Constantinos Parisinos shares his experiences of working in several New York hospitals and some personal reflections on the US healthcare system. 

Children enjoying a burst pipe in Harlem, Manhattan, NY

Introduction

New York (NY) serves as a micrograph of the World, a centre where all cultures and races seem to blend into a frantic race towards achieving the great prize known as the American dream. It is a city where art, music, finance, health and science all seem to cherish as their Capital, and an unmistakably intriguing place to visit on my elective. Being able to work in internationally renowned hospitals, situated in the most diverse city in the world, whilst gaining first hand experience of a completely different model of healthcare delivery were the main reasons I wanted to work in NY. I was to spend 4 weeks in emergency medicine (EM) rotating between St Luke’s and Roosevelt Hospitals, and a further 4 weeks of general surgery at the Presbyterian Hospital. The aims of my elective were to bring my existing knowledge into practice, and by choosing such general fields, I hoped to gain more experience in applying clinical decision making when faced with a broad spectrum of presentations. (more…)

Cynthia Santos writes on the hurdles that people providing and undergoing cancer treatment face and her involvement in patient advocacy groups and how these can make a huge difference to how patients experience cancer healthcare.

In 2006 I started the Patient Advocacy Group in the hope of alleviating the difficult experience a patient and their family goes through when the diagnosis of cancer is made. I was inspired to start the program after having gone through this experience myself when my father was diagnosed at Memorial Sloan-Kettering with brain cancer during my first year of medical school. When my father lost capacity to speak and make decisions I became the prime person managing the health care of my father. Even as a medical student I often times felt confused and lost managing his appointments, prescriptions, chemo/radiation schedule, and the numerous other physical demands involved in caring for an incapacitated loved one. I was surprised to find other patients’ families who felt the same way, especially at Memorial Sloan-Kettering, a hospital known throughout the world as being the leader in cancer care. Later that year I went to a Patient Advocacy Conference at NYU and found medical students who shared similar feelings and started an action group at Bellevue to aid underprivileged patients and their families manage the treatment of complex diseases. After hearing about the positive work that other medical students have done I decided to bring this sort of opportunity back to Cornell. Eventually, the Advisory Board for Coordination of Care was started, which consists of various hospital administrators, physicians, social workers, nurses, patients, and medical students.Every year, millions of Americans will undergo cancer screening; this year it is estimated that 1.4 million will acquire cancer and 560 million will die from their disease. (1)  Access to quality care has a significant influence on the prognosis of cancer. Unfortunately, problems with access to cancer services have been documented in nearly all locations and populations. For example, Memorial Sloan-Kettering is ranked the best hospital in the Northeast for cancer treatment in the 2007 U.S News and World Report. (2) However, barriers to effective management exist within this institution, especially regarding the treatment of at risk populations with low socioeconomic statuses. The institutional barriers that exist in Sloan-Kettering are primarily due to a lack of coordination and an inconsistency regarding patient education throughout multiple departments. (more…)

Prem Jesudason shares experiences of working in hospitals in New York and Australia.

Why stick to one hospital on one continent if you have time for more? With ten weeks available to me for an elective I decided to be ambitious, buy a round-the-world plane ticket and organise two hospital placements. I spent four weeks at an intensive care unit in New York City, and four further weeks in the busy emergency department at the Gold Coast Hospital in Australia.

New York city skyline

New York City

New York City is not only one of the world’s biggest and busiest cities - it is an amalgamation of thousands of different peoples and cultures, built upon its long history of immigration. As a result, the New York Downtown Hospital caters to a varied cross-section of patients. The hospital serves nearby Chinatown and the people of numerous ethnicities that populate Manhattan’s Lower East Side. Additionally, it is the closest acute care hospital to Wall Street and the business district: the financial hub of the USA.

The hospital’s intensive care (ICU) unit consists of 18 beds and treats both medical and surgical cases. Prior to my elective I had minimal experience of working on an ICU, therefore this placement was an ideal opportunity to develop both my knowledge and skills in managing severely ill patients. My primary duty in the ICU was to present cases during medical and surgical ward rounds, which required a detailed understanding of patients’ clinical problems. This was not easy at first since the majority of ICU patients have complex illnesses and there was often a lot that I did not understand. However, medical and nursing staff in the unit were both knowledgeable and helpful: soon I felt like part of the team, which allowed me to learn quickly and to really enjoy the placement. Additionally, I spent time shadowing both junior and senior doctors to develop my knowledge in various specialties such as respiratory medicine and gastroenterology.

Typical cases seen on the ICU included bacterial pneumonias, diabetic ketoacidosis, renal failure and heart failure. I became familiar with the management of septic, cardiogenic and hypovolaemic shock. More unusual cases that I had not seen before included aspergilloma, Stevens-Johnson syndrome and ovarian hyperstimulation syndrome.

I did find that life on an ICU is not easy - it can be challenging and exhausting in many ways. There is a physical and emotional demand when providing care for patients who are either very ill or critically ill. Inevitably some of those cases I presented on ward rounds did not have happy endings, therefore it was important to be able to emotionally deal with a patient’s death.

My time in New York was a largely positive experience in a fascinating city. However, the main disadvantage with an elective in the USA is that doctors are sometimes unwilling to allow students to perform procedures, such as cannulation and arterial blood gas sampling, given the increased threat of medico-legal action in the US healthcare system. Despite the lack of opportunity to practice clinical skills the placement was hugely rewarding and it allowed me the valuable experience of working with critically ill patients. As I had a second placement arranged in Australia, what I had missed out on in New York I could make up for on the Gold Coast. 

Whitsunday Islands, Australia

Gold Coast Hospital, Australia

The Gold Coast is a 40-mile stretch of coastline in the southeastern corner of Queensland. The Gold Coast Hospital, located in the town of Southport, is publicly funded and is one of the largest teaching hospitals in Queensland. Approximately 500,000 people live along the Gold Coast, however the region is one of the most popular tourist destinations in Australia and the hospital serves both residents and tourists. As such, the emergency department, where I worked, is one of the busiest in the country.

My main duty was to clerk patients arriving at the emergency department, and present my findings to senior members of the team. I also spent time shadowing medical staff when more seriously ill patients presented, for example those with major trauma. Another duty was to perform clinical skills such as obtaining venous blood samples, arterial blood gas sampling and inserting peripheral venous cannulae. I clerked patients with very varied presenting complaints, such as shortness of breath, chest pain, vaginal bleeding and minor trauma.

One interesting case that I was involved with was a 43-year-old man presenting with chest pain and shortness of breath; subsequent investigations confirmed a pulmonary embolus. Another case was that of an 18-year-old man with a 16-hour history of abdominal pain, who was diagnosed with acute appendicitis and referred for surgery. These two cases were especially useful since the conditions are common in the UK, therefore it was a valuable experience to be involved in the diagnosis and initial management of the patients.

Additionally, I was involved in the management of a 46-year-old woman who had been bitten by the venomous common brown snake. This allowed me to become familiar with both first aid of a bite and definitive snakebite management. An important role of an overseas elective placement is to broaden your knowledge and to gain experience of situations that may not be encountered at home. Interestingly, cases of snakebite are occasionally seen in UK emergency departments especially given the increase in tropical snakes in zoos and as household pets; therefore, the skills that I learnt on this placement may one day, however unlikely, prove useful.

I feel that after four weeks in Australia I met my aims for the elective. Not only had my knowledge of emergency medicine developed, I also gained experience in other specialities such as obstetrics, gynaecology and paediatrics. My history taking and examination skills improved as did my practical skills. Furthermore, hospital staff were welcoming, and consultants were keen for elective students to find a balance between work and enjoying the attractions of Australia. I was allowed a number of days off to travel North along Australia’s East Coast, taking in Fraser Island and the Whitsundays - must-see sights for any visitors to Queensland.

Conclusions

My elective placements were both great learning experiences as I developed my knowledge and skills in numerous acute care disciplines. I would recommend an elective placement in Australia as it is a fascinating country and hospitals generally have a laid-back atmosphere. Queensland is one of the most geographically varied areas on the planet, with rainforests, coral reefs, deserts, beaches and much more to keep any elective student occupied. New York City also has much to offer, but if organising an elective placement in the USA, be prepared to work some long days and find out beforehand what you will and will not be able to do (for example, in some hospitals you may not be allowed to take blood or insert cannulae).

My words of advice for those organising electives are that round-the-world plane tickets offer flexibility: other than the placements in New York and Australia I had time to travel through the Canadian Rockies and Hong Kong. Remember to research your destinations well, find a balance between work and holidaying, and above all, have fun.

Prem Jesudason

Final Year Medical Student

University of Leeds
pjesudason@yahoo.com

Anand Bhat tells us more about the inequalities in his own state, Texas, and also describes his experiences in the US-Mexican border

Until the immigration debate caught fire last year, the US-Mexico border was only known for Tejano music, stolen Senate elections by future presidents, and sleepy towns waking up to the new realities of NAFTA (North American Free Trade Agreement) and the War on Drugs.  Little attention, however, is paid to the inhabitants of the border compared to those who illegally cross it. 

 The United States is known for being the only industrialized country without guaranteed, comprehensive universal health care.  But perhaps less known is that my home state of Texas has the highest percentage of adults and children uninsured (1).  And perhaps not known at all to the outside world is that the lack of health insurance is worst in the counties along the Mexican border. (To see a map of the area, go here) (more…)

A multicultural meal at the home of one of the program directors

Can you imagine Israeli, Palestinian, Jordanian and Canadian medical students, enjoying Toronto’s sights, cooking and eating multicultural meals together, planning cooperative medical research projects, and learning together about caring for children in the emergency department of a major Canadian hospital? (1)

It happened this summer in Toronto during the International Pediatric Emergency Medicine Elective (IPEME) organized by the Canada International Scientific Exchange Program (CISEPO), the Peter A. Silverman Centre for International Health at Mount Sinai Hospital, and the Division of Paediatric Emergency Medicine at the Hospital for Sick Children.

As medical students, the elective offered us an excellent opportunity to learn about paediatric emergency medicine and international health, while developing a better understanding of each others’ cultures and perspectives. Medical education consisted of lectures on common topics in paediatric emergency medicine, such as fever, sepsis, abdominal pain, poisoning and jaundice. We also attended workshops on casting, suturing, and cardio-pulmonary resuscitation. Can you imagine Israeli and Palestinian students put casts on one another, laughing the whole time and making a complete mess? Despite our different backgrounds, we had a wonderful time together. (more…)