Weston Park Hospital

I did my elective in clinical oncology at the Weston Park Hospital in Sheffield, which is one of three specialist cancer hospitals in the UK.  My aim was to confront what I felt was the most difficult part of medicine: end of life care. I wanted to find the elusive balance between being empathetic, without feeling emotionally drained, but neither neglect patients’ emotion needs. Furthermore, I wanted to know whether or not I could cope with death, a topic I had avoided for too long.

Two patients I will always remember. The first was an urgent admission of a patient with new onset amnesia caused by brain tumour. The patient was unaware of his change, but the spouse’s tears emphasised the severity of the amnesia that had eroded his identity.  I did not know what to do or say and my nightmare was becoming a reality. No longer could I hide behind medical facts and I needed to provide emotional support, but how? Thankfully the oncologist intervened by pacing his succinct information in relation to their emotions and concerns.

This patient underwent emergency neurosurgery but treatment was not curative. I felt sad, but this was actually sympathy since the treatment bought the patient time to compress his most important life experiences into the limited time frame and still feel fulfilled. Now I understood why I would not engage emotionally with palliative care patients as this always made me question my own mortality. However, death no longer bothers me, as I have seen how people can adapt by accomplishing achievements they would have otherwise postponed or abandoned altogether.

The second patient was pregnant and had delayed her cancer treatment till after childbirth. This might avoid the risk of harm to her child related to the treatment, but this might also raise the likelihood of a worse prognosis for her. Initially, it felt odd to provide treatment that was not curative, but allowing symptom control so that she could arrange plans for her child’s care, made me feel satisfied and privileged in supporting her. No longer did oncology appear to be concerned with death, but about preserving patients’ options, opportunities and hope.

Overall, oncology is useful for revision because it is a multi-system specialty that involves all age groups in addition to its many social issues and so this encourages students to be more holistic in their management plans. Furthermore, this elective helped me broaden my understanding of palliative care, chemotherapy and radiotherapy planning which showed me how to apply anatomy to clinical situations. There are many opportunities to practise and develop your own communication style with patients, as well as when liaising with colleagues in medical and surgical specialties. Also, the doctor-patient relationships are more personal and humane due to frequent outpatient follow-up, which is uncommon in most other specialties. This hospital also offers a variety of lab based and clinical research projects to pursue since your timetable will be flexible and can be tailored to your needs.

The advantages of staying in the UK for your elective is that what you learn will be fully applicable to your future practice and it will provide you useful networks that could be invaluable for securing later training posts. Also you will know more about the workplace and area to help you decide whether or not the post is suitable for you.

Finally, my patients have led me to re-think what is most important to me and to not leave things until later, as unlike my oncology patients, I do not know how much time I have left.

William Lee

william_22_lee(a)hotmail.co.uk

Having presented two posters at the 17th International Student Congress of Medical Sciences (ISCOMS), which took place on June 9–10, 2010, at the University Medical Center Groningen (UMCG), Groningen, Netherlands, I was invited to take part in an ISCOMS international research fellowship (IRF). This opportunity enabled me to participate in ongoing fundamental research in a laboratory of my choice. My application for the IRF was selected, along with 21 others, on the basis of my previous research experience, my curriculum vitae, a letter of recommendation from one of my previous supervisors, and a letter of motivation for applying for an IRF.

I chose to work in the department of pathology and medical biology during my IRF as the project that was offered to me appealed the most. I worked on the validation of a mouse model for the study of diabetes enhanced restenosis. In doing so, I obtained experience in performing (immuno) histochemical and immunofluorescent stainings as well as subsequent quantitative computerised morphometric analyses. This was something new to me as there are few opportunities to do similar research in developing countries like Pakistan.

Life at UMCG was hectic but fun at the same time. It was a pretty long walk from the University International Housing Office (where I stayed) to the hospital. The working day would kick off with a cup of hot chocolate for me, after which it would be attending the lab and working on the project which was assigned to me; attending the noon lunch conference and finally some literature research in the University’s Central Library, sometimes till late in the evening in order to write up an abstract of my work. Honestly speaking, it took me a few days to settle myself into the Dutch system and the working style of the research lab, as it was very different from my previous research experiences. But even the long hours of work didn’t seem tiring because of the constant motivation from the supervisors and the incredibly conducive environment at the UMCG.

Time flew by pretty quickly as I got more and more satisfied with my work. There was so much to learn from the supervisors at the UMCG—some of the best research and the latest equipment, including a TissueFAXS machine—and a whole new face of the research world opened to me. I learned so much in this short span of 2 weeks.

The hard core research activity of the mornings was at times followed by an evening’s social programme organised by the ISCOMS organisation. These would usually be dinners at famous restaurants with all the participants being invited. One such programme included a global dinner, where each participant had to cook a dish that represented their country. Finally, as the entire IRF came to a close, each of the 22 participants had to present their abstracts. This provided a basis for everyone to learn more about the work their fellow IRF participants undertook and how they made the most of their time.

Overall, the entire ISCOMS Congress and IRF was a remarkable learning experience. Moreover, it gave me an opportunity to widen my social circle and interact with students with similar research backgrounds and interests as me.

At this point I would like to thank Professor Jaan Luk Hillebrands, Jill Moser and the entire ISCOMS team for making this a success for me. I shall cherish the memories for many years to come.

Mohsin Shah
mohsin255(a)hotmail.com

In today’s elective report, Gurmeen Kaur writes about her experiences at the ISCOMS Research Fellowship which followed the congress of ISCOMS itself. The elective report complements today’s blog by Rachit Kapoor.

All the ISCOMS Research Fellows

I had the great opportunity of attending the ISCOMS Research Fellowship (IRF) at the University Medical Centre, Groningen in the Netherlands in the second half of June 2010. Groningen, situated in the northern part of the Netherlands, deserves the title bestowed on it – ‘the city of talent’!

There were 22 participants from different countries working on 12 projects. All stayed at the same international student accommodation; living, cooking, eating, and working together, making it an experience that left memories to cherish!

The IRF followed the International student congress of medical sciences (ISCOMS) and lasted two weeks. The congress itself having over 300 participants from about 53 countries, it was an honour for the 22 of us to get a chance to stay on for another fortnight at the university and experience research, work hands-on, and interact with the medical faculty at the University Medical Centre in Groningen.

The fellowship started with an opening ceremony where we got to meet previous IRF participants who were now doing their PhD’s at the university. We also met our respective supervisors, and planned our short projects for the coming two weeks. The days to follow were full of work fun, frolic, more work and more fun! We worked really hard in the lab in the day, did detailed literature searches in the library, learnt to find our way around in the Netherlands and had wonderful dinner parties.

Kidney centre Fellows

Because I was in the Kidney Centre, I got a chance to visit the experimental nephrology lab where I saw cell cultures of proximal tubular cells as well as podocytes in liquid media, RNA extraction and polymerase chain reactions, as well as being given a chance to view the histopathology slides of normal and knockout mice as well as human kidneys.

Besides this, my project involved analysing a data set of over 800 patients and writing up an abstract entitled ‘Renal haemodynamic parameters in post-transplant patients – a long-term follow-up.’ The hospital has an excellent transplantation unit and hence we got the chance to hone our statistical skills by analyzing the huge data set provided to us.

We visited the renal hemodynamic lab in the Department of Nuclear Medicine where we saw the effective renal plasma flow and glomerular filtration rates being measured using I-hippurate and I-Iodothalmate and steady state by collecting repeated urine and blood samples.

Other IRF-students got the opportunity to see an open heart surgery, worked in the stem cell and immunology labs, designed protocols for future work in their own countries based on their experience in the Netherlands, and were given the chance to apply for a PhD position at the university by attending the walk-in interview session with Dr Gerjan Navis, MD, PhD, who was in charge of the research fellowship. In short, the list of fabulous experiences was endless!

The social events, too, were a major highlight of the Fellowship. On one such dinner, all participants prepared their country’s traditional food and dressed in costumes of their own country and everyone enjoyed the multi-ethnic cuisine. We relished amazing Dutch pancakes at another dinner party held on the ‘Pancake Ship’. The parties, the shopping expeditions, bowling, and even grocery shopping bring on an exciting nostalgia!

To bring an end to the scintillating fortnight, there were the IRF presentations at which all research fellows presented what they had achieved in the past two weeks. They also discussed how the IRF would help them with their future assignments. On behalf of all the 2010 IRF I would like to thank the entire ISCOMS organizing team, all our supervisors and guides and my IRF friends!

Gurmeen Kaur
kaur.gurmeen@gmail.com

In today’s elective report, Mazin Alsaffar, fourth year medical student from Hull York Medical School, University of York, UK, describes his experiences at WHO, where he worked for three months, mainly at the Health Action in Crisis unit. Mazin describes the need for and immense importance of public health, which he learnt fully to appreciate during this internship.

I wanted to pursue medicine as a career for the right reasons, seeing it as a fantastic career that is very rewarding. I realised that in order to have a true impact on improving the health of communities, I needed to meet health problems before they occurred: the quintessence of public health medicine. That is why I did an internship at WHO headquarters in Geneva.

What is the purpose of the World Health Organisation? It is the directing and coordinating authority for health within the United Nations system. They are responsible for providing leadership for global health matters, determining the health research agenda, setting standards and provide technical support for countries in crisis. [1] I decided to apply to their internship programme and specifically to the Health Action in Crisis (HAC) unit. HAC’s main purpose is to saving lives and reducing suffering in times of crisis, building efficient partnerships for emergency management, advocating for political support and developing evidence based guidance for all phases of emergency work in the health sector. I was accepted in to the programme in the summer of 2007. Although a little nervous, I was excited at the prospect of being in Geneva for the summer and working for a major international health organization. Geneva is truly an amazing city, there are many international organizations operating in the city. United Nations (UN), International Organization for Migration, International Organization for Labour, Doctors without borders, UN AIDS, UNICEF are only but a few that operate within the UN compound.

The WHO headquarters house nine main departments [2]

· Director general’s office
· Family and community health
· General management
· Health Action in Crisis (HAC)
· Health security and environment
· Health systems and services
· HIV/Aids , TB and neglected tropical diseases
· Information evidence and research
· Noncommunicable diseases and mental health
· Partnership and United Nations reform

I arrived at 8.30am, security was tight and every legal document was searched as well as several copies of my WHO contract. On arriving at the HAC offices I saw that things were already hectic, I was introduced to my supervisor who happened to be in charge of the HAC department. Dr Ala Alwan has an interesting background; he practised medicine in Scotland and obtained his postgraduate training and qualifications in the United Kingdom. Following his return to Iraq, his home country, he held several positions in clinical and academic medicine and public health. He was Professor and Dean of the Faculty of Medicine, Mustansiriya University, Baghdad. He joined WHO as Regional Adviser for Noncommunicable Diseases in the Regional Office for the Eastern Mediterranean. He then served as WHO Representative in Oman, and Director, Division of Health Systems Development within the region. He assigned to WHO headquarters as Director for Noncommunicable Diseases Prevention. He was also Minister of Education and Minister of Health in the Government of Iraq.

I was soon put to work; my main focus was working on the progress reports; these reports are not only published on the WHO website but are also sent to the WHO country offices around the world. These reports consisted of any major events occurring in the crisis countries; it included epidemiological data, death tolls and amount of medical aid needed. The information was gathered mainly from the international offices of the countries concerned. Another task that I had was to write the country profiles on the HAC website, mainly focussing on the Horn of Africa as well as Iraq. This was not easy; the country profiles are also sent to the international offices and contain introductory information regarding the countries, emergency medical history and a lot of epidemiological data. This information was gathered from partner UN organisations as well as contacting the health ministries of the countries concerned.

The above was the bulk of my work for three months; however, I also had to attend weekly HAC meetings with all the directors. An advantage of being a WHO intern was attending international meetings. I was invited to attend a meeting with the Red Cross/ Red Crescent organisation where they discussed their humanitarian work in Iraq. This gave me a great insight into the work that this organisation is doing on the ground. The main highlight for me was meeting the Director General of the WHO, Dr Margret Chan. She is most famous for confronting the first outbreak of H5N1 while she was Health Minister in Hong Kong. Her advice to me and my fellow interns was invaluable.

My three months were nearly over and I had met many great people, most importantly I gained so much knowledge into the world of International health. It made me realise that public health is the essence of medicine, much greater change and good can happen through one decision. The HAC environment taught me that every small detail matters in humanitarian relief work and that medical experience is very important in public health practice. I will continue my International health experience by working at the United Nations systems Influenza coordination unit in New York for my elective period in my fifth year of medical school. I hope to one day be involved with the WHO and non-governmental organisations.

Mazin Alsaffar
hy6ma@hyms.ac.uk

1 World Health Organisation. (2010). WHO Agenda. Available: http://www.who.int/about/agenda/en/index.html. (accessed 13.5.2010)

2 World Health Organisation. (2010). WHO structure. Available: http://www.who.int/about/structure/en/index. (accessed 13.5.2010)

(From Justin Bishop 2009, Exposé, Vanity Fair, US, viewed 15 February 2010, )

The word “plastic” in plastic surgery is derived from plastikos, an ancient-Greek word for “to mold”. Indeed, the roots of such practice can be traced as far back as 1500 B.C., during which it was a common practice in Indian societies to amputate the nose as a punishment for committing adultery. With the advent of anaesthesia in the mid-19th century, new techniques for the treatment of battlefield wounds were developed for those injured and scarred in the World Wars. In 2005 however, according to statistics from the American Society of Plastic Surgeons (ASPS), more than ten million cosmetic plastic surgery procedures were performed in the USA, an increase of almost 40% since 2000 (1). You don’t have to be a medical student but surely you must be a little bit interested by this? And what-ever happened to the credit crunch?

With this in mind, and having previously done two Special Study Modules (SSMs) in Anatomy, I decided to do an elective at the Glasgow Royal Infirmary’s Canniesburn Plastic Surgery Unit, the regional referral centre for the West of Scotland and also the biggest in the UK. I also became involved in a Plastics-related research project at my university’s Anatomy department during this time.

I was assigned to the Blue team (Head and Neck), which my supervisor belonged to, and I was able to rotate through the Red (Breast and Trunk) and Green (Limbs and Trauma) teams as well for thorough exposure during my time at Canniesburn. My weekly schedule included ward rounds, clinics and clerking in new patients on Mondays and Wednesdays, theatre all-day on Thursdays, and research on Tuesdays and Fridays. While this might seem somewhat disjointed, I found this setup to be quite enjoyable actually as it gave me sufficient time between clinical days to read up on what I had seen and how it related to my research project.

Perhaps it was a blessing in disguise, but I certainly felt that I was thrown in at the deep end when I first started my elective. There are usually not many students around but despite the surgeons’ keenness on explaining the procedures, I was inundated with a myriad of technical terms. Free flap? Pedicled flap? Z-plasty? V-Y advancement? It was a steep learning curve but with support from my supervisor and a logbook of cases that I observed and assisted in, I gradually began to find my feet and I progressed from passive observation to assisting in surgeries – scrubbing-in, performing different sutures, taking skin grafts, and even, making simple incisions. I was also fortunate enough to have several unique experiences such as observing cosmetic practice at my supervisor’s private clinic and being filmed live while assisting on a procedure that was broadcasted throughout the UK!

Example of pre-operative planning

In medical school, we are taught to always ask if the patient has any other concerns. I always felt this to be a bit redundant for why else would a patient come to hospital? That was until I met this particular patient who presented with a basal cell carcinoma above her lip and told me “I just wish it wasn’t there” because she was getting married next month. It was at this very moment when I could fully appreciate the aim of plastic surgery – to seek a fine balance between the restoration of function and an aesthetically pleasing appearance. It was also this very patient who enabled me to finally appreciate the relevance of my research project on the anatomy of facial artery perforators in the design and use of local flaps for the reconstruction of such facial defects.

Overall, I feel that I have grown and matured both personally and professionally over the course of my elective. I might sound biased but I strongly feel that plastic surgery should become a part of the core undergraduate curriculum. Not only will it dispel any unfair, preconceived ideas of the discipline as one being indulgent in cosmetic procedures as fuelled by the media’s portrayal, it will also provide ample opportunity for the student to learn the anatomy of various body regions during the same timeframe as compared to rotations in other surgical disciplines, and to have a continuum in learning that covers all aspects of the biopsychosocial model of health care.

Zhi Yang is a fourth year medical student at the University of Glasgow
0609608n(at)student.gla.ac.uk

References

1. American Society of Plastic Surgeons. Industry leaders, analysts forecast cosmetic plastic surgery market [homepage on the Internet]. Illinois, USA: American Society of Plastic Surgeons Plastic Surgery Educational Foundation; c2010 [cited 2010 February 15]. Available from: http://www.plasticsurgery.org/Media/Press_Releases/Industry_Leaders_Analysts_Forecast_Cosmetic_Plastic_Surgery_Market.html

London has always been a second home to me, having spent a part of my early childhood years in England it was always a wish to go back and experience working there. Another passion was to work in the field of molecular biology. Watching experiments and new discoveries being revealed made me look for a research elective during my medical school and I was lucky to get a 6 week research attachment at the Department of Craniofacial Development (CFD) at King’s College London.

Being accepted at King’s College London was an honor as the institute holds a great name and is among one of the world’s top 25 universities. With immense delight I immediately applied for a visa, with which I had no difficulties and enthusiastically started preparing for my trip. Luckily, a family friend of ours offered to give me a room in their house which made matters much simpler as accommodation in London can be quite expensive.

On my first day on Floor 23rd CFD of the Guy’s Hospital, I was warmly welcomed and introduced to the team. I was assigned a workstation and found out everything I needed to know about the project I was to work on. My supervisor kept things simple and I was taught precise protocols. Soon, I started working independently at my bench and could address questions regarding my project. It was entirely up to me as to how many hours I wanted to work, and I made full use of this wonderful opportunity. I would leave home at 8am, arrive around 9:15am; and would work till late at night. I tried to do as much work as possible so that there was a valuable contribution from my side in the project.

Dr Isabelle Miletich and me at the lab

What I Learned

It was amazing to do experiments that I would normally just read about in books. The aim of the project was to study the early development of the jaws in mouse embryo. I learnt a variety of techniques in my short attachment which included preparation of plasmid DNA, transforming bacteria with plasmid DNA, use of restriction enzymes (e.g. EcoR1) and analysis on agarose gel, preparation of RNA probes labeled with Digoxygenin, dissection of mouse embryos under the microscope and whole mount in situ hybridization on mouse embryo. Every minute of it was incredibly interesting. Though the research environment was new to me, it didn’t take me long to settle in. I also attended weekly lab meetings and seminars.

Students from KCL, Germany, Switzerland and Pakistan at the meet-up

The Social Life

London is a lively city and just travelling through it is mesmerizing. Weekends were always spent roaming and of course shopping at Oxford Street.

There was a gathering organized by the KCL students for the visiting electives students in all departments of KCL were we exchanged cultural and academic knowledge. I made friends for life at CFD, and also had a chance to revisit them this year.

In Conclusion

It’s entirely up to you how you make your elective useful; my interest in medical genetics grew with each day of lab work. I now have clear vision of how genetic mapping and research is being done, something which unfortunately is not much emphasized in Pakistan for an undergraduate student. I have a new approach to research and I took up courses on coming home which polished my skills further. At present, I have submitted a case report regarding something totally different from my research elective at King’s but it was because of this elective experience that I was constantly re-exploring things. It was because of Dr Paul T Sharpe that I had the opportunity to work with such an excellent team and Dr Isabelle Miletich made my attachment easier by helping me through lab work and otherwise. It was an excellent educational experience one should have at least once in a lifetime.

Sara Bughio is an intern at Liaquat University Hospital, Jamshoro, Sindh, Pakistan
sara_bughio@hotmail.com

The Paul O’Gorman Leukemia Research Centre

It was January 2009 and I can precisely recollect the instant of excitement, when I was greeted with the acceptance letter of University of Glasgow. I had been scheduled for a 6-week research elective at the new Paul O’Gorman Leukemia Research Centre, a centre committed to hard core leukemia research. After a long wait of eleven months, the moment had finally arrived. I was on my way to the United Kingdom for an exhilarating new learning experience.

As I settled myself at the Murano student village in Glasgow, it was already time for the beginning of my elective. I woke up around 6 in the morning and started the long walk towards the research centre. I got a bit confused at first, and had a hard time finding my way. After asking numerous people for directions I finally reached the 3rd floor of the new building on Shelley road – my workplace for the next month and a half. It was a warm welcome. I was given a workstation and an overview of the entire research centre mechanism along with details of the project I was going to work on in the forthcoming 6 weeks.

From the next day onwards it was a busy schedule of getting up at 7:30 in the morning, dressing up and reaching the centre at 8:45; attending the lab then occasionally shadowing the clinicians at various floors; attending the noon lunch conference and finally working on the project that was assigned to me, sometimes till late in the evening. Honestly speaking, it took me a few days to set myself into the system and work style of the research centre as I was used to the methods used back at my medical college in Pakistan. But even the long hours of work didn’t seem exhausting because of the interesting work and incredibly conducive environment. Discussing patient histories and carrying out physical examinations and then relating it all to the hematology questions required a lot of brainwork. In addition to that, it was a similar routine in the lab. Working for hours; finding the effects of drugs that were yet to be launched. My interest in hematology grew numerous folds during the elective. I got the chance of writing and submitting a case-report on Systemic Mastocytosis, a rare disorder, along with an abstract of my work to the 50th British Society of Hematology Annual Meeting. Not only that, I took this unique opening and wrote a full paper on my research project. My project included finding the effects of a novel aurora kinase inhibitor/Jak inhibitor, AT 9283 (Astex Therapeutics) on Chronic Myeloid Leukemia Cells (CML) in vitro. This project highlighted the therapeutic potential of drugs like AT9283 and identified Jak2 as a valid target for further study in CML.

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Palliative care has a few different definitions, but essentially it’s symptomatic and holistic care of dying patients. Most of the palliative care caseload have cancer, but the remit covers all progressive life-threatening illness, which can include, for example, AIDS, cancer or neuromuscular diseases. Most palliative care is carried out by general practitioners and hospital physicians, but there are also specialist palliative care teams, who care specifically for patients whose symptoms are difficult to control. I did my elective with a specialist palliative care team, split between hospital and community work in Great Yarmouth.

Why Stay in the UK?

I chose to stay in the UK, and close to home, predominantly for health reasons – I wasn’t fit to travel abroad, due to an illness that sprung up and got in the way just before heading out to Perth in Australia, my original plan. Although I was initially disappointed not to be going on my Australian adventure, this elective has presented me with plenty of reasons why staying at home was a good choice! Firstly, I’m close to my family, so I’ve had the opportunity to see plenty of them. If I’d done the elective as planned I would barely have had time to say “hello” after finishing my exams – an experience that in my case means locking myself in a dark corner of the library for three months – before jetting off to foreign climes. I’ve already undertaken some of my medical training at the James Paget hospital, which means that I already knew my way around, which wards did what, and many of the doctors I’d be working alongside were. Many people enjoy getting to know a new hospital and a new city during their electives, and that’s great, but for me, already knowing the hospital meant that I could focus on learning medicine, rather than learning my way around. Maybe my congenital lack of sense of direction has something to do with that! I’ve also had some lovely weather, as it’s the middle of summer here while it’s winter in Perth, and I’m only a short walk from Gorleston Beach when I want to spend an evening chilling out with a book and watching the ships.

Why Palliative Care?

This is a question I’ve been asked quite a few times since I decided what I was doing with my elective – why Palliative Care, why not something exciting? Fair enough, this isn’t the quickest-pace department I’ve ever been in – in fact, although we’re always busy, I think we see the fewest patients per day here of all the placements I’ve ever done. Although I change my mind about my future career plans approximately every five minutes, my plan when I was looking into what to do for an elective was to work in general practice. From experience I know that GPs are quite involved in the care of their patients at the end of life, but I also know that it’s not an area that’s much talked about – neither Oncology nor Palliative Care are covered as specialities in their own right at UEA, which means that before I started reading up on it for the elective, I didn’t really know much about what would be involved or how to manage patients at the end of life. I also enjoy getting to know my patients and having longer slots of time to talk to people, and have enjoyed the bits of oncology I’ve come across so far in the course, so I decided that Palliative Care would be a specialism I’d enjoy eight weeks in, and would benefit from in terms of learning things I’d use in the future.

What’s the James Paget Hospital Like?

The James Paget University Hospital is a smallish hospital in Gorleston, near to Great Yarmouth in Norfolk. At the moment, there are no specific palliative care beds available, so patients being looked after by the team are spread around the hospital, on whichever ward looks after their medical problem – for example, lung cancer patients on the respiratory ward. There are no hospices in the area, the closest one being Priscilla Bacon Lodge 25 miles away in Norwich. There are, however, some little community hospitals in the area, where patients can be looked after by nurses and seen by their own GPs. Although the team are based at the James Paget, they also see patients in these community hospitals and in their own homes, which allows excellent continuity of care when patients are moving between the various locations. The hospital is, incidentally, named after the surgeon, originally from Great Yarmouth, who named Paget’s disease of the bone.

What Did I Do?

I spent the first part of my elective shadowing members of the team to get a grasp of how they worked together, who did what, and how the team functioned as a single unit. Much of this time was spent shadowing the doctors in palliative care, and seeing how they interacted with other members of the team. I also shadowed the Macmillan nurses to see what they actually did with their patients out on home visits, and went with them to their teaching sessions where they educated staff on the wards about introducing the Liverpool Care Pathway. Once I felt I had a grip on how the team worked, I spent much of my time shadowing the palliative care specialist doctors, but also spent time in Oncology clinic, where I saw some of the patients I had met in a purely palliative setting, having chemotherapy either to improve symptoms or to lengthen what life they had remaining, which gave me an interesting look at the patient’s journey and what different experiences they have coming into the same hospital, for treatment for the same illness, under different teams.

I was also lucky enough to have the opportunity to follow several patients through their journeys. I spent a lot of time talking to one lady who, although they should be able to cure her, needs a lot of symptom management in the meantime. I met her shortly after her surgery and have followed her through for the full eight weeks, seen her discharged from hospital, getting settled back at home, switching her medications back over, and starting to recover. I’ve also, therefore, seen the effect that a terminal diagnosis has on whole families, particularly through the home visits I’ve been able to go on – going into a patients home, I have found, is a great way of getting to know the family dynamics and how the patient’s life really is. I’ve known many patients take special care to come and see the doctor, and do their best to try not to look too ill so that the doctor feels as though they’re helping, whereas when you see them in their own home and the adaptations they’ve had to make to be able to cope with their illness, that gives me a much better idea of how ill they really are.

I carried out an audit while I was there, looking into the dependencies of palliative care patients compared with that of patients on two of the medical wards. This was really interesting, as it meant I had my own workload as well as shadowing, and my own patients to follow up. It has also given me a good experience of what is required to undertake an audit, a process I previously understood to be important but had little insight into its realities.

What Have I Learnt?

Academically, I learnt a lot about symptom management that seems to have passed me by during the course of the medical syllabus. I knew the analgesic ladder as it applied to patients with musculoskeletal problems, but I’ve only now learnt about the management of cancer pain, for example, the conversion between different opiates, and how to work out a good breakthrough dose. I have also learnt a lot about the practical management of neuropathic pain, which is difficult to get on top of effectively, and managing nausea and vomiting caused by various different problems in palliative care.

Palliative care can be very much more patient-centred than most aspects of medicine – because it’s not curative, there’s no one right answer in how to deal with any problems. For example, symptom management can vary widely – I’ve met several patients who preferred to be pain-free but drowsy, and a few others who preferred to be alert enough to really interact with their families, and are willing to tolerate some pain in order to do so. In the management of malignant bowel obstruction, some patients would prefer to vomit more frequently in order to avoid having an NG tube, others prefer the opposite. Although this is the way the palliative care team work, this taught me the difference between having been taught palliative care, and having only studied “standard” medicine and surgery – many members of the medical and surgical teams couldn’t get their heads around not doing what the textbook recommended. There were also a lot of clashes between the medical team and our team, which really opened my eyes to attitudes: some quotes from doctors which I think I’ll never forget, include “Well, he has to have it, that’s procedure” and “He’s dying anyway, what’s the point?” I’m so glad I’ve learnt how to deal with these attitudes now, because I think if I’d met them for the first time when I start my F1 posts (the first year of being a practicing doctor), I’d have been thrown completely.

Contrary to a lot of the more traditional advice for medical students, I did find myself becoming attached to some of my patients – and I don’t think that was an unhealthy or damaging experience. Yes, it meant that I was sad when they died – but it also gave me the ability to get really angry when their treatment wasn’t optimal, and to really empathise with them and talk to them about their problems, and I think these things really helped me to manage patients to the best of my ability. It has also meant that I’ve got to grips with dealing with a patient’s death, a challenge I haven’t often been presented with as part of my degree

Becky Wilson is a fifth year medical student at the University of East Anglia.
beckyannabelle.wilson(at)googlemail.com

Daniel Keith shares his experiences

During my eight week rotation in Obstetrics and Gynaecology I was given the opportunity to spend 2 weeks working anywhere in the world, to see a contrasting picture of women’s health. I chose the gynaecology department at the Sarajevo University Hospital. (more…)