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