Category: Uncategorised

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sam Myers
UCL

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

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

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

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

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

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

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

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

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

Non-Medical Activities

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

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

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

Alan Greenstein
QMUL

INTRODUCTION

I undertook my elective at the Royal Melbourne Hospital (RMH), Australia. During this time, I rotated through endocrinology and ICU.

My motivation for choosing Australia was two-fold: it constituted an opportunity to experience a different healthcare system whilst working in an environment not too dissimilar to the NHS. I hoped to transfer knowledge and skills learnt during my elective to practice back in the UK. A further attraction was the absence of a language barrier, which would allow me to learn quickly and effectively. Given the current state of the NHS and the proposed introduction of the new junior doctor contract, my awareness was heightened to claims of greater job satisfaction in Australia. In other words, I was going to see for myself whether the grass really was greener on the other side!

THE ROYAL MELBOURNE HOSPITAL

I chose the Royal Melbourne Hospital (RMH) because of it’s central location and reputation as a Level 1 trauma centre¹. I have always been interested in acute and critical care, something which was enhanced by my 4th year ACC placement. For this, I was placed in a DGH (District General Hospital) and whilst a useful teaching opportunity, I felt it lacked the excitement and drama of a regional trauma centre – an experience many of my colleagues enthused about. By contrast, RMH is a tertiary level referral centre with highly specialised critical care facilities^1,2. It is one of the largest hospitals in Melbourne with a capacity of 1400 beds¹ and is located in the centre of the central business district. Melbourne has a varied demographic, and as such the Royal Melbourne is responsible for treating a diverse cross-section of patients³. This includes the local aboriginal community as well as a large migrant patient population, for whom language and differences in culture pose a significant barrier to healthcare access⁴.

Within Australia, much like the UK, there is a defined public and private sector. RMH is based within the public sector and whilst services were rationed based on clinical need, the strain appeared far less than in the NHS. Healthcare is delivered primarily by Medicare, a state funded healthcare system which is free at the point of delivery⁵. Although a government-led service, there is variation in policy between individual states⁵. Despite this service, many Australians, choose to pay for private healthcare insurance, which in turn alleviates pressure of demand on the public sector.

AIMS & OBJECTIVES: 

My primary aims were:

1. To develop skills and knowledge transferable to my future practice as a junior doctor, whilst at the same time gaining experience of a healthcare system with different cultural groups to that of the UK.
2. To gain first-hand experience of the Australian healthcare system and working environment, to see if this would be a country in which I would like to work in the future.
3. To gain greater clinical experience in acute and critical care. Develop confidence in managing the critically ill patient, building upon the skills and knowledge gained in the RRAPID element of the Leeds MBCHB course.
4. After having spent a year gaining specialist knowledge, I wanted to refresh my general medical knowledge ahead of 5^th year. In particular, to extend my skills in history taking and clinical examination.

ELECTIVE ACTIVITIES

During my time at RMH, I participated in ward rounds, attended clinics and was involved in educational activities such as teaching and simulation. I had the opportunity to lead handovers and perform many of the roles expected of an FY1 doctor; as such it was extremely useful preparation for 5^th year as well as my future clinical practice.

On endocrinology, I spent most mornings with the “residents”, equivalent to UK foundation doctors. Here, I was able to consolidate clinical history and examination skills as well as basic skills such as venepuncture and cannulation. The remaining time was spent in clinics, where I was encouraged to conduct my own clinic lists and with supervision, formulate management plans. On ICU, I had the opportunity to participate in procedures such as central lines and intubation. This was in addition to ward rounds, where I was encouraged to present complex patient histories.

CASE DISCUSSION

On reflection, I experienced a number of notable cases during my time at RMH. However, there is one case in particular, which I feel warrants further discussion: a patient with whom I had contact with during both my endocrinology and ICU rotation. The patient concerned was a 39 year-old aboriginal man (Mr. X), who presented in type 2 respiratory failure secondary to severe bronchospasm. He presented with worsening dyspnoea following a 2-week history of coryzal type symptoms including dry cough and intermittent fevers, for which he received no medical care. Initially, treated with nebulised salbutamol and oral prednisolone, Mr. X’s condition deteriorated and ultimately required intubation and transfer to ICU.

A type 1 diabetic (T1DM), the physiological stress induced by the bronchospasm triggered a diabeteic ketoacidosis (DKA) (blood gas pH 7.1, blood glucose of 38mmol/l and blood ketones 5mmol/l). Blood gas results revealed a mixed respiratory and metabolic acidosis; requiring both endocrine and intensivist input. Management of his DKA involved rehydration with crystalloid fluids and an insulin/potassium infusion.

Medical records revealed extensive alcohol and drug history as well as a long-standing history of T1DM with poor compliance. This was further suggested by a right transmetatarsal amputation for complications of peripheral neuropathy. There was also note of previous criminal convictions.

Examination findings were as follows: Mr X was intubated, sedated and paralysed.

A: The patient was intubated with an endotracheal tube measuring 7.5mm and 23cm at the lips.

B: Oxygen Saturations were 97% on FiO2 100%, ventilatory support (SIMV – synchronised intermittent mechanical ventilation). Air entry was equal and bilateral with symmetrical chest wall movement. A prolonged expiratory phase with wheeze heard on auscultation.

C:BP 84/50, MAP 58, HR 82, peripherally cool with a delayed capillary refill time of 4 seconds.  No audible murmur. Mr X required boluses of matrimonial to maintain SBP > 80 and a MAP > 55

D: Afebrile. GCS 3 (E1, Vt, M1) – patient was intubated, sedated and paralysed. BSL 35mmol/l

E: Abdomen soft and non-tender.

Lines:

(1) CVC (Central Venous Catheter) inserted and position in subclavian confirmed by CXR and blood gas aspirates.

(2) Right radial arterial line in situ

(3) Bladder catheter in situ

After three days in ICU, Mr X was successfully extubated and we were able to take a more detailed history. It became evident that Mr X was socially isolated having previously resisted all medical and social intervention. The formal organisation of western society i.e. our norms, rules and customs are antithetical to the Aboriginal way of life^4,5. This manifested itself as a barrier for Mr X resulting in his previous failure to access appropriate care. Although, staff members maintained professional throughout treating Mr X, I observed that they lacked the empathy so clearly demonstrated to other patients. There was an unsaid disapproval that his medical deterioration was self-inflicted, which in turn contributed to a paternalistic approach towards him. I saw how this approach created a viscous cycle resulting in Mr X withdrawing further from medical advice, such that three weeks later he was readmitted with a further episode of DKA. I was advised that this pattern was not untypical for patients from an aboriginal background^4,5. I was shocked by the degree of cultural insensitivity and the importance of appreciating cultural differences so as to remain non-judgmental.

OVERALL REFLECTION

I found many aspects of Australian public healthcare to be similar to the NHS, namely the standard and quality of medical care. However, there were definite differences between the two, mostly due to the varying cultural groups that exist within Australia. For example, there is a huge disparity between aboriginal and non-aboriginal communities, with members of the indigenous population inherently disadvantaged. I observed a definite paternalistic attitude towards such patients and in my opinion a shameful disregard for their autonomy. This disparity is highlighted in the above case where Mr X’s physical and social neglect was such that he was at a point of absolute desperation. The paternalistic and controlling approach employed by previous medical staff had alienated Mr X such that he had come to avoid seeking medical attention. To me, the economic and cultural divisions seemed far more pronounced in Australia than in the NHS.

Above all, I have taken away the importance of holistic and patient-centred care, and seen how the attitude of “the doctor knows best” can be to the detriment of the patient. There did not appear to be the same emphasis on communication or patient choice, as I have experienced in the UK. It was on these occasions, I felt proud to be training in a system where doctors are encouraged to seek out their patient’s concerns, allowing for shared decision-making.

Overall, I had an absolutely fantastic elective experience, both medically and culturally and on reflection, I do feel that I have satisfied my aims and objectives. I have gained knowledge and enhanced skills, which I will ultimately be able to transfer to my working practice. Through attending simulation training on airway management and being actively involved in a patient’s resuscitation, I do feel more confident in managing a critically ill patient; something, which will be invaluable to my future working practice. During my time at RMH, I also gained experience in managing emergency conditions such as DKA, something with which I am expected to be familiar as a foundation doctor.

And so, in answer to whether the grass is greener on the other side, I would say that there are certain attractions, which would undoubtedly appeal to any doctor looking for a change in working environment, not least the weather and less strained resources! However, as I prepare myself for life as a junior doctor working in the NHS, I can be satisfied with the quality of care that is provided and which hopefully, I will help to deliver.

REFERENCES

(1)  The Royal Melbourne Hospital. About RMH. 2016. Available at: https://www.thermh.org.au/about/about-rmh (Accessed 13/09/16)

(2)  The Royal Melbourne Hospital. Intensive Care Unit. 2016. Available at: https://www.thermh.org.au/health-professionals/clinical-services/intensive-care-unit (Accessed 13/09/16)

(3)  Australian Government: Australian Bureau of Statistics. 2016. Available fromhttp://www.abs.gov.au/ausstats/abs@.nsf/mf/3101.0 (Accessed 13/09/16)

(4)  Australian Government: Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people an overview. 2011. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737418955 (Accessed 13/09/16)

(5)  Australian Government: Institute of Health and Welfare. 2014. Available at: http://www.aihw.gov.au/australias-health/2014/health-system/ (Accessed 13/09/16)

 

Sophie Ellis
Leeds

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