Category: Uncategorised

Introduction

When deciding elective destinations, I searched for a placement where I could make a contribution, whilst gaining confidence in my clinical skills in a challenging environment with limited resources. Clinica Esperanza on the island of Roatan, Honduras had all this and so much more! The clinic functions as a combination of primary care and emergency medicine, in part due to the fact that the local hospital with an A&E has not received medical supplies for over 6 months.

Reflection

One of the most challenging parts of working in a foreign environment, yet also one of the major benefits, is the vast cultural differences that inevitably exist. Roatan is no exception. Learning more about such differences was one of my elective objectives, and one that was most certainly achieved. I was soon struck by the fact that the typical age of first pregnancy is 18, malnutrition is widespread with limited opportunities for work and an endemic obsession with sugary, fizzy drinks. I saw that it is not enough to simply take a history and examine a patient. The area they live, the job they do and their religious beliefs are completely intertwined with their health outcome. For me, this was a learning point that I will undoubtedly take with me everywhere I go.

I relished the opportunity to practice health promotion in a place where few patients achieve more than a primary school education. One example of this was a patient we diagnosed with type II diabetes for the first time. This diagnosis required me to educate the patient about nutrition, such as avoiding fried and sugary foods, as well as trying to warn her of the potential complications, her treatment options and invite her questions, all of which while talking in a foreign language. I found this to be surprisingly rewarding, especially when she returned for a follow-up appointment the following week with much improved glucose levels, and bringing stories of the changes she had made to her diet.

There were certainly aspects of the placement which far exceeded my expectations and even surprised me. One example was having the opportunity to gain new perspectives towards global health and learn about the differences in medical practices across the world, such as the local ‘bush medicine’. In an area with a large obese and Afro-Caribbean population, there is an unusually low incidence of cardiovascular disease. Whilst of course there are many factors that can cause this, I learnt not to be too quickly dismissive of remedies that have been used for thousands of years.

One of my learning objectives was to practice clinical techniques such as cannulation and suturing. Unfortunately I do not feel I had sufficient opportunities to fulfil this objective, owing to the fact that the clinic functioned mainly as a primary care unit, and thus most emergencies went to the emergency room at the local hospital. However I don’t believe this negatively impacted on my experience but it does mean I will endeavour to gain more exposure to such procedures during my DGH placement.

I was, however, very pleased to have the opportunity myself to make a difference to the clinic, one that will hopefully be sustained long after I leave. I was delighted to be awarded a bursary from the RCOG to allow myself and Rebeca to complete a research project during the elective placement. The recently introduced cervical screening programme was highlighted as an area that is underfunded and in need of improvement. The haphazard introduction of this programme has meant many patients may be being missed due to the opportunistic recruitment of patients, as well as results not being delivered appropriately. Through developing a new data collection system, as well as retrospectively collecting data from the smears already completed, we have identified patients who need to be recalled for urgent follow up, as well as making recommendations that hopefully ensure that the limited resources of the clinic are directed more effectively, thus allowing more patients to be helped.

During my elective, I found that the impact of poverty further compounded in a health system requiring patients to pay for consultations, investigations and medications. Decisions weren’t made solely on the basis of what would be best for the patient and, having been educated within the luxury of a National Health Service, I found this particularly challenging. However, I recognise that in a time of austerity and budget cuts, we will all have to factor limited resources into patient care. Thus, having more confidence in my ability to diagnose, or at least treat empirically without expensive investigation as well as recognising when these are justified will benefit all of my future patients.

The impact on my professional practice

The time I spent at the clinic has undoubtedly changed my professional practice, as well as my own outlook. Early on in our placement, we had an emergency situation of a young boy who was desperately ill. Seeing a team pull together so seamlessly, needing few words to communicate whilst battling with limited resources was incredible, despite the heart-wrenching circumstances. On a daily basis I had to adapt to the limited availability of tools we so frequently take for granted, which left me with no option but to develop my clinical accumen. Further, being able to work in an independent manner but with plenty of supervision from experienced doctors encouraged me to hone my decision making skills, and gave me confidence.

I enjoyed the diversity of the patient presentations and had the opportunity to work in gynaecology, saw many paediatric patients and managed a vast array of general medical patients. Communicating complicated information in another language was a difficult but important lesson. I realised that the challenge of working with patients from different cultural and ethnic backgrounds is so much more than just a language barrier, and this is even more relevant when working back in the UK. I will endeavour to understand how to approach topics such as sexual health or alcohol drinking in each new community I work with.

Limitations

If I returned to the clinic, which I certainly hope to do, I would change some of my objectives to allow me to gain even more from the opportunities we were presented with. One would be to learn more of what is normal. Seeing such an array of patients daily is the perfect opportunity to practice many clinical exams, such as using otoscopes and ophthalmoscopes to be able to appreciate physiological variants as well as pathology. Clinical knowledge can also be gained in the specialities of tropical diseases and nutrition. Members of the clinic run nutrition classes in the community and I would have liked to be involved in running such classes.

Another area which can be developed in this environment is decision making skills. The wealth of support from experienced doctors encouraged me to be independent whilst still being safe within my personal limits. Whilst at the clinic I took part in a community outreach programme, where members of the clinic go to local communities and give nutrition classes, hand out food parcels and education to prevent delayed presentation when illnesses develop. I would love to have done it more often. We have suggested that the clinic includes a weekly visit to the community in the volunteer program in the future.

Conclusion

I believe I was able to contribute to the clinic through our research project, and providing recommendations which will be used to apply for funding for an HPV testing programme. Further, each volunteer gave a teaching session, and I contributed to the shared knowledge of hypertension, and was able to highlight differences between UK prescribing practices, and the USA.

I would like to continue to help the clinic by raising awareness of their work. I will have the opportunity to do this when I present our research to the RCOG, in the hope of encouraging visiting gynaecologists to choose a placement in Roatan, which could allow the re-opening of the birthing unit at Clinica Esperanza, and provide expertise that could be used to train local doctors in techniques such as colposcopy and ultrasound.

I had many exciting, unexpected and educational experiences during my placement at Clinica Esperanza and would thoroughly recommend it to any medical student considering an elective in the developing world.

Brooke Calvert (
UCL)

 

In December 2013 I left the UK bound for Johannesburg for my medical elective in the Trauma Unit of Chris Hani Baragwanath Academic Hospital, Soweto. Affectionately known as Bara, this vast hospital is the only one in Soweto, serving the entirety of its 5 million inhabitants. With a world-wide reputation matched only by that of the area in which it nestles Bara is the polar opposite of the hospitals in which I have been so far; as such I was excited but extremely nervous about working in the Trauma Unit.

The trauma unit alone has 184 inpatient beds, 4-round the clock trauma theatres, a triage area with space for over 50 trolleys, 10 resuscitation bays and 10 dedicated ICU beds. This all sounds very impressive and gives the illusion of a well-resourced, adequately funded unit. However it is important to bear in mind that Baragwanath rarely operates under 100% capacity, more often 150%, and is underfunded to the degree that the doctors need to provide resources such as paper, printers and sometimes gloves.

When pay-day rolls around for 5 million Sowetans or the famed Pirates play The Kaiser Chiefs in front of 90,000 strong crowd the World’s most infamous township gives it’s only hospital a run for its’ money; often causing the unit to close for 2-hour periods in order to begin to clear the backlog. The level of violence in Johannesburg is like nothing I had ever seen before, not saying much for a middle-class 24-year old from West London, but when you consider that not a day went by at Bara without more than twenty stabbings or shootings this statement would ring true for most.

What is the source of the endless stream of accidents and emergencies at Bara? Well, quite simply it is The Sauce. A lethal mixture of township-brewed hooch, unemployment, overcrowding in a vicious cycle of poverty. Whether shot for a wage packet, hit by a drunk-driver, involved in a bar brawl, crushed by a collapsing wall or caught in a shack fire, it is fairly certain that at least one of the above is to blame.

My days began at 6:30am with ward-rounds followed by ward jobs, assisting in theatres and manning the surgical ‘pit’. Students were expected to do two 30-hour on-call shifts a week in addition to normal days. Apart from infinitely improving my clinical skills, teaching me procedures seldom needed in UK hospitals and honing my decision making prowess, this enabled the trauma team to truly bond. Everyone who works in the trauma unit is extremely helpful and friendly, no matter how busy the day is everyone is pleased to see you and all the registrars and consultants take the time to teach you, whether it’s for an hour during a ward round or for the two minute walk to the CT scanner at 3am. Every moment was used as a teaching opportunity and every teacher was happy to do it.

The demographic of patients seen at Bara often only complicated the task in hand, with 80% HIV positive, 60% with TB and drug resistance on the rise; treating patients was always a balancing act of treatment, adverse-effect and seemingly unsurmountable infection. Confounded by ever-changing available medication, some thirty different language profiles and more often than expected losing patients in the 10km of corridors and shack-like wards, sometimes for days at a time.

I learnt a huge amount at Baragwanath, not least volumes about trauma medicine and working in a resource-scarce environment. However more importantly I gained infinite teamwork skills and now understand that no matter how difficult the working environment and how busy each day, a good, cohesive team, at every level from porter to consultant can transform a potentially disastrous scenario into one that is difficult, stressful and unbelievably exhausting but ultimately extremely satisfying, most importantly successful and even enjoyable.

This was not an easy elective to go on, I did not have weekends or evenings to explore and I found the level of violence in a community that lacks autonomy extremely challenging; however it is definitely one of the best experiences of my life, which cannot begin to be expressed in a page. I met an immensely capable and welcoming team who gave me a unique opportunity to work with staff and patients who are some of the most friendly, vivacious and appreciative people I have come across. I am extremely grateful to the Jewish Medical Association UK for helping me to go to South Africa and I would recommend Baragwanath as an elective for anyone in search of a brilliantly satisfying yet challenging experience.

Leah Rosenbaum
UCL

I undertook a medical elective in Jerusalem, Israel. This involved six weeks in the Plastic Surgery Department at the Hadassah Ein Kerem Medical Centre.  Plastic Surgery was my chosen speciality in this elective, because I have had very little exposure to the specialty prior to commencing this elective.  Israel was my chosen destination, being renowned for its infrastructure and innovations in healthcare.

The Plastic and Aesthetic Surgery department at Hadassah is renowned on a global level and in Israel for its work in reconstructive surgeries for trauma and congenital malformations, and cosmetic surgery. It is also well known for its work in paediatric plastic surgery, hand and microvascular surgery.  The hospital, a very modern sprawling complex in the Judean hills, which includes a medical and dental school sits at the forefront of Israeli Healthcare, and is known for its progressive and high standard quality care.

Healthcare in Israel is universal, and all citizens are mandated to have medical insurance with any of the four Health Maintenance Organisations, which receive funding from the government, derived from the health insurance tax.  This entitles access to basic medical and dental health coverage. Individuals also have the right to purchase additional private insurance to cover additional treatments not covered by the basic insurance.

At Hadassah, the day commenced very early with ward rounds assessing new emergency surgical intakes to the department, and reviewing the progress of postoperative patients. This was followed on alternating days with time spent in the operating room, or the day and minor surgery clinics.  Furthermore there were afternoon pre-operative meetings for patients admitted for elective procedures, to make final assessments and discuss with the patient and other surgeons about the proposed surgical procedure.

Being a student in the department I was well received and strongly encouraged to have hands on participation.  Despite having no previous experiences with plastic and reconstructive surgery, I was able to apply knowledge from other specialities I had come across.  Most notably dermatology, seeing as the most common presenting cases were dermatological related especially with the high prevalence of lipomas, congenital nevi, skin cancers (BCCs, SCCs and melanomas), and burns.  It was surprising to note how much crossover knowledge from other specialities are involved in managing cases, such as in the repair of cleft palates and ear reconstruction for microtias, drawing knowledge from other specialities like ENT and Maxillofacial surgery.

Furthermore it was surprising to know that most of the breast surgery (in particular reconstructive) was performed by the plastic surgeon, in comparison to being performed by the specialist general surgeon in the U.K. In my time in Hadassah I got to observe and participate in various types of breast repair from implants, flap reconstruction, fat grafts as well as nipple reconstruction and breast augmentations Having a good knowledge of anatomy is key to achieving good aesthetic results, and the six weeks in plastics afforded me time to revisit and reapply knowledge of the subject.

As a surgical speciality, I had many occasions to scrub in and assist with surgeries both in the operating room and day clinics. Which made for greater appreciation of surgical procedures, as well as serving as an avenue to practice suturing, whilst learning new suture techniques.  Towards the end of my elective I had the chance to perform minor procedures under supervision, such as the excision of suspicious moles and lipomas.

As a foreigner in Israel, cultural differences such as having Sundays as a working day, differing dietary customs or the cessation of activity within the city on Shabbat made for rapid readjustments.  More so was getting used to a new language. Although most Israelis speak English, Hebrew is the working language and was the language-spoken in majority of consultations, however this didn’t hinder my learning as the doctors always readily provided translations. Jerusalem is a very dynamic cosmopolitan city, and having Spanish and French for second languages certainly had its benefits within and outside the hospital.

Summertime in Israel also meant having time to do a lot of travelling, from exploring Israel’s stunning and diverse landscape, to adventuring along its numerous hike trails.  From experiencing its colourful and vibrant urban life, to marvelling at its ancient monuments, learning and appreciating the history, cultures and religions that enrich the Israeli heritage.

My time in plastic surgery has provided much insight about the specialty, removing misconceptions about the profession.  I got to see how integral the plastic surgeon’s role is in relation to other medical and surgical disciplines, and also appreciate the science, craft and artistry involved in this discipline.  My hospital experience coupled with this cultural discovery, have surely made this elective both a unique and memorable experience.  I would like to express my gratitude to the Jewish Medical Association (UK) for their support of my elective.

Adeoye Debo-Aina
Belfast

Going into my elective, I had the following learning objectives:

1. To consolidate clinical skills needed for practical procedures such as cannulation and venepuncture, using equipment that may initially be unfamiliar.

2. To gain an understanding of the fundamental similarities and differences between America and Britain with respect to the delivery of acute healthcare.

Introduction

Sinai Hospital of Baltimore is a 600-bed community hospital serving the 600,000-strong population of the city of Baltimore, in the State of Maryland. Sinai is a teaching hospital for medical students from the Schools of Medicine at Johns Hopkins University and the University of Maryland, with all full-time faculty staff holding academic positions at one or other of these two institutions. The vast majority of patients seen are African-American or African-Caribbean, and there is a high burden of cardiovascular morbidity.

The Emergency Room (ER) at Sinai is known as ER-7 because it is divided into seven departments, each catering for various acute presentations. It accommodates a total of 30 beds. Much as in the UK, the ER has a triaging system, an urgent care centre for minor complaints, a paediatric unit and an observation centre. However, as opposed to having one unified majors area as I have been used to in UK hospitals, Sinai ER has a dedicated chest pain centre and an emergent care centre. The purpose of the latter is to provide high-intensity care for critically ill patients. Like St George’s Hospital in London, where I trained, Sinai is also a trauma centre, accepting victims of gun crime amongst other presentations.

In my time at Sinai, I worked 8- to 10-hour shifts (including 4 nights) with multiple emergency physicians, nurses and physician assistants in all areas of the ER except paediatrics. This exposed me to chronic, subacute and acute presentations covering all body systems, including those with which I had perhaps been less familiar, such as dental problems and wound management.

I chose America because I wanted to experience medicine at its most advanced. Additionally, having relatives in Baltimore was a good reason to spend my elective in Maryland. Lastly, NICE recommends that all junior doctors be familiar with its guidance on managing acutely unwell patients in hospital.[1] I chose emergency medicine because I reasoned that since it deals primarily with acute disease management, it would be a valuable experience at my junior stage irrespective of my eventual chosen specialty.

Discussion of learning objectives

Prior to starting my elective rotation at Sinai, though I was knowledgeable in the theory of suturing and gluing wounds – including the requirement to maintain sterility, irrigate and anaesthetise the wound and provide wound care advice to the patient following closure – and though I had practised on synthetic skin, I had not actually sutured a real wound in a live patient. The ER was a perfect setting to increase my proficiency in managing real wounds. I sutured, glued or stapled several patients’ wounds, all in different anatomical areas and resulting from various mechanisms of injury. I thus became comfortable at performing these skills.

Additionally, I had the opportunity to further my skills in venepuncture and cannulation, since nearly all patients seen in the ER required basic blood panels and/or intravenous access. I occasionally also had the opportunity to practise taking an arterial blood gas (ABG) sample. Being cognisant of the fundamental technical principles of venepuncture, cannulation and ABG-taking was vital in allowing me to successfully complete these skills despite using equipment that differed slightly from what I had been used to back in the UK. Finally, I continued to develop my skills in recording and interpreting ECGs (EKGs) as well interpreting radiographs and CT scans in the acute setting.

From my time experiencing healthcare in the UK and now America, I have realised that the fundamental difference between the two health systems is the extent to which they are publicly or privately funded. Whereas the UK subscribes to a public, tax-funded system, the US employs a private, insurance-driven system. Simply speaking (and this is perhaps overly simplistic), whilst the UK has adopted a socialist healthcare system since 1948 with the setting up of the National Health Service (NHS), the US continues to operate by the capitalist principles of competition and ability to pay. Indeed, many Americans with whom I spoke whilst on elective referred to the UK system as delivering “socialised medicine”. In political terms, you might say that the UK NHS is rooted in left-wing ideology (it was the Labour party who established it in 1948), whereas the US system adheres to right-wing thinking.

It is true, however, that in recent years we have seen both countries’ health systems veer politically more towards the centre ground. In the UK, the Conservative-Liberal Democrat coalition, by introducing the Health and Social Care Act (2012), has abolished Primary Care Trusts (PCTs) and replaced them with Clinical Commissioning Groups (CCGs), which allows newly-established consortia of GPs to commission health services from bidding providers, so as to meet the specific health needs of their respective local populations. This has strengthened competition within the NHS, aiming to increase patient choice and drive up standards of care. In the US, under the Affordable Care Act (2010), or “Obamacare” as it has come to be known, the number of Americans now able to access basic health insurance has increased by an estimated 8-9 million. This still leaves approximately 30 million Americans with no medical insurance, potentially denying them of urgently needed treatment. Notwithstanding these recent legislative reforms, which have brought both countries more towards the political centre ground, the aforementioned public-private comparison, broadly speaking, remains valid.

As a way of increasing efficiency and expediting the treatment of patients, Sinai Hospital ER employs a team of scribes working in conjunction with emergency physicians to record histories and examination findings. I have not seen such a system in UK hospitals. Many of these scribes were prospective medical school applicants, using the opportunity to gain experience of healthcare with practising emergency physicians. The partnership worked well and I thought it led to a more efficient use of the doctor’s time, with less emphasis on paperwork.

Finally, the 4-hour A&E target in the UK is non-existent in the US.

Evaluation

The most common presenting complaints I saw at Sinai mirror those I saw during my final-year Emergency Medicine placement in the UK: namely, dizziness; chest pain; shortness of breath; abdominal pain; back pain; headache and lacerations. These symptoms have wide differentials, so it is important to rule out life-threatening diagnoses early, for example, stroke, acute coronary syndrome, deep vein thrombosis, pulmonary embolism, pneumothorax, ruptured aortic aneurysm, sepsis and cauda equina syndrome. I saw well in excess of 100 cases at Sinai and had the opportunity to observe the response to trauma calls. Several patients with gunshot wounds were admitted and managed in the trauma bays in accordance with the American ATLS guidelines.

In discussions with emergency physicians and in observing their practice, the litigious culture that seems to pervade all aspects of American society, including healthcare, became apparent. The unceasing threat of litigation prompts many emergency physicians to order investigations that may not strictly be necessary, for fear of missing a diagnosis and being subject to a resulting lawsuit. This lack of monetary stewardship is often compounded by the very palpable mind-set amongst some patients that because they have medical insurance, they almost have the “right” to any and all investigations and treatments, which will duly be paid for by their insurance company. Although this probably results in a lower diagnostic miss rate than in the UK, in my opinion it detracts from the doctor’s clinical judgment. If any and all investigations are ordered every time without diagnostic indication, this reduces the importance of a prioritised differential diagnosis list. It also means patients are exposed to unnecessarily high radiation doses in CTs, radiographs, angiograms and nuclear scans.

I have inevitably considered which of the two systems I prefer. The American, privately-funded system results in shorter waiting times for referral to secondary care specialists compared with the UK – there seems to be no such difference in the delivery of acute healthcare.[2] However, about 30 million (or one tenth of) Americans still have no medical insurance even with “Obamacare” having been in full force since the beginning of 2014.2 In contrast, the publicly-funded NHS provides a universal, comprehensive service, free at the point of need that does not depend on ability to pay, but also leaves open the option of private healthcare where the individual can afford it. Funding the health service, rather than being an individual problem as it is in the US, is a national problem in the UK. It cost the government £108 billion in 2012-13 [3] and puts a heavy burden on the UK annual public spending budget. The US spends twice the amount on healthcare per capita as the UK, but this offers no health advantage over the UK.2

Having gained experience of American healthcare, I have come to appreciate the value of the NHS in providing a high standard of care to patients, free at the point of need. We have a unique health system in the UK, which it is vital to protect and sustain into the future.

I think it is worth adding that my experience of Baltimore’s thriving Jewish community was very positive. I had the opportunity to attend an AIPAC regional policy meeting, which brought together under one roof hundreds of AIPAC members from several neighbouring American States. This meeting alone exuded a tremendous sense of unity in the common goal of protecting the interests of the State of Israel.

In summary, I can confidently say that my elective rotation at Sinai was a worthwhile experience, both for my personal and professional development. I would like to express my thanks to the Jewish Medical Association (UK) for supporting my elective.

References

1. National Institute for Health and Care Excellence (NICE). Acutely ill patients in hospital, NICE, 2007. Available at: http://www.nice.org.uk/CG50. Accessed 10 June 2014.

2. K. Davis, C. Schoen, and K. Stremikis, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally 2010 Update, The Commonwealth Fund, June 2010. Available at: http://www.commonwealthfund.org/publications/fund-reports/2010/jun/mirror-mirror-update. Accessed 10 June 2014

3. NHS Choices website. About the National Health Service (NHS), 2013. Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx Accessed 10 June 2014

Aryeh Greenberg
St George’s Hospital Medical School, London

In April 2015 I left the UK to spend seven weeks in Shaarei Zedek Hospital – three weeks in the Emergency Department and four weeks in the Obstetrics and Gynaecology Department.

The Emergency Department had undergone a major reconstruction in 2004, increasing its capacity by 330%, and as such is the busiest Emergency Department in Israel. The Department is housed on the 2nd floor of the hospital, and it was explained to me how the lower 3 floors of the hospital had been built underground – including the Radiology Department and operating theatres – in order that the hospital would be able to continue functioning during wartime.

I arrived on my first day and was welcomed by the head of the department. He showed me around and explained the setup of the department. The emergency room is split into different sections including surgery, acute medicine and orthopaedics. Each section has its own set of doctors who exclusively see those patients. The Department is close to the Radiology Department and the operating theatres, allowing fast and effective diagnosis and management of patients. There is another smaller area in the Department called ‘mahalchim’. Patients are sent here by the triage nurse who deems their condition to be more minor, and the setup is similar to a GP clinic. It was here that I was able to sit in my own room and see patients alone, before presenting my findings to the doctor and agreeing on a management plan. There was a huge variety of patients here, including a patient taking warfarin who presented with minor bleeding and a patient with Crohn’s disease who presented with diarrhoea.

During my time in the Emergency Department I rotated around the different areas which enabled me to see a wide variety of patients. Whilst many of the doctors spoke English, very few of the patients did, which enabled me to practise both my conversational and medical Hebrew. Although it was challenging to work in such a fast-paced department in a language in which I am not fluent, I very much enjoyed the challenge and my time there.

After my time in the Emergency Department I spent 4 weeks in the Obstetrics and Gynaecology Department. This was a huge department with a large labour ward, daily clinics such as fertility clinics, In Vitro Fertilisation (IVF) clinics, antenatal clinics, general gynaecology clinics and more. Each morning there was a Multidisciplinary Team (MDT) meeting where interesting or complex cases were discussed and management decisions made. On the first morning I was welcomed by the head of the department and introduced to the team after the MDT.

Most of my time was spent rotating through the different gynaecology clinics. One patient who stands out in my mind is a lady of Ethiopian origin who attended the fertility clinic. She had had one pregnancy four years previously in Ethiopia which had ended in a stillbirth and a surgery of which type she was not clear. However, since then she had not had a period, bringing into question whether the operation she had had was a hysterectomy. The doctor had to break the news of this possibility to her, and arranged for her to have an ultrasound to determine if this was the case. Observing this case emphasised to me the difference in health beliefs between cultures and the importance of both an honest and an empathetic approach when it comes to breaking bad news.

During my time in the Department I was given the opportunity to spend some time in the IVF lab where egg retrieval was carried out. Follicular fluid containing eggs was aspirated and the fluid was then passed through to the IVF laboratory where a technician identified the eggs and prepared them for incubation. It was very interesting to watch the high level of expertise displayed by the laboratory technicians.

I thoroughly enjoyed my time in Shaarei Zedek and would like to thank the Jewish Medical Association UK for supporting me in my elective in Israel.

Miriam Sharman
Imperial College London

This year’s annual meeting of the Myers Brookdale Health Advisory committee (of which I am a member) was arranged helpfully to coincide with the 6^th International Jerusalem Conference on Health Policy. Amongst the several hundred delegates were a dozen or so from the UK, including some eminent health policy and health services research academics. The US was more generously represented, and we were told by Orly Manor, Chairman of the Board of the Israel National Institute for Health Policy Research, which sponsors the Conference, in her welcoming address, that in all there were representatives of 43 countries present. Orly told us some of the medical history of the area, including about Sir Moses Montefiore’s physician, no less than one Dr Thomas Hodgkin [1798-1866; as in lymphoma], who is buried in Yafo.

The plenary presentations were mainly excellent, and overall the standard in parallel sessions was every bit as good as other quality international conferences I have attended.

We heard from Israel’s new Director General of the Ministry of Health, Moshe Bar Simon Tov, who summarised Israel’s demography and its democratic system of government. Demographically, Israel’s over 75 population is growing at five thousand per annum. In healthcare, he emphasised the diversity of both workforce and patients, with comments such as the routine care of elderly Holocaust survivors alongside wounded Syrians in the Northern hospitals. He also pointed out that Israel spend 7.5% GDP on health, compared with the OECD average of 8.9%. Israel is clearly pleased to be included in the OECD. Regarding healthcare, Moshe went on to describe the notably short length of stay in Israel, reflective in part at least of good after care, a well known stumbling block for the NHS. He also mentioned data – the largest Israeli Kupat Cholim [Health Plans], Clalit, apparently has the biggest medical database in the world: not only does that offer great opportunities for health research, but maybe it is something to show our NHS leaders, before the next massive speculative investment in Information Technology.

Other plenary speakers included Martin McKee (LSHTM, UK), Patricia Shaw (Herts, UK), Christian Lovis (Switzerland), David Hunter (Durham, UK), Victor Rodwin (NYU, USA) and Peter Smith (ICL, UK). Perhaps the lightest comment was the cautionary lesson about carelessly attributing causation to correlations – Christian Lovis gleefully told us that there is a strong correlation between countries with high chocolate consumption and the number of Nobel Prize winners: did I say he came from Switzerland?!

Between sessions, and even during them, as well as over lunch or coffee, or while peering at ePosters, there were lots of opportunities for networking. The atmosphere was very sociable, English was the common language and there were many new contacts to be made. During a social event at the Israel Museum, for example, I met a Vietnamese dentist who had completed her Public Health Masters at the Hebrew University the previous year and had returned to meet her tutors and other former students at the Conference, as well as to present her dissertation findings at a session.   I asked her why she had chosen Israel to study and it seems she just fancied the idea, and her country had sponsored her to do so. Two young men from the US were studying medicine at Tel Aviv – one of the dedicated courses taught in English solely for overseas students, who are expected to leave Israel when they graduate.

The final plenary session took us away from health policy completely. We welcomed Professor Eliezer Rabinovici, a physicist from the Hebrew U, who has been heavily involved for 20 years in an international collaboration, SESAME, building a CERN-like synchrotron in Jordan. He emphasised the nature of the project, which relied on total trust between scientists from all over the world and, in particular, between scientists from several unlikely collaborating countries – including Iran, Jordan, Turkey and Israel. As he reminded us, at its inception, the former Egyptian president Hosni Mubarak had “taken politics out of science” in order for the collaboration to flourish.

Having attended the 5^th International Conference three years ago, I had learned a bit about the dynamic of the meeting and the Israeli attitude to overseas visitors: along with the general good mood and friendliness, there was a widespread assumption that if you were attending the Conference from overseas, unless you had an obviously Jewish name or visible identifier such as a Yarmulke, you would not be Jewish. So, whilst as a tourist I had never recognised this phenomenon, at the Conference it became the norm to bring into conversation that yes, you had visited Israel many times before, that you had relatives living in Netanya {or wherever} and yes, that you were able to read/understand/speak {as applicable} Ivrit – and maybe some Yiddish for good measure. At the 5^th Conference, I jokingly explained this experience to an Israeli delegate, whose advice was that I should go and buy a Magen David pendant and wear it prominently around my neck to make life easier for the Israelis!

I am looking forward to the 7th International Jerusalem Conference – hopefully in 2019. Overall, the standard is high and the Conference offers the opportunity to Israel to showcase some of the high quality research being undertaken there, to share the comparative achievements in terms of health outcomes and the inclusion of speakers from diverse communities in Israel, the PA and around the world. I would very much like to encourage expansion of the UK contingent in attendance on that occasion.

 

Fiona Sim

 

 

I spent my elective working on a paediatric oncology ward at Tata Medical Centre (TMC), a specialist cancer hospital on the outskirts of Kolkata, India. TMC is a charity hospital where the cost of treatment is subsidised with donations from philanthropists. India’s public healthcare system has many financial restrictions and when state hospitals cannot provide patients will often turn to the private sector. However, this alternative is beyond the means of many in India and charity hospitals provide high quality medical care to those who would otherwise not be able to afford it. This is important in oncology, as cancer treatment is expensive, but even more so in paediatric oncology, as the parents of young children are typically young themselves without the savings to support medical treatment.

Working at TMC was an eye-opening experience. Children’s cancer is one of the most difficult areas of medicine to work in, but it is also one of the most rewarding. Many cancers in paediatric oncology do respond well to therapy but even in these cases the treatment programmes are prolonged and arduous, and demand great courage from the patients and their parents. Many children are too young to understand importance of treatment, which makes the process even harder. However, despite all of this I found that the children continued to confound my expectations, from their powers of recovery to their positive outlook on life. There is also a lot of support that patients can give each other. Accommodation was provided nearby for families to stay during treatment, and meeting others going through similar ordeals was helpful for both the children and their parents.

Medical care at Tata Medical Centre is not fully subsidised and patients contribute to the costs of treatment, especially at the start of therapy while paperwork is being processed. Because of this, even with financial aid families with low incomes still face limitations on what treatments they can afford. It is a frustrating experience as a medic to know what treatment a child needs but be unable to give it. Additionally, the intersection between illness and poverty can lead to painful decisions for the parents. Cancer treatment can bankrupt a family, and they must take into account factors such as how many other children are at home to support, or how likely the cancer is to be cured. Sometimes cost dictates the ceiling of care that can be offered. Certain cancers can only be cured with a bone marrow transplant, but their cost is beyond the reach of most patients at the centre. It is difficult to see children with cancers that might have been treated successfully if they had been born in the UK, or if their families were more prosperous. In other cases cheaper drugs have to be used despite the increased risk to the patient’s health. Cheaper antifungal drugs can inhibit the breakdown of chemotherapy and increase the risk of side effects, such as permanent liver or nerve damage. The antifungals that do not interact with chemotherapy are unaffordable for many, and so patients are forced to use cheaper antifungal cover that carries a greater risk for their health.

There are aspects of the Indian healthcare system that the UK could learn from. Patients were asked to buy certain medical supplies themselves, such as lumbar puncture needles. The result was a relatively small financial burden on each patient but a significant saving on the part of the hospital. In the context of an underfunded NHS, minor or nominal payments from each patient could lead to greater savings overall while minimising the impact on the population. Similarly, the centre chose not to fully subsidise their medical treatment. This was primarily to make their funds go further, but some also argued that financial contributions lead to patients taking more responsibility over their own health. These approaches to medical care are not commonly discussed in the UK. However, the use of financial contributions to influence personal behaviour, as has been seen in the recent charges for plastic bags, is likely to gain greater prominence in public debate in the future.

The most I learnt at TMC was by observing the teamwork in the paediatric unit. The unit had a sense of equality that is unusual to find in medicine, where the consultants encouraged their juniors to challenge their decisions and would consider them seriously. This lead to constructive discussions about the patients to which anyone could contribute, rather than the head of the team dispensing a string of instructions. The patients benefited from the closer attention to detail; the fellows benefited from being pushed; and the consultants benefited from the contributions of the whole team. It is an atmosphere that I would like to replicate myself in the future, but one that is easily squeezed out by the everyday pressures of hospital wards: too many patients with too little time.

Whilst in Kolkata I also worked a state hospital to compare the delivery of care between the two systems. The clearest difference was the sheer volume of people that the state hospitals treated, with crowds filling up the courtyards and corridors every morning. There were limited beds on the wards and so most were deferred to overflowing outpatient clinics. Personnel were a major cost, leading to single nurse for each ward. Much of the traditional role of the nurse was replaced by families looking after their relatives and I met one young girl with leukaemia who would assist the junior doctor with his procedures on the ward.

I found the state hospital full of passionate doctors struggling to work within the confines of a poor system. They had limited resources, but the resources they did have were not being used efficiently. My ward would turn patients away for lack of space even though there were empty beds in the ward next door, because the hospital management wouldn’t allow them to use other beds. Other challenges lay in government mismanagement. During my stay the state of West Bengal was holding elections, which occur district by district over a month. Rather than giving hospitals funds for medical supplies, the West Bengal government buys them in bulk and delivers them to the hospitals. This means that medical deliveries are dependent on government bureaucracy and during elections that bureaucracy grinds to a halt. While politicians were insisting publicly that their hospitals were well stocked, on the ground resources were running short and it was estimated that the shortages could continue for months after the election. It was not just drugs that were in short supply. Many blood donation centres closed down during the election leading to a shortage of blood products. None of these problems were due to funding – they were problems rooted in a system that was failing to utilise its resources effectively.

I was in India over Pesach and I joined the Jewish community for their communal Seder. The community used to number over 6000 before World War II but has dwindled today to less than 30. They have a fascinating mix of traditions – some Sephardi traditions, a scattering of European tunes, and an Israeli pronunciation of Hebrew. This was the first year they were running a communal Seder and it was held in the Kolkata Jewish Girls School, which has a British-style school hall with wooden plaques listing the accolades of past students. Two young Chabad students had come out from New Jersey to help run it, and I had not appreciated before the impact they can have visiting small communities across the world. The Seder meant a lot to the locals and it was heart-warming to see the strength of their Jewish connection. It was an amazing experience to sit down in one room with most of the Jews in the whole city, along with all our different languages, and take part in a ceremony that Jews have been performing together for millennia.

Alongside Kolkata’s small Jewish community there are three large beautiful synagogues. Recent renovations have rendered the synagogues unrecognisable to how they appeared a decade before, with the smallest synagogue now being used regularly for Shabbat services. This synagogue had been used for years as storage for the merchants working on street below and the stall-keepers were very upset to discover that their free storage space was, in fact, a historic place of worship. One merchant, apparently no stranger to chutzpah, was still attempting to pursue legal action through the courts.

I travelled out to India to see the differences in the provision in care in a country with far greater financial limitations than where I trained. However rather than the differences between the two systems, what I found most striking were the similarities. The conversations with patients, the concerns that came to light, the discussions amongst medical teams and the factors weighed up in medical decisions were all the same. Despite the foreign language and cultural differences I found myself in a familiar environment. I feel that this is because the relationship between patients and their doctors remains unchanged regardless of where the medicine is practiced across the world, with its empathy, compassion and hope.

Noam Roth
UCL

I spent my elective working with Hillside Healthcare International. This is an American charity base in the Toledo district of Belize. The charity provided me with a variety of learning opportunities in different settings: a free standing clinic, mobile clinics into remote villages, community education programmes, and home health.

The aim of my elective was to enhance my medical knowledge, to gain practical knowledge of tropical diseases common to Belize and to gain all round experience interacting with patients in a different foreign country. I also wanted to experience working in a resource poor environment.

The Toledo district is the most southern district in Belize. It is also the most rural and the poorest. Most emergency care, maternity services, paediatrics and some chronic disease management is free and provided by the Ministry of Health. Hillside gets some of its medicines from the Ministry of Health free and works alongside the Ministry. Hillside also receives donations (usually from the USA) of medicines.

Hillside provides the local communities with medical care including pharmacy, nursing and physiotherapy. Whilst there I was able to actively be a member of the multidisciplinary team working alongside other medical students, pharmacy students and physiotherapy students as well as our qualified preceptors.

Whilst at the free standing clinic we would see patients from all walks of life – locals and tourists. All the services that Hillside provides are completely free to everyone and we never turned anybody away. The nearest hospital was a 20 minute drive away; this has an emergency room, 5 doctors, an ophthalmologist and the only dentist in the district. However, the nearest general surgeon was in Dangriga (20 minute flight away), and for most specialists we needed to refer to Belize City. Consultations in Belize City are not free and would often be too expensive for most of our patients). The lack of resources locally did limit what we were able to do but we made the most of what we had available. Furthermore some patients were reluctant to go to the hospital in Punta Gorda either because of the cost of the bus and/or because of a previous bad experience.

As well as the free standing clinic, I was also given the opportunity to go on many mobile clinics. This involved packing all our equipment and medicines into a jeep and driving (sometimes for about 3 hours) to the villages. When we arrived we would set up a pop-up clinic and see patients in their own village. I visited every village on the map apart from San Bonito Poite (which I did not reach due to bad weather and impassable roads). This provided me with a unique opportunity to not only visit the rural villages but also see the country and its population at work.

For many patients in Belize going to the doctor means taking the day off work and paying to get there (usually by bus). This means that many people do not come to the doctor unless it’s absolutely necessary. This is why rather than waiting for the patients to come to us, we went to the patients. Whilst in the villages we saw patients that otherwise would not have sought medical attention.

In the villages we were unable to perform blood tests or get x rays. The only tests available to us were blood sugar monitoring, urine dips and pregnancy tests. Not only was this a very valuable experience as it allowed me to see what rural life is like in Belize but it also showed me the importance of taking a good history and examination as I had to rely on that rather than tests to diagnose and treat. Furthermore the only medications/treatments we had were the ones we brought with us. This meant that often we would substitute medicines and use the second/third line treatments or use medications off license.

Another aspect of my time at Hillside was the home visits with the nurse. This involved going to patients homes, accessing them and treating them. Mostly these patients were “palliative” meaning that they had a long term condition that was not going to get better (mainly because they could not afford the treatment). Often this meant seeing patients who back home in the UK would be treated and cured, which at points made me quite emotional.

Furthermore we would visit patients who required wound care for diabetic ulcers or the disabled who were unable to come to the clinic. Not only did this show me how privileged we are to have the NHS but it also allowed me to see into people’s homes. This opened my eyes to how the local people lived and showed me the contrast between living conditions within Belize and compared to here in the UK.

In addition to the more clinical work, Hillside also gave me the opportunity to educate the public about health (mainly diabetes and hypertension) at health fairs in some of the villages. This involved us going into the communities, taking blood pressures and sugars, and providing advice and information on diet etc. This added another aspect to my elective; I learnt the importance of education, something that back home we take for granted. Most people did not know what high blood pressure was or how diabetes can affect their lives. We also provided contraception advice and talked about the importance of family planning. What struck me most whilst taking part in these fairs is that a proportion of the population are from Mayan descent and speak Ketchi (with some limited English), and there are no words in Ketchi for family planning or the anatomy of the female reproductive tract. This made educating them about family planning options particularly difficult and challenging not only for me but also for the clinic staff who acted as translators as well as performing their own tasks.

Cases

The majority of the cases that I saw whilst on my elective were what is most common in Belize: diabetes, heart disease and stroke (1) but I also saw some more unusual diseases that I would not see back in the UK, such as scabies, worms and Chikunguya. Some of these cases really stood out for me and provided me with important lessons.

There is very little mental health provision in the Toledo district of Belize. There is one psychiatric nurse for the whole district, no psychiatrists and no mental health hospitals. An American couple came into the clinic; the husband had already been diagnosed with depression and started fluoxetine six weeks before. He was also an alcoholic and gets violent when he is drunk. The couple had just moved to Belize to set up an ideal life but everything going wrong and they were both under a significant amount of stress. The wife was self-harming as she did not know what to do and her husband has attempted suicide in the past and has current suicidal thoughts. I was very worried about the couple and did my best to counsel them and to offer any help I could. If this had been in the UK I would have wanted to admit them both for psychiatric care but I was unable to do this. The best that I could do was to start the wife on an antidepressant, make them both promise not to act on their suicidal thoughts and ask them to come back next week to have another discussion. Neither returned. I thought about suggesting that they return to the USA where they have some family and friends to support them but I do understand that this could be considered a step backwards and that they could feel like they were giving up. On reflection, I believe that I did the best I could in the situation. I hope that they do return before anything serious happens.

When I first arrived in Belize I was expecting to see many vector borne diseases such as dengue fever, zika virus and malaria. However this was not the case. I saw only one of two patients with suspected Dengue/Zika. This is mainly due to the efforts of the vector control department. I spent a morning with them: we went into gardens and educated people about the best ways to prevent mosquito breeding. We also put tablets in still buckets of water to kill any existing mosquito larvae.

Whilst at the clinic I saw a young man who came in with a rash, sore throat, joint pains and fever. He had the classic villiform rash and a low grade fever. The fever, sore throat and joint pains started three days prior to the rash. We were unsure of the exact diagnosis (Zika or Dengue) as his presentation fitted both. We sent off some blood samples – these take up to eight weeks to get results as they are sent to Barbados – for epidemiological reasons and then treated him symptomatically. We warned him and his wife (who was asymptomatic) to use two methods of contraception for the next six months as a precaution. What surprised me most about this case was how well he seemed. He only came in because he had developed a very impressive rash overnight, he just “felt like he had flu”.

Reflection

I really enjoyed my elective and feel that I gained immensely from it. As mentioned above I feel like not only did I enhance my medical knowledge, but also I gained many insights into what it is like to live and work in poor communities. I was fascinated to see how people live in Belize and know that what I have learned will stand me in good stead in my future practice both at home and abroad. I now want to go back to the clinic and precept in my F3 year if I am able to do so!

References

1. World Health Organization. Belize: WHO statistical profile. [Online]. 2015. Accessed 20th September 2016. Available from; http://www.who.int/gho/countries/blz.pdf?ua=1 .

David Gold
Leeds

The 6th Anglo Israeli Cardiovascular Symposium took place on the 7-8th December 2016 in the beautiful setting of the Rimmonim Galei Kinneret Hotel, with a view over Lake Tiberias.

The Symposium displayed some of the very best of British and Israeli cardiology. A variety of wonderful speakers and leaders in their fields provided updates on their latest research and there were important take-home messages for clinical practice. Highlights included the talks given by Prof Ulrich Sigwart (University of Geneva, Switzerland) who spoke about alcohol septal ablation in hypertrophic obstructive cardiomyopathy (HOCM); Prof Sanjay Sharma (St George’s Hospital, London) who gave an update on the electrocardiographs (ECG) ) of young athletes: and Prof Michael Glikson (Sheba Hospital, Ramat Gan, Israel) who provided important lessons that could be learned from the comprehensive Israeli implantable cardioverter – defibrillator (ICD) registry.

The symposium provided an excellent opportunity for conversation and relationship building between Israeli and British cardiologists. The Israeli participants included both Jewish and non-Jewish doctors – the conference was opened by Dr. Ofer Amir, Director of Cardiology at Poriya Medical Centre, which was the hosting hospital, and in his talk he explained how Muslim, Christian and Jewish doctors in his department work together seamlessly, provide an example of religious co-existence in Israel. He said that there are Palestinian cardiologists in training at Poriya hospital and then transferring their expertise upon their return to their home hospital.

As an FY1 doctor, embarking upon a career in cardiology, I was honoured and delighted to have been invited to attend the conference. I thoroughly enjoyed both the subject matter, and the opportunity for networking with British and Israeli cardiologists alike. I feel that this opportunity will prove beneficial to me when embarking on specialty training in the UK, and will also allow me to consider future potential collaborative projects with contacts in Israel. These symposia, creating and fostering connections between Israeli and British cardiologists, are a wonderful opportunity and I would be delighted to help organise them in the future.

(Dr) Brett Bernstein

FY1, North Middlesex University Hospital