retinal pathology. I was able to observe many procedures during clinic time, such as anti-VEGF injections, laser such as the Yag and laser for diabetic retinopathy. I was also exposed to paediatric ophthalmology for the first time – where I saw a completely different range of pathology and I was able to appreciate the different aims of treatment when treating children vs adults (for example patching to improve eyesight).

I felt that doing my elective in an area that I saw much less of in medical school gave me an opportunity to learn a lot of new skills and to broaden my knowledge in a way I would not have other wise done.

I found the Sydney Jewish community incredibly warm and welcoming whilst I was there and this really enhanced my experience.

I am very grateful to the association for their generous contribution towards my elective.

Jessica Solomon
UCL

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

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

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

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

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

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

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

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

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

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

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

Being in Israel

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

 

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

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

 

The number of kosher restaurants is also a great plus!

Charlotte (Dodi) Levene
Imperial College School of Medicine

In 2013 I spent six weeks in a hospital in Nkhoma, Malawi. The hospital was in a beautiful rural village at the bottom of a mountain with limited resources, financed by Church of Central

Africa Presbyterian (CCAP). It had a handful of wards: general male, general female, paediatric, labour and two theatres. You could walk through the whole hospital in three minutes. Staffed by one senior physician and one senior surgeon from the US and Holland respectively. The nurses were all

Malawian and could speak English, but almost all the patients only spoke Chichewa. I was there over Rosh Hashana, Yom Kippur and Succot which was an interesting experience as there were unsurprisingly no Jews in Nkhoma.

Traditional healers

Malawian culture places ample emphasis on traditional healers. There is no primary health care, general practitioners don’t exist. However, many patients will seek a traditional healer as a first port of call. It has a significant impact on healthcare because it results in many patients presenting with late stage diseases after the traditional healer failed to cure them for a period of time. Moreover, patients often trust traditional healers more than conventional healthcare, which can make management complex.

Limited resources

Investigations were not always readily available. Blood tests were often very limited if they didn’t have the money that week to pay for reagents required to run the tests. Chest x rays were sometimes not possible if there was no running water to develop the films. This meant having to triage the patients who most needed the tests.

Language barrier

Although I learnt some terms in Chichewa, the local language, most of the time I was taking histories and examining patients either with the aid of a nurse translating, or using solely non verbal communication. This made consultations both challenging and at times amusing when trying to portray vomiting or diarrhoea through the art of acting.

Tropical disease

Tropical diseases were prevalent, but not as much as I thought originally. I learnt a reasonable amount about diagnosis and treatment of these diseases, e.g. schistosomiasis, but I learnt a lot more about the common diseases that one sees in the UK, e.g. heart failure and pneumonia.

Because patients presented late, clinical signs were more readily detected and the number of patients with organomegaly doesn’t compare to that which you see in the UK.

Religious beliefs

I was surprised to learn about the impact of religious beliefs. The local community were devout Christians and the Chaplain played a key role as part of the medical team. Many patients were either terminal, dying, or died in hospital. The chaplain was always called to see the patients and family to help explain, reassure or comfort them, making a huge difference to the patient, the family and the general atmosphere on the wards. It was interesting to discuss the similarities and differences with the Chaplain from a Christian and Jewish perspective on science, modern medicine and death. The patients trusted the Chaplain more than the medical team. He played such a crucial role in comforting the patients but also in explaining conditions to patients bridging the gap between their traditional religious beliefs and our modern understanding of science and medicine 

Patient with breast cancer.

Three weeks into my elective, I saw a 52 year old female on the acute medical ward. She had presented with a cough and shortness of breath. I took a history from her with Catherine, one of the nurses, translating for me. After the history, I thought a simple pneumonia was the most likely explanation for her symptoms. Other infectious diseases would have to be on my differential as well, e.g. TB. As usual I proceeded to examine the patient, not expecting to find anything remarkable aside from maybe some respiratory signs. When it came to exposing the patient’s chest, I was shocked. On her right breast was a horrible fungating breast cancer.

Although I am uncertain as to whether or not I drastically changed my facial expression to express my shock, I doubt I was able to stop myself from reacting to it as I was totally unprepared. The patient did not seem to mind the cancerous growth spread across engulfing her breast. She simply said it’s been there for while. I completed the rest of the examination and heard some crepitations in her right lower base. She did in fact have a pneumonia as well as the fungating breast cancer.

This case had an impact on me in terms of understanding why patients seek medical care. This patient had a fungating breast cancer for at least a year yet she didn’t seek medical care until she contracted a pneumonia. This puzzled me. A woman in the UK would not wait for a breast cancer to grow through the skin, she would more often feel a lump earlier on and seek medical attention. People in the UK are educated, formerly or indirectly, about breast cancer. In schools, on television, or adverts on the tube, women know about breast cancer and are aware of what signs to look out for. Moreover, there is a national screening programme for it. This is diametrically contrasted with women in Malawi. There is little health education, formal or indirect, and there is no breast screening program. This patient did not know she had breast cancer because she did not know what breast cancer was or that it even existed. It did not bother her, she continued life with it. Ultimately her breast cancer did not disable her. As a mother, culturally her duty was to take care of the children, manage the home and cook the food. She was able to continue to do this until she developed a pneumonia. Although shortness of breath is seemingly a mild symptom relative to the gravity of a long standing invasive breast cancer, it was nonetheless more disabling for this patient. Patients in Malawi do not seek help because they are concerned about certain symptoms, they seek help if those symptoms are disabling because if they cannot work or fulfil their expected duty at home, they do not earn money, they cannot afford food and they starve. They do not go to hospital if there is merely pain, blood or deformities. They go to hospital if anything disables them, if it physically impairs their function.

This reminded me of the importance of public health education and screening programmes. People need to know about diseases so they can seek help before these diseases become untreatable. This patient’s prognosis was negligible. There’s no medical or surgical treatment available to her that will prevent her cancer from killing her in the near future. If either she sought medical advice when she first noticed a lump, or if there was a breast screening program in place, it would be a different story, one with a better ending.

Rosh Hashana, Yom Kippur, Succot

I knew before going that there was no Jewish community in Malawi, not even a Chabad, which was surprising. I therefore realised it was essential to bring a mascot, a religious item of sorts, to serve as a constant reminder my roots and religious Jewish persuasions. So I decided to be practical and brought with me a bulky, awkward to pack, space occupying Shofar. Despite the presence of my shofar, this was the first Rosh Hashana I had which did not feel like Rosh Hashana. I managed to find apples in the local market. Not really an M&S selection, not really golden or delicious. But there were four apples to choose from – apples bizarrely cost more than grapefruits in Malawi. I chose the two least bruised apples, some honey from Mzuzu. Very grainy. Bit too bitty. Semisatisfied with my apples and Mzuzu honey, I showered and donned my white shirt for the New Year, before struggling to explain the significance of eating honey on apples without sounding like a weirdo to the other medical students and volunteer doctors from around the world. Although Rosh Hashana wasn’t what it usually was for me, I invited a Malaysian and Dutch medical student round to my house to show them how it’s really done. Yom Kippur sadly also lacked the atmosphere which I take for granted at home. However, it was interesting to discuss with everyone, including the Chaplain the concept of a day of atonement, introspection and self reflection. And it was an experience breaking the fast for the first time on Malawian gin, something I will not  ever voluntarily be doing again. As for Succot, the best I could do was find a large lemon and some willow from the garden.

There was, however, one small aspect about being in Nkhoma which I found connected me to my Judaism unexpectedly. There were oftenpower cuts which limited us to candle light and restricted gas cooking. This meant on Shabbat, towards the evening there was an atmosphere that reminded of me Bnei Akiva camp where everyone sits around a table with no phones, no tvs, no computers and talks as it gets darker and Shabbat comes to an end. The abundance of candles available also made Havdala very easy and accessible.

Thanks to the JMA for all the support and enabling me to have a fantastic elective in Malawi!

Julian Gertner
UCL

Daniel Swerdlow from UCL went to Balfour Hospital in Orkney. His beautifully illustrated report can be found here as well as an interesting audit report.

In November-December 2012, I spent my six week elective placement in the Paediatrics A department of the Meyer Children’s Hospital in Haifa. I had been searching for a paediatric placement, preferably in a dedicated paediatric hospital, in Israel, in which speaking Hebrew was not a requirement! The Meyer Children’s Hospital is the only children’s hospital in Northern Israel and so seemed like an excellent choice where I could spend my placement.

The Rambam Campus primarily serves Haifa’s population, but also serves the wider population of Northern Israel. The hospital had a mixture of Jewish, Arab Muslim and Arab Christian doctors and patients, who were all treated together. Haifa itself is well known for the levels of religious co-existence and this was certainly the case within the hospital walls.

The department to which I was attached was a general paediatrics department and so I was exposed to a wide variety of paediatric conditions. Professor Shehadeh, the Director of this department, has a particular interest in type 1 diabetes, and therefore there were always a number of patients with newly diagnosed diabetes on the ward. The hospital is affiliated with the Technion Medical School and there was a firm of medical students on the ward together with me.

The day often started with a ward round, which was always attended by a very large number of doctors. Where conversations took place in Hebrew, one of the doctors or medical students was always happy to act as translator. During the placement I attended a number of the medical students’ bedside teaching sessions. All the doctors and medical students spoke English to a very high level and the medical students’ bedside teaching sessions were almost always conducted in English in order that I could join them. I was also able to clerk the patients on the ward who could speak English and then discuss the cases with one of the residents. All of the doctors and medical students on the ward were extremely friendly and helpful.

I particularly enjoyed being in the hospital during the festival of Chanukah. There was a strong holiday spirit with a seemingly constant flow of Chanukah treats for the children, including visits from all of Haifa’s sports teams! Another highlight was that the hospital is on the beach …..which is where a great deal of my free time was spent

During my elective I also had time to explore both Haifa and Israel more widely and spend time with friends who had made aliyah and moved to Israel permanently. A weekend spent at the Dead Sea was particularly memorable.

I had a rewarding, interesting and exciting time on my elective and would like to thank the Association for their support.

Amy Taylor
University College London

My elective was split between Cape Town in South Africa and Tamale in Ghana.

The first month was a placement in the Emergency Room at the Somerset Hospital in Cape Town. Whilst being state-funded, the unit was very well-supplied as it had lots of equipment sponsored by large South African companies. We were expected to start at 08:00 each morning for the Emergency Room ward round, at which we would see all the patients that had been brought in that night. We would get a number of jobs to do from that ward round, and once they were finished, we would begin seeing our own patients. The level of competence and knowledge expected of a doctor was similar to that expected In UK but the doctors’ practical skills were perhaps better. Socially the environment in Cape Town was vibrant, with a number of local medical students based at the hospital.

After Cape Town it was time to go to Tamale, a large town in northern Ghana. I was placed on the general surgery division, and this placement involved attendance in surgical theatres, ward rounds and surgical liaison in the Emergency Room. It was a very interesting month. Whilst many of the surgical trainees were far more skilled than their UK counterparts, the procedures in theatres were very similar. The main difference came in the clinics, where we would see very late presentations of serious disease such as breast cancer and hernias. The entire time there was very interesting.

The elective  was made possible in part by the generous contribution of the Association and the experience has contributed to my clinical practice and outlook in ways that I never thought possible.

Sebastian Vandermolen
King’s College London

I have had an interest in neurology for many years, and having completed my rotation at Queens Square in London, I was inspired to spend further time in the field. I have always enjoyed travelling and volunteering in Israel, and it now seemed like a perfect opportunity to spend time studying and working in Israel.

I spent 6 weeks in the neurology department of Hadassah Ein Kerem Hospital. It did not take me long to appreciate the truly outstanding level of personal care and treatment at Hadassah. It was heart-warming to see that at Hadassah, patients of all backgrounds are treated equally and indeed, the staff work together in harmony.

My supervising consultant was a humble man who is a leading expert in the field of multiple sclerosis. He introduced me to the department and to the various members of the medical team. My day would usually start at around 7.45 am, where I would help the residents in their daily tasks. We would then join with the consultant for the ward round, which often lasted until midday or, on Thursdays, when we had a Grand Round, well into the afternoon. The Grand Round is based on a traditional European-style round, with the whole medical team and consultants seeing all the patients. Despite it being a challenge to get to the front of the crowd of 20 or so members of staff on the round, it was nonetheless the highlight of the week. I also spent time in the various outpatient departments, and down in the busy emergency room, seeing the acute cases.

Medical students in Israel are active participants in the medical team, and I was encouraged to participate in ward round discussions, journal club meetings and indeed and was asked to voice my opinions on the diagnosis and management of patients. This collaborative approach with medical students allowed me to extensively increase my knowledge in the various fields of neurology. The department had a varied case load, and I was able to learn about a plethora of diseases I had never seen before in the UK. These included neuro-infectious diseases such as Lyme Disease and West Nile Virus and the neuroimmunological diseases such as ADEM, and optic neuritis. Whilst in the department, I was also able to complete a research study looking into the views and opinions of neurological patients of their treatment, exploring the psycho-social aspects of medical care.

Whilst in the department I was made to feel very welcome by the hospitable members of the neurology team. Despite having a limited Hebrew when I first joined, this proved not to be a major problem as I had first envisaged. The staff were very happy to talk in English, when necessary; and indeed many patients speak some English. Furthermore, it proved to be a fantastic opportunity to improve my Hebrew. However, I found that as the weeks went on, I improved my Hebrew dramatically, and indeed was even able to learn a little Arabic, which is widely spoken by many of the patients at Hadassah.

Whilst in Israel, I was also able to attend the Israeli Neurological Society Conference. This meeting, held annually, brings together physicians and researchers from Israel. It was an opportunity to hear about the multitude of pharmacological, technological and scientific breakthroughs in the various subspecialties of neurology.

Throughout my time in Israel I was also able to experience the full benefits of Israeli society and culture. I attended a number of social events, visited some historical museums and travelled to some intriguing archaeological sites. Other highlights of my trip included travelling to Tverya and Tzfat.

I would highly recommend any student to carry out their elective in Israel, and in particular, the experience that can be gained from studying at Hadassah Ein Kerem. I am happy to assist any other student who has any queries, advice or tips for spending time on elective in Israel.

Finally, I am extremely grateful for the very generous award from the Jewish Medical Association towards funding my elective, without which I would not have been able to have had such a thoroughly enriching academic and cultural experience.

Benjamin Artman
University College London

On the 10th of February 2013, after completing my final year examinations at Oxford University, I left England on my medical elective. I had three main aims for this period :1) To broaden my insight into global medicine and the cultural factors involved in this, 2) To experience how health care is delivered in places other than the UK, 3) To both use and build upon my clinical knowledge from medical school.

I began my elective with five weeks in Israel, where I had arranged through the Ben Gurion Medical School in Beer Sheva to spend some time initially in Tel Aviv experiencing the Refugee Clinics, and then in Eilat in the Emergency Department.

The Tel Aviv Refugee Clinic was based in Jaffa, run by the Physicians for Human Rights (PHR) organisation. This clinic, served by volunteer doctors and other staff, aims to provide health care to anyone without the means to receive it in Israel. This includes migrants, asylum seekers or anyone whose legal status is as yet undetermined. What was evident from the start of my time at PHR was the huge range of cultural and religious backgrounds that attended the clinic. On my first day alone we were presented with patients from Somalia, Nigeria, Eritrea, North America, Argentina, and Palestine, offering a huge range of languages, and backgrounds. Despite very few consultations being held in the patient’s or the physician’s first language, the staff at PHR amazed me with their huge range of language abilities, allowing consultations to occur despite this. I spent time with a range of doctors and nurses each day, from the triage nurses, to specialist psychiatrists and surgeons, providing huge variety in aspects of clinical care. For example, one patient I saw with the family doctor regarding a chest infection, I then saw later with the psychiatrist for post traumatic stress disorder which was related to his seeking of asylum in Israel.

A highlight of my time in Tel Aviv was an evening spent with the mobile sexually transmitted diseases (STD) clinic, the Lewinski Clinic, which is based in the Tel Aviv new central bus. The mobile service is a relatively new project, set up to serve high risk populations that were at less likely to seek medical help. This particularly includes refugees, sex workers, drug users, and those living in more deprived areas of the city. The clinic really opened my eyes to the depths of Tel Aviv as we visited the brothels and overcrowded apartments serving as centres for groups of refugees. They provided information, advice, contact points and also confidential STD testing to anyone wanting it. Most of the places we visited knew the clinic staff and welcomed them in, a relationship which has taken the staff a long time to establish, and I was grateful to be able to be a part of this.

My experience in Tel Aviv was a huge contrast to the medicine I am used to in England. Even more so than the medicine itself, my learning focused on the backgrounds of some of the refugees, the cultural diversity present within these communities and the medical and social problems that are associated with this. From taking patient histories it was evident that many of the patients had made huge journeys and been placed in diverse undesirable situations along the way to reach Israel and seek asylum. These were situations which I had never experienced before in medicine, and highlighted the specific social needs of these patients along with the medical needs we all have. The volunteer doctors were fantastic at providing both social support and medical care to the patients that really needed it after arriving from often awful situations to a completely new and unknown place to them.

My Tel Aviv placement was supervised by Professor Alkan who was fantastic both at teaching in the clinic, and also as a host. He educated me into the history of Israel, its politics and populations as well as providing stimulating medical cases. I also got to meet some of the medical students in Israel, and it was great to compare our experiences of medical school and to make some new friends.

As well as my work within the clinics, I had some time to explore Israel itself. Having never been there before, this was something I was looking forward to doing very much. I made a day trip to Jerusalem which offered so many wonders to see, with the Old City showing an unbelievable mixture of religious backgrounds working together. Having a keen interest in cooking, I found Israel to be full of culinary delights. I very much enjoyed going to the buzzing Carmel Market in Tel Aviv, and having Shabbat dinner with Professor Alkan’s family, as well as tyring the delicious local street food such as falafel, baba ganouch and sabich. A highlight also was the festival of Purim whilst I as in Tel Aviv. During this weekend the whole city was alive with music, dancing, and happiness, with people dressed in every imaginable costume: it really was an occasion to remember.

For the second half of my time in Israel, I worked in the emergency department of Joseftal hospital, Eilat along with three other students from Ben Gurion University. With just 65 beds, this is the smallest and southernmost hospital in Israel, and serves a vast area including most of the Negev Desert. The emergency department is run by Dr Arad who, along with his team, was extremely welcoming and a fantastic teacher. At 8 am each morning the day would begin with a roundup of the patients from the day before and any new admissions. Dr Arad would focus on the conditions which came up and use these as the starting point for teaching sessions within the meeting. This was great as it meant we covered a wide variety of emergency medicine topics, constantly testing our knowledge and learning new things. I would then spend the day clerking patients – if they we able to speak English or using my limited French – and improving my practical skills of suturing, plastering, chest drain insertion and lumbar punctures, many of which I had not had the chance to do before. Being one of the closest emergency centres to the Red Sea, the hospital has a special interest in hyperbaric medicine, having a decompression chamber onsite. This was a completely new and interesting experience in medicine for me, and despite not seeing any patients with diving related problems, I gained excellent knowledge on the methods used in this area of medicine.

The population attending Joseftal hospital was a big contrast to those in the Refugee Clinics I had experienced in Tel Aviv. There were very few immigrants, with the largest population consisting of local people, closely seconded by tourists. The hospital covers a vast area, with no other emergency department for 240km, and so many patients had travelled a long way to be seen. Any emergencies that could not be managed in this small hospital were transferred to Soroka Hospital in Beer Sheva either via ambulance or helicopter. Joseftal hospital itself was undergoing renovations whilst I was there, expanding the emergency department and modernising the equipment, which will be of huge benefit in the future as often space was limited, and I imagine this is even more of a problem during the peak summer season.

Eilat was an incredible place to spend a few weeks, getting excellent medical teaching accompanied by great weather despite it being Israeli ‘winter’, and a beautiful coast line to explore after a day at work. The other students and I stayed in a flat owned by the hospital which was within walking distance, and despite being fairly basic with minimal cooking facilities, was adequate for the small amount of time we spent there each day. We ate lunch every day at the hospital, which provided a fantastic spread of unlimited hot options, soups and salads for just one shekel (around 18p!) which kept us going for the rest of the day. Along with the other students and doctors, I snorkelled in Coral Bay, hiked in the desert, and even had a weekend trip to Petra in Jordan. I would thoroughly recommend this placement to anyone interested in Emergency Medicine as Dr Arad is an exceptional teacher, and the small department makes it a very friendly and welcoming environment to work in with many opportunities for developing practical skills.

Overall my experience of medicine in Israel was absolutely fantastic and one I would recommend to anyone. Splitting my time in two locations provided huge variety in the populations and the medical problems as well as allowing me to see a larger area of the country. I feel I met all of my initial aims of experiencing global medicine, foreign health care and practicing and improving my clinical skills, with the practical skills particularly being highlighted during my time in the Emergency Department in Eilat. I also feel I exceeded these initial aims, gaining a far better understanding of refugees in general as well as their medical problems, cultural diversity within medicine, the history and politics of Israel and Jewish culture, and aspects of medicine I did not expect to encounter such as hyperbaric medicine. I made friends and contacts both of other medical students in Israel, and doctors, that I hope to keep in touch with for many years to come, and who helped to make this experience so memorable.

I would like to thank the Jewish Medical Association (UK) for making this learning experience possible for me. Not only has it been medically stimulating, improving me as a doctor in the future, but it has also opened my eyes to a fantastic country I previously knew very little about. I cannot speak highly enough of my time in Israel, and I am very much looking forward to going back to this wonderful country, hopefully to experience more medicine there in the future.

Victoria Ormerod
Oxford University

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

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

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

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

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

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

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

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

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

Miriam Burns
King’s College London

Adam Sher travelled to Tygerberg Academic Hospital on the outskirts of Cape Town, South Africa. He has a BMedSc in Medical Ethics and Law, for which his dissertation was a consideration of the relative merits of the Israeli Patients Rights Act 1996 and English law when patients refuse life-saving treatment. He further developed his work on patient autonomy in South Africa, and considered the concept of ‘trust’ within physician-patient relationships. He found that due to the unique character of the South African healthcare establishment, paternalism reigned despite attempts to empower the local patient population. His full report is attached here.