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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