Clinical Electives! Nine months ago when I first heard about them and started applying, I did not have the remotest idea of where it was going to lead me. The rush of adrenaline felt while applying, the palpitation experienced while opening the replies to my applications and the joy felt at being accepted, were all truly unbelievable feelings! Being accepted by Tufts University for a rotation in Gastroenterology at St Elizabeth’s, Boston was the start of an amazing journey that began several months ago. Having completed my rotation, I am now able to write a report describing my experiences.

The Hospital

Caritas St. Elizabeth’s Medical Centre is a community-based 317-bed tertiary care hospital located in the Brighton neighbourhood of Boston. St Elizabeth is a thoroughly modern inpatient and outpatient facility that is also a major teaching affiliate of Tufts University School of Medicine.

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Entry Into the USA

You realize how much you love your country when you are off to alien shores; I had the same realization when I landed on the Philadelphia International Airport. I had come for a 4 week elective rotation at the Rehabilitation Medicine department of Thomas Jefferson Medical College, Philadelphia. I was abroad for the first time in my life and was apprehensive about everything – the place I would be living, the hospital, not to mention the American accent. But the welcoming atmosphere at the hospital and the hospitality of the people of Philadelphia helped me feel at home; also it took me no time at all to get hold of the American English.

Another source of concern was the cost of living. As I am from India and that too from a very humble background, everything from food to housing seemed very expensive to me but then everyone seemed to be more than happy to help me find cheaper groceries or other stuff.

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Me and my attending hematologist – Rachel Rosovsky, M.D.

It was the 6th of September 2009 and I can precisely recall the moment of excitement at 9 in the morning when my inbox greeted me with the acceptance letter of Harvard Medical School. I had been scheduled for a one month externship rotation in Hematology department at the Massachusetts General Hospital, Boston under the HMS. The excitement only grew in the next few days with the visa interview, shopping and planning the trip. And I was finally, on the 23rd of September, heading for the US.

As I settled myself in a rented apartment in Boston, it was already time for the beginning of my rotation. My first day at Mass General was full of “Wow”s and “Oh my God”s. I stood there in the pleasant winter morning, looking at the some dozen buildings of MGH wondering which way to go. MGH is huge. After playing the ‘curious pedestrian ‘ for a long time, I finally reached the 7th floor Yawkey building – my abode for the next month. There I met a team of 1st and 2nd year fellows in Hematology. It was a warm welcome and I was given a workstation and an overview of the heme consult service that I was going to work on.

From the next day onwards it was an unbeatable schedule of getting up at 5 in the morning, dressing up and reaching the hospital at 6:50; attending 2 conferences back to back till 9; then shadowing the medicine teams at various floors till 12; attending the noon lunch conference at 12 and finally working on the heme consult patients that were assigned to me, sometimes till 9:30 in the evening. Honestly, it took me a few days to set myself into the system and workstyle at MGH as I was still in the hang of things back at my medical college in India. But even the long hours of work didn’t seem tiring because of the interesting work and amazing environment. Taking a detailed history, doing complete physical examination and then relating it all to the hematology questions required a lot of brainwork. The patient would then be discussed with the hematology attending and resident as a case presentation. It was such a responsible feeling that my note and workup plan would be put up in the patient chart with a small addendum from the attending. My interest in hematology grew several folds during patient discussions and reviewing blood slides and bone marrow aspirates. I also got a chance to observe and assist procedures like bone marrow biopsies.

Days passed by swiftly and I felt more comfortable and satisfied after each days work. There was so much to learn from MGH – the best patient care, the latest treatment protocols, a whole new face of research world, presentations and conferences… I could never learn more in such a short time. My own presentation on Myelodysplastic Syndromes was nerve-wracking but after it went well, I had acquired all the confidence I need for whenever I’ll need to prepare and give a talk.

Overall the entire month was a great experience. It taught me the essentials of the best patient care and the ‘American’ way of working. Apart from the letters of recommendations that one can get, the experience itself is worth having at least once. I shall forever remember and cherish the memories of – as my attending called it – the ‘DREAM HEME TEAM’ at the MGH.

Manav Sharma is an intern post graduate at the Institute of Medical Sciences in Rohtak, India.
manavsewak(at)yahoo.co.in

“I always wondered what place would be feasible (taking the cost of trip in to consideration) for me to do clinical electives in the US”

I am from a middle class family in India, so it was tough for me to decide to go for electives in USA (Being a forerunner in Global Health, I kept it as my top choice) considering the cost of living and the tuition fees for electives in various universities. But by God’s grace I got acceptance from SUNY Downstate Medical Center, New York. This institute doesn’t charge any tuition fee for electives. I got the opportunity to rotate in my dream specialty: Clinical Cardiology at King’s County Hospital Center (KCHC), Brooklyn, New York. This hospital is affiliated to SUNY Downstate Medical Center and provides patient care in all the basic and modern specialties of medicine. It comes under New York City Health and Hospitals Corporation (HHC), the municipal agency which runs New York City’s public hospitals.

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In May 2009, I travelled to New York City for my elective placement in maternal-fetal medicine. I chose this subject as in my obstetrics rotation at medical school I found it to be a speciality that was really hands on and extremely diverse. This elective was a chance to experience care in a first world country, where new techniques and procedures that are not yet in current practice in the UK are tested and to see how healthcare systems differ in their patient care. I would also be exposed to issues such as abortion, domestic violence and STI’s, which are all commonly encountered areas of practice in the UK.

My elective was organised as part of an exchange programme with Columbia University, College of Physicians and Surgeons. Columbia is the oldest institution of higher education in the state of New York and is a member of the Ivy League. Its main campus lies in the Morningside Heights neighbourhood of Manhattan.

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As we all know, the United States has been on the forefront of global health, and it was my desire to witness health care in such a setting. So in my final year of medicine I decided to pursue my electives there.

The Hospital

Kings County Hospital Center (KCHC) is located in Brooklyn, New York and was founded 175 years ago. Over the decades, Kings County has claimed many “firsts” in the field of medicine: it was the site of the first open-heart surgery performed in New York State; Kings County physicians invented the world’s first haemodialysis machine, conducted the first studies of HIV infection in women and produced the first human images using magnetic resonance imaging (MRI). In addition, Kings County has the world-renowned first Level 1 Trauma Center in the U.S.

Today, with over 627 beds, the hospital provides a wide range of health services, and specialties are offered in all fields of modern medicine. More than 200 clinics provide a wide array of ambulatory care services. An affiliation between Kings County Hospital Center and SUNY-Downstate Medical School has enhances the clinical, as well as the academic activities of both institutions.

Shaukat (left) outside Kings County Hospital

Speciality: Internal medicine (Gastroenterology)

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I forget exactly when this observership started growing on me. Maybe it was day 1 at the Beth Israel Deaconess Medical Center (BIDMC) or even the days before spent in nervous excitement about what to expect and wondering what would be expected of me.

BIDMC is a world in itself. Rightly known as the “Harvard with a heart”, it stretches across Brookline Avenue in Boston from East to West campuses with satellite buildings dotting the avenue. I took to it immediately on day 1 of my observership in Hematology-Oncology in July 2009. I was scheduled to be with the Consult Service for a month and my mind was already racing with a million things I wanted to do.

Dr. Reed E. Drews, Program Director of Hematology-Oncology, is a very distinguished hematologist-oncologist who is highly acclaimed by students and peers alike. I had googled him before coming to BIDMC and had read his superlative profile and numerous articles he had authored in journals. The prospect of interacting with him and his team was exciting as well as slightly unnerving.

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I was born and brought up in a doctor’s family, so the medical profession has appealed to me the most and I grew up with a staunch desire to become a doctor.Upon entering medical school, regular visits to the wards deepened my interest in the field and I became more inquisitive. Eliciting history, performing physical examination, making a differential diagnosis and recommending treatment options reinforced my conviction. I aimed to learn more and make a difference. The United States has been on the forefront of global health. I desired to witness health care in such a setting. So, during my final year of medicine, I decided to pursue my electives there.

I did a one month rotation in February 2009 at the Neonatal Intensive Care Unit (NICU) in the Brigham’s and Women’s hospital in Boston. It was a very enriching experience. Upon my arrival in Boston, I was welcomed by heavy snowfall. However, once I reached my room, the view from the window looked pristine and captivating, but I went to bed early to kick start my first day at the hospital.

The entrance to the Newborn Medicine Department

I woke up, got ready and reached the hospital at 8 in the morning. What struck me first was its immaculate and uncluttered appearance. On reaching the contact person I was allotted an ID badge and was introduced to the team at NICU. I was not very familiar with the working there as the pattern was little different from that in India, so I decided to observe the work on the first day. The house staff and the nursing staff were very helpful and generous in helping me comprehend the system. As I had studied in an English medium school from the beginning and the medium of instruction in my medical school was also English, language was not a barrier and I got used to the electronic records system pretty easily. I was assigned one patient on the second day. It was a 27 week baby girl admitted to the NICU for prematurity, respiratory distress and feeding immaturity. The baby was intubated to administer surfactant before she was two hours old. It was the first time I witnessed endotracheal intubation on a 27 week baby weighing less than 800 grams. I was mesmerized.

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Institute attended: The Henry I. Goldberg Radiology Learning Center for Advanced Imaging Education, University of California, San Francisco

Visited Hospital / Institution’s Description: UCSF Medical Center is one highest ranked hospitals in USA and a leader in medical innovations which have improved and saved lives. UCSF Children’s Hospital is equipped with more than 150 specialists in more than 40 different areas of medicine. It has programs designed specifically for young patients, including a 50-bed neonatal intensive care nursery, recreational therapy for recovering kids and 60 outreach clinics throughout Northern California.

Specialty Attended: Pediatric Radiology (140.19 Advanced Clinical Clerkship)

Typical Tasks: Students are usually required to reach the school at 9am and then work in the pediatric radiology reading room with the residents, fellows and attending on duty. They are taught how to read X-Rays, CT, MRI and USG using the Picture Archiving and Communications System (PACS). Students also accompany the mentors when they go for fluoroscopy or CT where they are encouraged to assist them. They work till 5pm daily through out the week. Students are to prepare and present presentations to the attending. At times they are also allowed to participate in some ongoing research project depending upon the individual capabilities and rapport with the mentors.

What I learnt from My Experience: The experience I acquired from UCSF was incredible. I was introduced with the latest technology now being used for radiological examinations and briefed on how to use it. One of the attendings (Dr. Charles A. Gooding) taught me how to read X-Rays, CT and MRI while another (Dr. Heike Daldrup – Link) allowed me to participate in the ongoing research project. She also taught me using various presentations of actual radiologic findings using her laptop. In short, it was a wonderful experience that brought about a significant change in my approach towards medical education.

Social Life: Social life in San, Francisco is awesome. I had no problem regarding residence, meals, trips etc. My landlord was a very honest and nice person so I had no problems where I lived. There are many Pakistani restaurants in San, Francisco so I was able to enjoy my favourite meals there. It is a place which is extremely magnetic, especially for tourists, so I spent my weekends visiting the city. Even though I stayed for more than a month I still missed many places worth seeing.

Elective Evaluation: This elective is particularly useful for all those who are interested in choosing radiology as a career but even those who are interested in some other specialty will learn a lot about their specialty and acquire a great deal of experience to further their education and skills.

Advice for Others: I recommend all the international medical graduates to go for this elective. Although the number of seats available is limited and only the radiology department accepts international students, it is one of the best places with best faculty and hospitable staffs as far as IMGs are concerned.

General Comments: Although I went to San Francisco for the purpose of doing elective, this is not all that you should expect because along with an elective in the world’s best ranked medical school, you also get a chance to visit one of the world’s most beautiful cities. San Francisco is adorned with beautiful beaches, the historic Golden Gate Bridge, cable cars, Coit Tower, Lombard Street, Fisherman’s Wharf and Golden Gate Park to name only a few. I would also like to mention the names of the staff that really helped during my elective, particularly Randy E. Ortega, Bernie Baccay and Nina Felizardo.

Mohsin Ullah is a final year MBBS student at Allama Iqbal Medical College in Lahore, Pakistan
mohsinzia16(at)hotmail.com

Country of Exchange: United States

State / City of Exchange: New York / Brooklyn. (Photo 1). New York City is one of the World’s biggest cities. Built upon its long history of immigration, it is an amalgam of thousands of people representing many different nations and cultures.

Photo 1: The Brooklyn Bridge and Manhattan skyline at night

Institution Attended: SUNY Downstate Medical Center, a tertiary care hospital. Opened in 1966, the University Hospital of Brooklyn is an 8 story, 376-bed facility in central Brooklyn. This hospital has 8 intensive care and step-down units, 12 operating rooms, an emergency services department, and a diagnostic and ambulatory surgery facility, an ambulatory care center with some 75 clinics, plus 3 satellite Health Centers and a nearby Dialysis Center. It is probably the only public hospital serving around 5 million people living in Brooklyn. (Photo 2)

Photo 2: The SUNY Downstate Medical Center

Period of Exchange: 1 month (March 30 – April 24, 2009)

Specialty: Internal Medicine (Electrolyte Disorders)

Typical Tasks: This elective was mainly focused on interactive sessions with two most competent faculty members of SUNY Downstate. Daily study period was divided into two interactive sessions. First session from 10:00 – 12:00 and the second session from 13:00 – 15:00. Students were given senarios and encouraged to discuss them among themselves and then come up with solutions. The problems were then discussed in detail with the mentor who provided full background knowledge and made sure that every participant understood the basic mechanisms involved. At times our tutor would play games with us. At the end of rotation, every student was evaluated on the basis of his/her overall performance. (Photo 3)

Photo 3: Mohsin and Doctor Carroll

Language Difficulties: As the medium of instruction in my home school is English, I did not come across any such issue. Although there was some hesitation in the very beginning, within a week everything was on track.

What I Learned from My Experience: I really got to know about the healthcare system in US. The most important factor was my exposure to a variety of advanced techniques used there for the evaluation of patients. I learned and experienced for myself that active learning is the best form of learning, which really boosted my confidence to participate actively in the ongoing discussions. Furthermore, a detailed command on electrolyte disorders and role of making calculations was a valuable addition to my existing knowledge. It really boosted my interest in the field of nephrology.

Social Life: On-campus housing is available in SUNY Downstate so accommodation isn’t a big issue. It’s therefore one of the very few universities which does offer these facilities The transport system of New York has a very well developed network of subway trains. You just don’t need your personal transport., especially since public transport is faster because of the heavy traffic on the roads. The people are very friendly and helpful. Some of the fellow students took me to Atlantic City in the neighboring state of New Jersey. (Photo 4)

Photo 4: A visit to Atlantic City

Advice for Others: Form a rapport with your mentor so that you will be able to secure a good letter of recommendation at the end of your elective because that letter really matters, especially when you are planning your post-graduation from USA. Contact the residential department before your arrival through email to make a reservation for yourself. Come on the registration day to complete your official documentation and OSHA training. Bring your passport with a valid visa because that needs to be copied and placed in university records. As the weather in New York is relatively cold, bring your winter clothes with you, especially the students from south Asia. I strongly recommend the international medical students to go for this elective.

General Comments: I know international students come here for getting US clinical experience but I would advise you to make sure that you spare time to explore New York.

Mohsin Ullah is a final year MBBS student at Allama Iqbal Medical College in Lahore, Pakistan
mohsinzia16@hotmail.com