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Elective – Taupo, New Zealand, July-September 2007

Title and Aims
The title of my project was an elective in general practice in an urban area of New Zealand focussing on nutritional and integrative medicine and researching health inequalities.

My main aims were to gain an insight into cultural and socioeconomic health inequalities and differences in health behaviours in a developed country, and to learn about the significance and uses of nutritional and integrative medicine.

I am also particularly interested in the field of general practice as a possible future career. I valued the opportunity to gain more of an insight into the day to day work of a G.P. and hoped to improve my skills in differentiating between signs and symptoms that necessitate secondary referral and those that can be adequately managed in the general practice environment. I also aimed to improve my practical skills in areas such as minor surgery and suturing, steroid joint injections and swabs and cervical smears.

Dr Davies is a renowned expert in the field of nutritional and integrative medicine and I was very keen to have the opportunity to learn from his knowledge and experience in this area of medicine. I felt that this was a field about which I knew relatively little. Yet many patients I have met during my clinical years of medical school have enquired about the differences that nutritional medicine and alternative medicines can make to their health. I hoped to gain the confidence and understanding to give patients more certain advice concerning these factors in the future. This is relevant to patients who keep kosher as well, as many eat a mainly vegetarian diet if kosher meat is difficult or expensive to get hold of, so it important that such patients do not develop deficiencies of vitamins or minerals such as iron.

Reflection on Elective Period
During the elective period I led consultations, before seeking concurrence from Dr Davies at the end. I was therefore fortunate to see a wide variety of patients with conditions including nephrotic syndrome, post traumatic stress disorder, autism, impetigo, Achilles tendon rupture, bipolar disorder, dermatomyositis, and many more.

I learnt many useful skills during my elective placement. I gained experience in practical procedures, including suturing, minor surgery, urine analysis, administering intramuscular injections, smear tests, calculating paediatric drug doses. I feel that having led many consultations with patients my history taking, examining, management and teamwork skills have improved. I now feel much more confident with these skills, which I hope will help me with many areas of medicine.

Having my own consultation room to see patients, with minimal time pressures gave me a unique opportunity to get to know the patients well and to listen to their opinions and fears. I feel that I learnt a great deal from this. The elective experience has made me realise how important, even as junior medics, our time and effort is to patients and how ultimately, respecting their individuality and their choices, will make me a far better doctor.

I also learnt how to deal with complicated and challenging consultations – including patients who were being diagnosed with cancer and multiple sclerosis, and a patient who was at the end stage of metastatic prostate cancer. The consultation with Mrs CM, an anxious and demanding patient, was also difficult, as she had felt let down by doctors in the past, and also presented with confusing and unusual symptoms of itchiness and burning pain all over her body. She had already been seen by a neurologist, who had found nothing wrong. I was confused by this, but when I questioned her further I discovered that she was going through a divorce and finding life difficult in general. After discussion with the GP, I suggested a course of an SSRI, and although Mrs CM was initially reluctant, she eventually agreed to this. I found this consultation challenging, but learnt that listening to your patients concerns is vital, and sometimes a problem cannot be solved immediately but may need persistence and time. I also realise now the need sometimes to look beyond my immediate impressions and be open to other possibilities.

I now understand a great deal more about nutritional medicine, particularly the vital roles of minerals such as zinc, iron and selenium, and how imbalances of these minerals can contribute to a variety of health problems. I feel that the knowledge I have gained concerning nutritional medicine and the differences that adequate nutrition can make when tackling many diseases will be invaluable to me in my future career, and will hopefully enable me to offer further help to my patients. I realise now that this is something I have seldom considered in the past, as I have often concentrated heavily on pharmaceutical treatments when seeing patients on the wards, without asking them about their diet and appetite. In the future I will try to also ensure that patients realise the importance of a balanced diet as well as their medications, and will aim to look into possible nutritional or mineral imbalances in patients who are not recovering as well as expected or have unusual symptoms.

I also discovered that there appear to be inequalities in health between Maoris and European New Zealanders. Many Maoris who I saw had health problems related to smoking, mental health problems particularly alcohol and drug addictions, and a higher rate of unemployment. I still do not fully appreciate the reasons for these inequalities but feel that I have a greater understanding having undertaken this elective – it seems that social inequalities and relative poverty are heavily linked to the health inequalities I observed.

I feel grateful to have had this opportunity and very much enjoyed my elective.

Reflection on Logistics

Having travelled independently before, I was aware of the importance of forward planning therefore I organised flights, insurance and accommodation well in advance (figure 1). I should have applied for my visa earlier as I found myself worrying that I would not receive my passport in time to travel! I have not travelled to the developing world before and found my ‘to-do’ list slightly daunting. This included vaccinations, anti-malarial tablets, personal medical supplies and trying to make the most of a seemingly very limited luggage allowance. In June I tried to make contact with the people I would be working with in Kenya. I was assured that I was expected but was unable to make contact with the staff independently. In the future I would make sure to leave extra time when contacting people from a country where the communication links are not as advanced as those in the UK.

Figure 1.

Elective Period Experience and Learning

Half of my time was spent volunteering with the KOP staff working in the rural areas surrounding Kisumu. The remainder was spent at the Provincial General Hospital. I originally aimed to spend as much time as possible working in the community however, on arrival it became apparent that communicating with the relevant people in the community was difficult. Transport links were poor and travelling alone as a white woman was unadvisable. Therefore, I made all my visits with KOP social workers and a community health worker. During my first week at PGH I was attached to a different specialty each day, allowing me to gain a general introduction to medical practice in Kenya. (figure 2). It is impossible to describe everything that I experienced here but most importantly, I was given the knowledge and tools that I needed to actively participate in the paediatric department.

Figure 2.

It quickly became obvious that this was not going to be like previous medical placements. The wards were dirty and crowded with two patients to a bed. Three nurses were often responsible for one hundred patients, including some who were critically ill. Drugs and medical equipment were in short supply and nothing was free (figure 3). The majority of patients were poor and often had to forgo expensive drugs and tests. A doctor informed me that 15% of all admissions died in hospital. During the first week I learned a lot about general tropical medicine and undertook some background reading on these subjects to help prepare me for the rest of the placement.

Figure 3.

Price list of patient contributions for common procedures/investigations at PGH (N.B. average adult salary is 65p a day).

Paediatrics at PGH

I was immediately included in day-to-day ward work (see figure 4). The paediatric building had four wards (main ward, high dependency, oncology and malnutrition) and various outpatient clinics. I assisted doctors on the main and malnutrition wards by clerking patients, assisting on ward rounds and with emergencies. Figure 5 is taken from my personal notes and gives an indication of the conditions I was being exposed to on a daily basis and learning how to diagnose and manage. Whilst I was working on the ward I helped one of the nurses to complete a mini-audit of the past few months. This involved looking through notes and entering data onto a computer program (figures 6 and 7).

Figure 4.

A typical day on the paediatric ward at PGH

Figure 5.

Figure 6.

Admissions to the paediatric ward at PGH January-May 2007

Figure 7.

Mortality by primary cause January-May 2007

Community Work with KOP (Kenyan Orphan Project)

I spent 1-2 days a week doing community work. Some days were spent with a community health worker doing VCT (voluntary counselling and testing for HIV) and home visits. My experience with VCT was fantastic. The staff had been trained to see HIV/AIDS as a disease which affects people holistically (figures 8 and 9). I was also given the opportunity to accompany health workers by bicycle on home visits to people living with HIV/AIDS.

Figure 8.                     

VCT (National Guidelines for VCT, Kenyan Ministry of Health.

Figure 9.

KOP looks after many vulnerable children who have mostly been orphaned by HIV/AIDS and live with carers. Others are supported financially so that they can continue to live with their families. KOP also runs other projects, which I visited, including a street childrens’ centre and several rural feeding programmes. Unfortunately, it is beyond the scope of this summary to talk in detail about the children whom I came into contact with (figure 10). Meeting the children and discussing them with their social worker gave me an insight into their lives and the problems that they face. Whilst I was living in Kisumu I had a chance to visit most of the children KOP looks after in their homes and to speak to them and their carers. I also visited the charity office in order to meet other staff members and learn more about the children.

Figure 10

A brief summary of some of the KOP children whom I met

Reflection on Elective Period Itself

Being in Kenya was a steep learning curve. As well as learning what British textbooks say about tropical diseases I was given an insight into how they are managed in developing world conditions with limited resources. In particular, I learned a lot about HIV/AIDS. The work I did at PGH and with VCT provided me with a good background understanding of HIV/AIDS helping me to engage with the KOP children on a personal level and to consider problems that arose.

I had to adapt quickly to a new culture and ways of doing things. For example I often had to consider how to manage a patient when resources were limited, something I rarely consider in the UK. In Kenya people have a very flexible approach to timekeeping which made forward planning difficult. However, as the weeks went on I learned to adapt to this more spontaneous system. Kenyan society approaches child-rearing differently to the UK. For example, children often wander alone outside their houses as soon as they are old enough to walk. In hospital I was surprised to see most of the parents just lying with their children in bed. During painful procedures the parents often had to be encouraged to help calm the child. When asked, one nurse said that many Kenyan parents do not believe in displaying affection openly. Children are expected to be brave and strong. One day I was invited to lunch by one of the KOP foster parents. The children were called in after we had finished eating and were allowed to eat the scraps of food that we had left. Two children were under 18 months old. Nobody helped them to eat but they had already learned to eat anything without much assistance or coaxing. I did not see children with behavioural or feeding problems which British healthcare professionals are confronted with on a regular basis. Daily life is a struggle therefore children become resilient and resourceful from a young age. Interestingly, all the children I met were friendly, helpful, polite and excited about by their surroundings.

I knew that I would have to deal with very difficult situations. However, I found that the most challenging were simple and avoidable. Many babies died at PGH due to dehydration secondary to diarrhoea. The mothers did not realise how simple and affordable treatment was and waited too long before seeking help. Similarly, many children died from aspiration as staff were unable to monitor them closely enough. I continued to be challenged, frustrated and upset by these situations throughout my time in Kenya but I did learn to restrain my emotions and get on with the task at hand, a skill that will be useful in the future.

Post-elective period

I have returned to the UK with a much better understanding of tropical medicine and the challenges confronted daily in the developing world. I feel that I met my personal aims and objectives although I undertook a broader range of activities than originally anticipated. Through direct contact I learned about the needs of children affected by HIV/AIDS. I visited some schools, orphan feeding centres and a street children centre but did not feel that I had sufficient information and experience to undertake a project focussing specifically on the different models of care for these children as most of the KOP children were being fostered in their own communities. Instead, I was provided with opportunities to do hospital paediatrics and VCT which were logistically much more accessible to me. Next time that I plan a trip I will consider logistical obstacles i.e. transportation much more carefully to ensure that my aims are achievable. I have also learned that it isn’t always possible to make detailed plans and sometimes one must be prepare for the unexpected.

I want to spend time working abroad later in my career. My work on the ‘front-line’ in Kenya has taught me a lot however, I think that if I undertake further work in the developing world my skills would be put to better use on a more specific project. For example, there was an American team at PGH whilst I was there who had come solely to operate on burns patients. I have spent a lot of time considering the people I met and the difficult situations that I was confronted with. For years I listened to British politicians discuss debt relief and the importance of HIV/AIDS education. However, I needed to experience the situation in Africa on a first-hand basis to appreciate what was being said. Education, particularly of women and children, is crucial. Health education is an area which I am particularly interested in as it combines my background in youth work and informal education with medical knowledge.

Practicing medicine in Kenya is very different to that in the UK primarily due to financial limitations. Being in Kenya has made me aware of the value of the medical equipment and drugs used in the UK. I have returned with a new appreciation of the NHS. Overall, I am very grateful to have been given this opportunity to work abroad and experience daily living in a completely different culture to my own. Having time on my own away from the daily pressures of the medical course in the UK has reminded me why I initially wanted to become a doctor and has provided me with skills and knowledge which will be used for the rest of my career.

Dana Niry

Elective Report

I spent the first 3 weeks of my elective at the Emergency Department of Ichilov Hospital, Tel-Aviv.

Ichilov General Hospital is one of the three hospitals comprising the Tel-Aviv Sourasky Medical Centre, the main hospital in Tel-Aviv and the third largest hospital complex in Israel. Tel Aviv Sourasky Medical Centre is affiliated with the Sackler Faculty of Medicine of the Tel Aviv University. 

Ichilov is situated in Central Tel-Aviv and is famous in Israel for being the hospital to which Prime Minister Yitzhak Rabin was driven to, and later died, in November 1995 after he was shot during a peace rally.

The Ichilov Hospital Emergency Department is the only emergency department in the city of Tel-Aviv. As such, it has sole responsibility for 24 hour-a-day medical and disaster care for a population of some 400,000 permanent inhabitants of the city and some 1 million daily transients. Admission causes include approximately 40% medical cases, 30% surgical and 30% trauma/orthopaedics.  The department is permanently staffed by emergency medicine, medical, surgical and intensive care specialists.

Israel is generally influenced by the USA and the delivery of medical care is no exception.  However, money for health care and education in Israel is provided exclusively by the national government. This is similar to the UK, and different to the US, where funding for patient care and education is mostly private.

The Israeli approach to Emergency Medicine training is different to EM training in the UK and the US. In Israel, Emergency Medicine is a super-speciality rather than a primary speciality as it is in the UK and the US, and the Emergency Department is staffed with specialists in other medical and surgical domains, who have undergone another 2.5 years of training in EM.

The routine work in all departments is carried out in Hebrew. However, Emergency Medicine is the only department which requires fluency in Hebrew to undertake an elective. Most doctors speak very good English, and many patients do as well. The hospital staff is used to communicating in English with experts from other countries and students from the Tel-Aviv University American MD program and would assist students who require help with non-English speaking patients.

The doctors were very friendly and communicative and I received a lot of bed-side teaching. At first I was shadowing other doctors clerking patients. Fairly quickly, one of the doctors said, in the typical Israeli directness: “You should see patients on your own; you won’t learn anything from watching others”, at which time I started doing the same kind of job as the first year doctors (equivalent to FY1) - clerking the patients, writing up a management plan and presenting it to a senior doctor who must sign any investigation or treatment plan. Seeing patients in this manner gave me a safe environment in which to become more confident in all aspects of my history taking and examination, as well as forcing me to work on my diagnosis and planning. The ED doctors asked many questions and encouraged me to think laterally and systematically.

I gained a lot of hands-on experience and was encouraged to perform procedures including wound care and suturing, abscess incision and drainage, lumbar puncture, gastric intubation, venepuncture and catheterization, and arterial blood gases.

Theoretical lectures are not given as part of the Emergency Medicine elective program. However, I was invited to join lectures given to Tel-Aviv University medical students by doctors and surgeons from the ED. The lectures were of very high standard and I found them interesting and useful. I also got a lot of opportunistic teaching from the very enthusiastic and knowledgeable staff.

The electives are what you make of them.  Doctors are very open and approachable and one can learn a lot.  If enthusiasm is shown, they respond very positively.  In a spare hour, I decided to take a look at other departments as well in order to gain a broader insight into the medical care in Ichilov. 

As an example, on my first day I met a German student who was doing an elective in Internal Medicine. She was very impressed by the team and offered that I should join her department for half a day to see what they did. Although I was not officially rotating in Internal Medicine, I was very warmly accepted by the department\'s staff who included me in their discussions and even invited me to their weekly case presentations meeting. I was also impressed by their efforts to make my friend feel welcome and included by conducting the discussions and the meeting in English instead of Hebrew.

Another example is of the neurosurgeon I met at the ED, and when asked whether he thought I could spend a day in the Neurosurgery department, he immediately organised for me to be in theatre the next morning.

The difference in mentality between Israelis and Brits is, as expected, reflected in the dynamics between the different hospital staff as well as between the doctors and patients. The hierarchy between the different health professionals is not as obvious as it is in the UK. Junior doctors may call senior doctors by their first name. Surprisingly, nurses would often tell doctors if they disagreed with their management plan. On one striking occasion I accompanied a senior doctor to see a patient who was a drug addict and who was suspected to have infective endocarditis. The doctor took his blood as he said that “the nurses wouldn’t do it”. Nevertheless, the Israeli lack of formality also has its advantages and the atmosphere between the colleagues and between the hospital staff and patients is more open and personal, which means a pleasant working environment and  that patients feel less nervous and more at ease to share their thoughts and concerns.

Israelis work a lot, but they are also laid back and know how to relax. The friendly attitude made it easy to quickly become friends with the junior doctors, who are all knowledgeable high-achievers and taught me a lot about compassionate and professional patient care, but at the same time the difference in pace and relaxed atmosphere meant coffee breaks were longer than I was used to from hospitals in the UK.

How to apply

Nothing could be easier!

The application is through Tel-Aviv University: http://www.tau.ac.il/medicine/Electives

Israelis do not like bureaucracy and filling out lots of forms, so no personal statements, references or transcripts required. All you need to do is fill out a form with your personal and Medical School details, your elective choices, a list of specialities you learnt so far and have it signed by the medical school.

The administration fee is the only cost and that is €25 (₤17).

As far as housing accommodation is concerned, I was staying at home, so did not have to worry about that. However, in the application form you can indicate if you need accommodation, and Tel-Aviv University will provide a room (I\'m not sure about exact prices, but it would be a lot cheaper than any college accommodation in Cambridge). Ichilov Hospital is located in a very nice area of Tel-Aviv. It is just adjacent to \"Kikar Hamedina\", a very posh and expensive shopping area. But if you do not want to pay over the top price tags, you can find more affordable shopping by walking 10 minutes to Ibn Gvirol or Yehuda Maccabi Street, where you can find many shops, cafes and bakeries.  

Not to mention the 20 minute walk to the beautiful coastline, dotted with cafes and restaurants, white sand beaches and the blue Mediterranean sea! Or the nightlife scene!

If you are interested in going to Israel for your elective, please do not hesitate to contact me with any questions you may via info@jmeduk.org. 

Acknowledgments

I would like to thank the Jewish Medical Association UK for their financial assistance with my elective.

Sefwi Wiawso – The Jews of Ghana

Carly Szasz

c.szasz@bsms.ac.uk

On completing my elective, Amy, a Catholic friend from university, and I began our trip to the Jewish community in the village of Sefwi Wiawso, in the western region of Ghana. After a full day’s travelling on various busses, we arrived in the wilds of rural Ghana at half past five on a Friday. The Jewish community is well known by the other locals and whilst waiting to be picked up, we were asked on more than one occasion ‘are you Judaism?’

Once we arrived we were greeted by our host family with a ‘Shabbat Shalom’ and given the best room in the house. Imagine a basic 1950s living room and add two beds. Once they realised we hadn’t eaten, we were fed in true Jewish style. The Friday night candles were lit and the Kiddush wine I so fondly associate with Shabbat was replaced with Coke and Sprite.

The community of about seventy families is run by brothers Joseph and Alex Armah. Joseph, the elder, is the father of six children with an array of biblical names such as Rachel, Rebecca and Isaiah. On Saturday morning we walked to the Synagogue which was an unimposing, single storey brick building with no electricity. Inside there were rows of benches, a table used for a Bimah, covered by a white cloth and embroidered with a Chananukiah and the Hebrew letters spelling ‘Shalom’.

There were about thirty people at the Shabbat morning service, most of them children. There seemed to be very few of the older generation and whether that was representative of the community as a whole was difficult to say. The service was mainly in Twi, the local language, interspersed with a few words in English, for our benefit I think, followed by blessings in Hebrew. An American visitor who had recently been to the community had taught them basic Hebrew and many songs and like at home, the children went up on the Bimah at the end of the service and sang Adon Alom.

We spent the afternoon at the family home, playing cards with the children, teaching them songs and immersing ourselves in village life. It was a strange and an exciting experience seeing young African children, I had never previously associated with Judaism, sitting around a blackboard learning Hebrew and singing Hebrew songs. My weekend in Sefwi Wiawso was totally surreal and our short stay was but a moment’s glance at the diversity of the Diaspora. From the wealth and glitz of London communities to the basic, no frills Bimah and Shul in Ghana. Who would have thought?