Medical Elective Report

An Elective In Zanzibar

An elective in the Caribbean

December 2011

Aim

To explore healthcare and its delivery in a lesser economically developed country; drawing comparisons with the NHS with the intention of trying to shape our services for the better on my return.

Objectives of the Project

i) To become emersed in the medical culture of Papua New Guinea, exploring beliefs, behaviours and attitudes towards health in a population very different from our own.

ii) To see how specific groups of people in Papua New Guinea interact with healthcare services: specifically women, the elderly and people living with chonric diseases.

iii) To learn more about tropical diseases and H.I.V. from patients and professionals from a experiential point of view

iv) To consider how the delivery of healthcare may be tailored to a more economically strained setting and how money (or the lack of it) effects healthcare provision in Papua New Guinea.

Explain how you achieved the aims and objectives of your elective.

Objective 1: I sought out patients from the groups I was considering and kept anonymous records of their management/presentations etc.  I contrasted the patient's treatments to those in the UK, in my reflective journal.

Objective 2: Each day I have seen cases of malaria in addition to TB, HIV, leprosy, tropical splenomegaly, worms etc. I have learned their presentations/managements and have made a portfolio of interesting cases.

Objective 3: The lack of resources available was evident: e.g. the hospital lacked a water supply most days. Each evening I reflected on how the staff dealt with such dilemmas in my journal.

Were there any flaws in the methods you used to address your aims and objectives? Describe them. If none, explain why you think there were not any?

On arrival, I discovered that the hospital had been hit by a tsunami caused by the Japanese earthquake. Hospital services had been reduced to cater only for emergencies.

Accordingly I modified the planned methods for my objectives to take this into account. E.g. for Objective 1, I had to examine how patients presenting with acute complications of chronic disease usually managed their disease, rather than attending their routine clinics etc.

'Flaws' in my planned methods were circumstantial rather than due to problems with my preparation and I overcame them by adapting my methods within the scope of broad objectives.

What were the Learning Outcomes from this elective? Were they what you expected?

During my elective I feel that I have met each of my planned learning objectives but the stark nature of some of the patient's conditions and circumstances has left a deeper emotional stamp on my memory than the intellectual exercise I wished to achieve.

It is one thing, for example, to want to understand how women interact with healthcare services in a developing country but it is very much another to be confronted by a woman in A&E who has suffered domestic abuse at the hand of her machete wielding husband whose only punishment would be a set hospital fine (6 pounds sterling).

Reflect on how your Elective complimented your medical undergraduate career (a deeper understanding of life; a better understanding of communicable diseases; etc.) Has it affected your future career intentions?

On reflection I realise that I have been able to develop many of the skills that have been fostered during my undergraduate training whilst studying in PNG; procedural skills, consultation frameworks, advanced communication techniques with non English speakers etc. These experiences will have direct practical value for my foundation training.

However, I now feel that other, less tangible, aspects of my study here will have a greater effect on me as a doctor going forward. I have witnessed the great social and physical impact of chronic disease on people who receive little treatment, been exposed to deaths from diseases I consider easily preventable, and seen the serious social stigma that people can receive due to illness and much more. These experiences have given me a greater understanding of what it is to be a patient, the patient's narrative. These are valuable insights that will remain with me forever and will improve my future practice.

My time in PNG has given me much exposure to infectious disease medicine and has perpetuated my desire for a career in this field. Having seen the importance of infectious disease prevention here, I am now strongly considering applying to spend some time at the W.H.O.

 

Would you recommend this location to another student? Why?

In PNG I have learnt not only about tropical disease, trauma etc. but also the art of practising medicine where resources are scare and poverty is abundant. All whilst bathed in the tropical sunshine of an island with some of the warmest people I've met. I would absolutely recommend it.

Daniel Cox

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The Cholera Unit following the Japanese Tsunami

Medical Records following the Japanese Tsunami

The Hospital Kitchen

The Pharmacy following the Japanese Tsunami

November 18th 2011

Elective in Australia

I spent my elective in Australia; one month in a GP practice near Brisbane and one month in The Royal Darwin Hospital in the Northern Territory. 

My GP placement helped me to develop my history and examination skills and because of the high incidence of skin cancers in Australia I was able to assist with many excisions and improve my suturing.  There were many similarities to general practice in the UK but significant differences in the way the healthcare system is funded, which was very interesting.  I also came into contact with conditions I hadn’t seen before; scarlet fever, Giardia from water tanks and Rickettsia from tick bites.  One patient brought in a funnel web spider that had bitten her but luckily there was no venom released!

Being in Darwin was a very different experience and was very interesting. A WHO report states that there is a 20 year gap in the average life expectancy of an Australian and an Aboriginal person.¹   I was with the Renal medicine team and saw the problems associated with the large area the hospital is trying to cover; the Northern Territory is six times the size of the UK with only five hospitals.  The hospital runs outreach clinics to improve healthcare access for aboriginal people living in remote communities and I was able to attend one of these on the beautiful Tiwi Islands.  Through talking to doctors and patients I was able to learn a little about Aboriginal culture and can appreciate some of the differences from Western society. 

This elective was fantastic and I learnt about renal medicine, the challenges faced in providing access to healthcare over a large area, and working with patients who have differences in culture and health beliefs.  I was very lucky to have this experience and greatly appreciate the bursary from the Kidderminster Medical Society that helped me go on my elective

Thank you!

Harriet Webb

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October 12th 2011

Year 1 Bursary Report

Hello, I’m Robyn Hill and you very kindly awarded me the KMS bursary last year. I’d like to take this opportunity tot hank you and show you a snippet of my life as a medical student at Norwich Medical School , UEA .

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20 July 2011

An Elective in Masaka, Uganda.       June 2011

James Parsons,     5^th Year Medical Student,     University of Birmingham

In April earlier this year I embarked upon my medical elective as part of the MB ChB programme at the University of Birmingham. I decided to travel to Kitovu Hospital, a small missionary led hospital in Masaka, Uganda.

The focal point of my project was to look at the diagnosis and management of HIV and Malaria. I chose to go to Uganda as these two diseases are the two biggest contributors in terms of mortality of the population.¹ Along with this I wanted to get a comprehensive experience of what healthcare systems are really like in  third world countries, where resources are often scarce and simple diagnostic tests are often unavailable. I therefore spent each week of my four week placement rotating between the four main wards in the hospital: Medicine, Surgery, Obstetrics & Gynaecology and Paediatrics.

During my first week I shadowed and assisted the hospital physician on the medical ward. This entailed daily morning ward rounds followed by ward jobs, procedures and medical outpatient clinics. HIV and malaria are common conditions. At any one point at least half of the ward (15 beds in total) were being treated for Malaria. These patients would often have massive hepatosplenomegaly and so I was able to practice and improve my examination skills to great effect.

This week also allowed me to see first hand the difficulties faced by doctors in the third world. During the week I was on the medical ward the radiographer was on holiday and so there was no imaging modality available at the hospital. Instead doctors would either have to send patients to the next large hospital to have an x-ray, which would often take days, or rely purely on clinical signs. This helped me to truly appreciate how lucky we are to have access to such comprehensive healthcare here in the UK.

Following this week I spent a week on the Paediatrics ward, which was coupled with both the Hospital Nutrition Unit and the Hospital Outreach Team. During this week I helped manage the 30 young children on the ward. I have yet to do Paediatrics as a specialty in the UK and so this gave me a brilliant opportunity to learn about the different problems children experience and also to learn how to go about examining a child.

As stated above I also got to spend some time on the Nutrition Unit where I was able to see numerous children with Marasmus and Kwashiorkor. I was shocked at how poor some of the families were. The parents often didn’t even have enough money to feed themselves, let alone their children.
 

My final two weeks were spent on the Obstetrics & Gynaecology ward and the Surgical ward. My week on the Obstetrics & Gynaecology ward allowed me to develop my confidence in dealing with and managing a pregnancy. I also got to watch and assist surgeons carrying out Caesarian sections, which was an extraordinary experience, as again I have yet to do my Obstetrics placement in the UK. The week I spent on the surgical ward was also just as rewarding. I was allowed to practice my suturing skills a number of times and I also watched several emergency operations being carried out.  

Overall my elective was a challenging but incredibly rewarding experience and I would like to thank the Kidderminster Medical Society for the bursary they provided me with to help fund it.

Many Thanks,

James Parsons

References

1.       WHO Mortality Country Fact Sheet 2006: Uganda.

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April 2011
 

A year in Natal

Thomas Mendes da Costa

KMS Bursary 2009/10

 MSc Trauma Surgery

Again I would like to express my appreciation for the bursary from the Kidderminster Medical Society which, despite the title of this article which will become apparent shortly, was used towards funding my recently completed Masters degree in Trauma Surgery from the University of Wales. Many reading this will I’m sure know my father Dr Baron Mendes da Costa, who worked as a local GP in Kidderminster for 30 years until his retirement early last year which I can assure you has done little to slow him down! Although following the same degree path, we have deviated widely in specialty, and I am currently in my third year as a registrar of Orthopedics and Trauma in the Severn Deanery. Whilst in the twilight of my career I am sure a quiet elective list of a bunion or two and the occasional arthroplasty will be quite fulfilling, my interest during junior surgical training has always been traumatology. It is this interest which has led me on to the Masters degree course run at Morriston Hospital, Swansea.

The trauma unit at Morriston Hospital is currently one of the few in the UK to offer all specialties required to support poly-traumatised patients on site, most centres requiring referral links to specialist centres as a patients needs dictate. This includes burns, plastics, vascular and neurosurgical teams to support the surgical, orthopaedic and intensive care teams who make up the front line trauma response team. This provided an ideal setting and a wealth of experience form which a years taught course programme was formulated, concentrating initially on the physiology of the traumatic process, kinetics of trauma, and the indication and effect of early resuscitative or emergency intervention, through to methods and timing of emergency and definitive surgery, and culminating in recovery and rehabilitation. Visiting military and civilian lecturers covered the broad range of challenges posed by the spectrum of both trauma and the individuals affected, with real time scenarios played out with (sometimes all-to-realistic) medical actors to ensure the practical and theoretical elements to trauma care were all addressed.

Following the taught course, a dissertation was undertaken, for which I studied open fractures of the tibia. If you will excuse the dramatism, this is essentially a broken shin bone sticking out the skin and the decision of exactly what to do with it. Treatment of the complex fracture patterns, with associated commonly severe soft tissue injuries, can be a difficult decision for patient and surgeon alike, as treatment varies from fixation and closure to amputation, with multiple options in between. These include a variety of fixation methods (plates, intramedullary nails and external fixators) and requirements for treatment of surrounding soft tissues (debridement, need for plastic surgical flap coverage etc). To assist the surgeon with this dilemma there are a number of scoring systems that are used on presentation to help guide treatment and prognosis, so as to select the best method for salvage and rehabilitation, whilst not exposing the patient to the risks of lengthy salvage operations which may increase the risk of morbidity or mortality without yielding a superior result. My study focussed on comparing one new and one mainstream scoring system with the well established system already internationally used but widely regarded as being of little practical use. These scoring systems would be used on all patients presenting with open tibial fractures, and the eventual outcome compared to the recommendation of each system.

A comminuted fracture of the distal tibia and fibula (Left) 

 Sability achieved with a bridging external fixator (Right)

Open fractures of the tibia are thankfully a relatively rare injury in the UK, making it an unsuitable location for this study. An area with much higher incidence of trauma was needed. Ngwelezane Hospital, in a township outside Empangeni in rural Kwazulu-Natal, South Africa, provides a tertiary referral service for trauma throughout the northern third of Natal, some 2 million people. Run by an ex-pat consultant from Sheffield and with a mix of Black African, Africaans and Western doctors, the hospital workload consists of high levels of interpersonal assaults, violent trauma and motor vehicle accidents, amid the epidemic of HIV and TB. This would be not only the ideal setting for dissertation data, but would provide an incredible training experience in the management of types of trauma usually uncommon and treated by senior surgeons in the UK.

Having obtained deanery and college approval, I commenced work as a medical officer in February 2010. The Orthopaedic department was extremely busy, and, along with a thankfully never-ending supply of nurse translators, and surprisingly patient locals who would think nothing of a four plus hour wait to see the doctor, the long queues of patients in chairs and on stretchers were tended to three times a week. Three all-day trauma lists ran side-by-side twice weekly to fix those who could wait, and a non-stop trauma list was available for the operative emergencies. Surgical instruments and implants were in good supply, but the pressures of blood shortages and periodic civil strike action were new challenges to face. Seniority was achieved quickly working in this environment, with surgical skills acquired being taught in turn to those more junior to enhance the strength of the available workforce.

Table Mountain from the V and A waterfront, Cape Town, South Africa

The levels and type of trauma was formidable. Gunshot and panga (African Bushknife) wounds were commonplace, with accidents involving overcrowded and poorly maintained vehicles often resulting in multiple severely injured casualties. Whilst I thankfully survived the year suffering nothing more that minor theft, the high walls, electric fences and numerous security companies offering armed response units at the press of a button bore testament to the perceived levels of danger in the area. This was soon a part of everyday life and certainly with the excitement of the FIFA world cup being hosted in South Africa (which anecdotally dramatically cut trauma rates), Natal was one of the most beautiful and culturally diverse places I have visited. The warm Indian Ocean, the spectacular Drakensburg mountains and multiple reserves sporting the big 5 were simply breathtaking. Be it vineyards in Stellenbosch, shark diving on the south coast or the beauty and cultural diversity of Natal, South Africa really does have it all!

Gans Bay, Western Cape, South Africa

During my eleven months in Africa, I succeeded in following up twenty patients with open tibial fractures to gain the data for my study which provided statistically significant evidence that their application can predict outcome and guide treatment. These systems were adopted in Ngwelezane Hospital following the study. Dissertation results from the university are pending and will be followed up by submission to publication in the international orthopaedic literature.

For any information regarding work or electives in Natal, South Africa, or enquiries from this article, please contact me at tommendes@hotmail.co.uk

Many thanks to KMS for their support.

Thomas Mendes da Costa

BMedSci BMBS MRCS

 March 2011

 Ostrich farm, Oudtshoorn, Western Cape, South Africa

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28th October 2010

Kidderminster Medical Society Bursary 2009

A report from Gemma Plant who was last year's recipient at Birmingham University Medical School.

I am writing to express my sincere gratitude to the society for the Bursary awarded to me in 2009. This has provided me with invaluable financial support during my first year of the Graduate Entry Course (GEC) at the University of Birmingham Medical School.  The money awarded by the Society made a significant contribution to my tuition fees for the year and helped massively to ease the financial burden of my return to student life after four years of full-time work.

I graduated from The University of Birmingham in 2005 with First Class Honours Degree in Biological Sciences, and then worked in Pharmaceutical Sales until returning to University last year.  I have always been interested in Medicine but my desire to become a doctor grew significantly as a result of exposure to the profession in my role as a Medical Representative.  The decision to return to university was a difficult one, since it involved many sacrifices. Before applying to university I felt I should gain direct experience of medicine. To do so I acted as a volunteer at Mary Steven Hospice, and I shadowed a number of doctors in both general practice and hospital. I was aware that there is significant competition for places on graduate courses and was delighted when I was offered a place to study medicine. 

The first year of the graduate course was very intense, involving study of what is normally two years worth of pre-clinical theory in nine months. Much of the learning process was “self taught” with the majority of the material in the year being predominantly based on problem based learning (PBL).

Overall I had a great year and found the work challenging but importantly interesting and rewarding. I have made some wonderful friends amongst my peers, since we depended upon one another for support as we progressed through the PBL modules. The learning process and experience was fantastic and has increased my passion to enter the medical profession.

Having successfully passed the initial year, I have now joined the third year of the Undergraduate course and am currently on my first clinical placement at Walsall Manor Hospital.  This is an integrated medicine and surgery placement and I have already seen many interesting cases and learnt many new skills.  Although the first few weeks in a hospital setting were daunting I love every minute of the experience and can honestly say I have never regretted my decision to return to study medicine. I will remain forever grateful and indebted to Kidderminster Medical Society for being a part of making it possible.

I had the pleasure of attending your annual dinner last month with one of my GEC colleagues. Both Julia and I had a lovely evening and very much appreciated being invited and made to feel so welcome.

Hopefully I will have the opportunity to train or work in the Kidderminster area and in some small way be able to repay the investment the society has made in my career.

Once again, my sincerest thanks for you support and commitment to me.

With all best wishes to the society and its members,

Gemma Plant

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June 2010

Medical Elective Report

 Kimberley Eaton Charnock
Year 5 Medical Elective
Batrs and the London

30th June 2010

For my medical elective I chose to go to Tanzania, Africa. The main reason for this was because I thought going to a third world country would give me great insight into working with few resources, being challenging as well as experiencing a completely different culture. I went to a large government hospital called, Mount Meru District hospital in Arusha, (Northern Tanzania) where I worked in obstetrics, general medicine and casualty/outpatient department. I also went to a remote Maasai village where I spent a week at a dispensary, similar to a general practitioner (GP).

In the obstetrics department I spent time learning from the staff, made up of doctors and nurses who were experienced in assisting childbirth. The delivery suite was an open 20 bedded ward, where all enter, were assessed and gave birth. So you could see all stages of labour simultaneously. Whilst I was there I assisted in vaginal deliveries, a breech delivery, neonatal resuscitation, watched caesarean sections and went on the daily ward rounds for all obstetric and gynae patients. This experience enabled me to develop my own confidence in delivery babies naturally, particularly as there was no analgesia.

The general medical ward was made up of all medical specialities. There were a total of 60 beds, half female, half male. But when the beds were full there would be more than one person to a bed, sometimes this made it difficult to examine patients properly. Often patients had infectious diseases such as gastro-enteritis/pneumonia and were sharing beds, which was obviously not ideal. I learnt how to treat diseases that are not common in the United Kingdom (UK), such as malaria and HIV as well as how common diseases such as pneumonia and asthma are treated in a third world country where there are no oxygen facilities. Here I worked with the Intern doctors (foundation year doctor equivalent), which was very good because we compared our education and learnt a lot from each other. I found there were limited investigation services available in the hospital, and even if a doctor ordered an investigation it was often not carried out due to demand, or no availability. There was no CT or MRI scanner and only one ultrasound and X-ray facility so actually getting a patient to receive this was rare, compared to UK. Anti-biotics were often unnecessarily used or multi anti-biotics were used, doctors were aware they were over-using antibiotics but said it was due to lack of availability of investigations, such as sputum sample culture and therefore it was better to give many broad-spectrum antibiotics. I think this will be a much bigger problem in the future, particularly in those with HIV. I saw quite a few diseases there which I will probably never see in the UK, such as a death from Pellgra, a vitamin deficiency.

I spent one week with a remote large Maasai tribe, where the population was about 4,000-6,000 people. During this week I went to the dispensary daily, where I worked with a doctor and a nurse. This was very similar to a general practitioner (GP). We would see patients on a first come first see basis. Patients often travelled from far away. I was surprised how many patients came with similar problems to the UK, such as head and back pain, muscle spasm etc.  The doctor also ran an antenatal clinic one afternoon, a current topic of improvement in Tanzanian, where they are trying to reduce maternal and baby mortality. This week was very enjoyable, where I learnt about tribal life, Maasai culture, all helped by living with them, and I also met the local “medicine/spiritual” healer man. He still sees a lot of patients for a variety of bodily and mental complaints, however the popularity is reducing with the availability of modern medicines and the ever-popular anti-biotic!

 I spent my last week in the casualty/outpatient department. As there are no GPs in Tanzania, all patients present to the outpatient or casualty department and are seen on first come first seen basis. This was a busy week, with many patients of every speciality including follow-up patients. It is from this department that people are admitted from the hospital too.

I thoroughly enjoyed my time in Tanzania and am eternally grateful for support I gained before going. All this made it possible for me to go. I learnt many things about the difference in healthcare worldwide and the importance of team work and a variety of education amongst health care workers, and just how lucky we are in England to have the NHS team.

 Kimberley Eaton-Charnock

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April 2010

An Elective In Zanzibar

Amy Mountain   -   5^th Year Medical Student-Keele University

I chose to undertake my medical elective in Zanzibar, a beautiful tropical island off the east coast of Tanzania.  The hospital where I worked was called Mnazi Mmoja, the only government run hospital on the Island serving a population of 1 million people.

The hospital is evidently deprived of resources-yet the staff utilise what they do have incredibly well.  I was shocked to learn that the only source of oxygen was in the intensive care unit.  Patients also have to pay for all interventions, medications and investigations.  Prices ranged from 75 pence for a full blood count to 15 pounds for an above knee amputation.  This was all very expensive for patients who try to avoid going to hospital and will seek ‘local remedies’ in the villages instead.

I spent 4 weeks on the female medical ward as well as time in the eye hospital, paediatrics and psychiatry.  Experience in so many specialities was great and so were the staff.  Common day to day presentations included malaria, diabetes, hypertension, anaemia (which was incredibly prevalent), complications of human immunodeficiency virus and diarrhoea.

One of the most shocking sights was when patients had severe diarrhoea.  If they were very weak they would be placed on a bed with the mattress folded in half.  This ensured that when they defaecated their faeces fell through the rusty metal springs of the bed into a bucket below.  No attempts were made to preserve the patients’ dignity.

There were many cases of cholera during our time there, possibly due to a 3 month power cut that affected the water supply.

A big learning curve for me was that resources were simply not available to perform multiple investigations and seek out a diagnosis as we do in the UK.  This often meant many patients were discharged without a diagnosis.  At first I found this frustrating but it did highlight how fortunate we are in the NHS to have a battery of tests at our fingertips and this is probably taken for granted at times.

I learned a great deal from this experience and I would like to thank the Kidderminster Medical Society for the bursary towards my elective.  It made my elective an even more enjoyable experience and one I shall never forget!

Amy Mountain

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October 2009

Katie Levitt             

An elective in the Caribbean, an experience of  healthcare in two developing countries

Details of Venues and health and safety: I spent a month at St Ann’s Bay Hospital, Jamaica and a month in Victoria Hospital, St Lucia. My supervisors at the institutions were:

Jamaica

Dr Horace Betton
St Ann’s Bay Hospital, St Ann’s Bay, Jamaica, West Indies

St Lucia

Dr Elisabeth Lewis
Victoria Hospital, Castries, St Lucia, West Indies

Main Report:

Aims and Objectives

The main aim of my elective was to experience healthcare provision in two developing countries. I wanted to contrast the healthcare provision, practice and attitudes towards health between the Caribbean and the UK. I was interested to gain the views and beliefs of patients and doctors in a foreign country to broaden my cultural horizons. I was also interested in learning about how healthcare is provided in these countries in contrast to the National health framework used in the UK.

Whilst abroad I wanted to challenge myself to learn medicine in an unfamiliar and self directed environment. I felt it very important to learn how to adapt to a new environment whilst continuing my learning; a skill I will need to implement when I begin my foundation year training.

I am now going to talk about the month I spent in each country separately, beginning with Jamaica.

Jamaica, September 2009

"It is the fairest island eyes have beheld; mountainous and the land seems to touch the sky”
Christopher Columbus, 1494 (1)

Jamaica is famous for having the most churches per square mile of any other country in the world. Ironically it is also famous for being a violent country, with an estimated 3 murders occurring per day. The official language of Jamaica is English and most correspondences are written in Standard English. However, the Jamaicans have developed their own spoken language, Jamaican Creole or Patois, which is a mixture of African and English. I soon discovered that patois is very different to the English language and would take some getting used to. I had a month to practice the language and learn about the culture in the St Ann’s Bay hospital, St Ann’s Bay where Columbus had landed many years earlier.

                 One of my first experiences in the hospital was that of a paediatric ward round. The paediatric ward, like all of the others, was nothing like the ones in England. They were all free standing buildings with windows without glass but shutters instead to keep the ward cool. Patients were crammed in to available spaces wherever possible, despite the number of curtains. Cleaning staff kept the ward generally clean, but not up to UK standards. Cobwebs were still visible in the corners of the rooms and dust had settled on the windowsills. Despite this all of the patients seemed generally happy and comfortable.

The first thing I noticed as we began the ward round is that the doctors do not wash their hands after each patient contact. Infection control in the form of hand washing is not as strictly implemented as in the UK. The doctors and ward staff can wear rings, watches and long shirts to work in; items banned in the UK due to the bare below the elbows policy. The doctors did not seem aware that the practice of hand washing was important in reducing the spread of infection. In the UK hand washing is so highly publicised and now the cultural norm. I assumed that the same practices would occur all over the world, based on clinical evidence. It was reported by the National Audit Office that hospital acquired infections could be reduced by 15% with correct hand hygiene (2). The lack of hand washing could be attributable to shortages or lack of cleaning products in the country. This has been identified by a paper looking at infection control globally. The table opposite shows just some of the problems that developing countries like Jamaica face relating to the implementation of infection control practices. The paper suggests that developing countries may be aware of the practice of infection control but do not have access to the training or funding to implement this practice (3). When I asked doctors about hand washing they were all familiar with the practice but were not strictly told to implement it. This experience, although a surprise, has shown me that healthcare is affected by many factors; money, culture and evidence based best practice are some of these. I was beginning to understand some of the difficulties and barriers that developing countries face to provide good healthcare.

The second thing that caught my attention on the ward round was the doctors’ lack of communication. It was the norm to stand around the end of the patient’s bed and talk about their history and condition without involving them in the conversation. This was often done without a curtain drawn around the bed, even when a physical examination was conducted. Usually once a management plan had been decided upon the doctor would communicate this to the patient or parent very bluntly and then move on. I found this lack of communication unsettling. From our first day of clinical practice we have had the skill of communication put at the centre of becoming a great doctor. Poor communication may be part of the culture in Jamaica, but it is very upsetting to observe. This experience has taught me the value of effective communication. I believe that the patient should always be fully informed, involved with decision making and respected as an individual and will always implement these when dealing with patients in the future

The St Ann’s Bay hospital is a Government run establishment. Despite this service users have to pay fees to the hospital for all medications, specialised investigations and for transportation, including an ambulance service. A ‘friends of the hospital’ group arrange fundraising events to raise money for the hospital to help subsidise the cost of care for those who cannot afford it. The experience of this provision of healthcare has made me appreciate the greatness of the UK’s ‘free’ National Health Service. All who require healthcare in the UK have access to it, unlike in Jamaica where if you cannot afford to pay you do not receive the care.

           of infection control, M. Nettleman, 1993

Table 1. Taken from Global aspects

Photograph of the St Ann’s Bay hospital

This was demonstrated whilst on a medical ward round. I met an elderly lady who had been admitted with a suspected stroke. The medical team looking after her wanted to get a CT scan of her head to confirm the pathology and diagnosis. However she had very little money to pay for the scan and her family were unable to help. This meant that the diagnosis was not confirmed by a CT scan and the extent of the damage to her brain remained unknown.

 There is no doubting that the Jamaican culture is a rich, diverse and dynamic one. Part of the culture involves a very paternalistic idea of healthcare. Doctors are seen as the ones with the medical knowledge and should always know what is best for a patient. Patients trust and respect the doctor’s advice. This is a vast contrast to the UK. We are moving towards a shared doctor-patient relationship, one in which the patients help in the decision making process of healthcare. Most patients in the UK like to be well informed of their medical condition and health and have a say in what is best for them. I was shocked to see this ‘traditional’ model of healthcare and how popular and happy patients were with it.

St Lucia, October 2009

                 St Lucia is a smaller Caribbean Island, situated farther South and East of Jamaica. It is part of the British Commonwealth and the Queen still appears on all local currency. Like Jamaica, St Lucian’s are extremely proud of their culture. I was lucky enough to experience Jouen Kweyol (or Creole Day in English) a cultural festival that celebrates the local food and national dress of St Lucia. The official language of St Lucia is English, but the spoken language mixes French, English and African to create a unique patois language. Like Jamaican patois, it was incredibly hard to understand and would require yet more practice in the Victoria Hospital, Castries to learn.

                 The Victoria hospital is a public, government run hospital that serves a population of 100,000 people. It is the larger of two hospitals on the island. At the time I was on placement in St Lucia a fire had swept through St Jude’s, the other public hospital on the island, which meant that the workload had considerably increased for all of the staff at Victoria. Although the hospital was a public one all patients that visited had to be covered by health insurance to pay for the costs, much like the system in the United States. A doctor explained to me how it was very common practice for a patient to provide the incorrect contact details so that they cannot be traced after leaving the hospital. The Government then clear the cost on behalf of that patient. This is a new way of cheating the healthcare system in the country that is becoming more popular with residents who cannot afford medical treatment.

                 My chosen rotation in this hospital was gynaecology. As part of the gynaecology rotation I spent a morning in surgery. There were two operating theatres in the hospital; one was specifically designated to obstetrics and gynaecology cases. There was a small recovery area between the two operating theatres and a corridor outside the theatre that was used as the waiting area. The operating theatres themselves looked out onto the Castries harbour with spectacular views. They were well equipped with the necessary modern technology, as used in England, but they did lack the laminar air flow mechanism which prevents the settling of organisms in the operating theatre and reduces post-operative wound infection (5).

I observed a caesarean section in surgery. The one thing about this operation that I will always remember is the poor communication with the patient. This lady was visibly distressed and anxious whilst waiting outside the operating theatre and at no point did any member of staff reassure her that everything would be ok. This was displayed again when the anaesthetist was speaking over the patient whilst she was being cleaned and draped for the procedure. It would seem that this is the culture in this country; one similar to Jamaica. Poor communication was demonstrated time and again whilst on ward rounds in the hospital. As a future doctor I feel that keeping the patient central to care and maintaining their dignity and respect is crucial. Observing this situation has made me realise just how important learning how to communicate well is and this is something I will strive to achieve throughout my career.

Photograph of the Victoria Hospital, Castries

Throughout my time in the Caribbean I have witnessed the presentation and treatment of tropical diseases that I would not have done in the UK. I have seen patients with rheumatic fever, sickle cell disease and many strains of Tinea. The rarity of these conditions in the UK motivated me to learn about them whilst out in the Caribbean. It was useful to relate the written textbook presentation of these illnesses to a real life scenario. I now feel that I have gained more knowledge of tropical illness and disease through firsthand experience of the conditions.

Conclusions

                   Experiencing healthcare provision in a completely different and diverse setting has been a highlight of my training so far. I wanted to gain a perspective on how healthcare is provided in developing countries and how it encompasses the culture and beliefs of patients and doctors. I feel that this has been successfully achieved. Through observation and involvement with the doctors who are providing the care in these countries I learnt about their attitudes to health. I was also able to gain an insight into the structure of their healthcare system in each country and compare this to the structure in the UK. Having the opportunity to learn about a culture that is very different to our own has been a vital part of this experience. I now feel more confident in dealing with patients in hospital who may be from a different culture or religious background to my own. I learnt to respect and adopt their culture during my time abroad, an aim that I wanted to achieve.

                   In conclusion, the experience of another countries healthcare system has been challenging yet rewarding. It has shown to me just how advanced healthcare provision is in the UK and how lucky we are to receive such good healthcare and modern facilities. I have learnt about barriers to healthcare provision in a developing country and the challenges that doctors in those countries experience.

References

1. Discover Jamaica, Geography
http://www.discoverjamaica.com/gleaner/discover/geography/geography.htm

2. Hand Hygiene. Use of alcohol rubs between patients: they reduce the transmission of infections. BMJ 2001. August 25;323(7310):411-412
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121017/

3. Global Aspects of Infection Control, Mary D. Nettleman, Infection control and hospital epidemiology, Vol. 14, No. 11, (Nov 1993), pp 646-648

4. Incidence and Prevalence of Diabetes in the Americas, Alberto Barcelo and Swapnil Rajpathak, Rev Panam Salud Publica/Pan Am J Public Health 10(5), 2001.

5. Rheumatic Fever, pp76-77, Clinical Medicine, Kumar and Clarke, 2005 Elsevier limited

6. An overview of Laminar Flow Ventilation for operating theatres, Queensland Health, October 1997.
www.health.qld.gov.au/cwamb/cwguide/laminar.pdf

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Letter received from Bursary recipient
Leila Bassir
Stourport-on-Severn
Worcestershire

November 2009

Dear Dr Lewis

Well, finally my first year has come to an end, and as requested, I would like to write and thank you for the bursary granted to me last year, and tell you a little about how I am getting on here at Swansea Medical School.

So, firstly, may I thank you most sincerely for accepting me for and granting me the graduate bursary last year, as my parents were both affected by the economic downturn, it was a great help not just for myself, but also a relief of pressure for them.

My first year at Swansea has passed very well. I thoroughly enjoyed every moment of the course, and am very pleased with my exam results.  As I wrote at the beginning of the year, anatomy has continued to be my most enjoyable subject, though unfortunately it is no longer on our curriculum, but neuroscience has taken its place as the next! Throughout I have found myself helped by the knowledge gained through my previous degree, which fortunately covered a lot of ground in clinical skills, and as we have now begun our ward visits, I have a chance to hone them upon actual patients.

This year has begun with quite a jolt compared to the last and promises to be an interesting one.  Last week, within the space of 48 hours, in fact, I found myself the Prince’s Foundation for Integrated Health Student Network Champion for Swansea, and I only replied to the email out of curiosity! Besides this, together with my colleague and selected champion for the Cardiff branch of our course, we are hoping to build an integrated health network within the university itself, working with both staff, students, medical and CAM professionals.  Below is a list of the aims and objectives for our intended project:

Foster an acceptance that many patients use CAM and thus it is necessary for all doctors to have an understanding of how the therapies work.
Understand the mechanism of action of different types of CAM, their side effects and potential interactions with conventional medicine
Promote open communication between CAM practitioners and doctors
Practical advice on how a doctor would access information about the potential interactions between conventional medicine and CAM
Gain an insight into the practice of both medically trained and lay practitioners within a given CAM speciality
Expose students to practitioners who have used CAM and conventional medicines in an integrated fashion

As part of this project we hope to find speakers to discuss the use of CAM and integrated medicine, including both lay and qualified practitioners in order to provide an insight into the spectrum of usage likely to be encountered, and hopefully, medical practitioners who use CAM or practice integrated medicine. Our main goal, not to create an argumentative rally of should it be used or not, but fostering the fact that as doctors, we will encounter patients using other therapies and as such it is best that when faced with a ‘what do you think, Doc?’ that we know a little of what they are talking about.

Besides the above project, I have also been involved in the creation of a new Medical School students’ magazine, both as lead typographer and contributor, and I would have included a first copy, but some of the authors made a decision to alter articles last minute, whilst I was unfortunately not around.  My name is still on the page as typographer, however, so if you would like a copy, ... I didn’t do it!

Right now, although I am enjoying everything, I still have no idea what I would finally like to do. I started off torn between rural GP, cardiology, neurology or surgery.  Half way through, I had doubts on the surgery. Currently, it stands at GP, neurology or anaesthetics, whilst a lot of my colleagues say they can see me as general practitioner. I do know, that I would like to be able to combine a little minor surgery into general practice, so A &E or rural GP are top of the list. I still have several years though till the final decision, and I am sure our ward placements this year, and our two years clinical in Cardiff should help me make up my mind; and, four years ahead is a very long time, whilst, four years previously, I had no idea I would even be contemplating studying medicine!

Once again, may I pass my greatest thanks,

Sincerely,

Leila Bassir

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