Overseas Medical Electives

My Elective at Johns Hopkins


Elective at Johns Hopkins At Baltimore


When the email from the Dean’s Office arrived in my mailbox informing me I have been selected for an elective at Johns Hopkins, I literally jumped for joy! Hopkins was a popular choice, for obvious reasons, and I had not expected myself to be one of the lucky few to be chosen. Life is good!

That night was to be a sleepless night. For a history buff like me, it was a dream come true to immerse myself in this world-renowned institution, dripping in medical history. Legendary figures graced and continue to grace this amazing hospital. What an experience it will be to walk down the aisles that giants like Osler, Halsted, Cushing and Blalock once patrolled, I thought as I lay in bed, my mind to busy fantasizing about the possibilities to doze off. Four months later, my dream was realized and I was not disappointed.

Johns (yes, with the tacky “s”) Hopkins was named after the banker who willed his estate for the establishment of a university and a hospital in Baltimore. A hundred years on, this Hospital has become world-famous, and has been ranked the Best Hospital in the US for 18 consecutive years by the US News and World Report. For its relatively short history (the hospital was completed in 1889), it has played an important role in the development of modern medical history. It was the birthplace of many clinical specialties, including neurosurgery, urology, cardiac surgery, paediatrics and several others. Here, Harvey Cushing first cut into the brain, once considered to be the last remaining sanctuary of the human body where the scalpel could not reach, and described his famous studies of the pituitary (hence the Cushing’s syndrome). Here, Walter Dandy clipped the first aneurysm and discovered the famous “air under the diaphragm” phenomenon. Here, Alfred Blalock devised his famous shunt with his African-American partner, Vivien Thomas…. The list goes on.

I chose to do 2 Sub-Internships, in Otolaryngology and Neurosurgery. I have always been enthralled by the anatomy and diseases of the part of the head, neck, and the brain, so these were natural choices for me. Furthermore, the two departments are ranked 1st and 2nd respectively in the US so I know I’ll be going to excellent programmes. I craved a hands-on elective where I will be able to perform procedures and manage patients at the highest possible level as a student and a Sub-Internship offered the best course for this goal. Certainly, doing the job of an Intern will require a much higher amount of effort on my part, but I was prepared to put in my utmost for this opportunity of a lifetime.

Now a trip to the US does not come cheap. The exchange rate then was not in my favour, neither were the sky-rocketing oil prices. I estimated that I will require S$10,000 for the trip, which is way out of my budget! Fortunately, a great blessing came my way… Through the recommendation of the Director and Deputy Director of Clinical Manpower at MOH Holdings (Dr Howard Foo and Dr Liem Yew Kan), I applied for and was awarded the National Healthcare Group’s Medical Education Travel Award, which greatly alleviated the cost of my elective. I met a Mexican medical student at Hopkins, whom I became good friends with, whose father had to mortgage his house in order to fund his 3 month elective at Johns Hopkins. Contrasting the help I received from NHG and MOHH with what my Mexican friend had to go through, I feel very blessed to be a medical student in Singapore where opportunities and resources are aplenty.

I am immensely grateful to the wonderful people at the MOHH Division of Clinical Manpower and the National Healthcare Group Clinical Manpower Team for their timely help. They had no obligations to help me, yet they did their best to help me resolve my financial issues so that I can have the opportunity to learn at Hopkins. The assistance they offered speaks volumes of their commitment to develop the human resources of the Singapore healthcare system. In Singapore, if you are of merit, the possibilities and opportunities are limitless. This is the very meritocracy which brought Singapore from third world to first.

A typical day at Johns Hopkins begins at 4.15am, when I will pre-round on the patients before the Residents begin their rounds at 5.30am. After breakfast, I either assist the surgeons in the Operating Rooms or join them in the Outpatient Clinics. As a Sub Intern, I was given a fair bit of responsibilities, both in the ORs and the clinics. I was responsible for taking the preliminary history and performing physical examinations and documenting the relevant findings in the case notes in the clinics. In the ORs, I was scrubbed in for most operations and sometimes functioned as the only assistant to the main surgeon. Initially, however, this was not the case. The trust of the Attendings and Residents had to be gained through hard work and enthusiasm on my part. When that trust was established, they quickly saw me as part of the team and gave me a lot more responsibilities from which I learnt a great deal. I thoroughly enjoyed working with the Faculty and Residents, most of whom are very willing to involve me and teach me, and I formed friendships with many of them.

My day usually ends after dark. During my rotation in Neurosurgery, I often leave the hospital after 9pm, sometimes after midnight as operations can drag on beyond the estimated duration. I relished every minute in the OR. I could stand for hours admiring the elegant movements of some master surgeons and feel fulfilled, inspired and immensely satisfied at the end of it. It is akin to watching a world-class concert, where every note is played flawlessly, you just had to give the musicians a standing ovation for their masterful performance and cry “Encore!” The experiences in the OR further roused my passion for surgery. During my Otolaryngology rotation, I was given the opportunity to practice microsurgery in the microsurgical laboratory where I learnt temporal bone drilling and inserted cochlear implants into cadavers. As a medical student!

After a long day at the hospital, I will usually reward myself with some good hearty American food. When the pangs of home-sickness strike, I turn to the packs of instant laksa, chicken rice and mee siam condiments which I brought from Singapore. When I savour the familiar taste and smell of Singapore, I know I made the right choice in setting aside space in my luggage for these condiments. There is a substantial Singaporean community at Hopkins. And we had gatherings on a number of occasions to cook good old Singaporean meals. Those who have been there longer usually host these gatherings for the new-comers. On those occasions, when Singlish is employed generously, and the fragrance of Singaporean food fills the air, one feels transported back home. The gatherings were some of the most memorable experiences I had there.

Some weekends were spent traveling, from Washington DC to Philadelphia to Buffalo, we traveled quite a bit along the US east coast. We even crossed the border to Canada, while visiting the magnificent Niagara Falls! I like Washington most of all, for its rich history, its spectacular Smithsonian museums that surprisingly offer free entrance to all, and its clean and efficient Metro. And I have to mention BUFFALO WINGS! Yes, the original Buffalo Wings from Anchor Bar at Buffalo. It’s the best food I tried in the US. The wings are so juicy and spicy, they numb your taste buds and leave a great sizzling aftertaste in your mouth. It’s a must-try if you ever visit Buffalo.

At the end of my electives, I spent 5 days in New York. We stayed in an artist’s loft at SoHo, which offers a fantastic panorama of Lower Manhatten, at a bargain. The Big Apple is a city where you will never be bored, not even for an instant. From shopping at Fifth Avenue to visiting the numerous museums to catching a Broadway musical, there are just so many exciting things to do! And of course, the food is great!! Being students on a budget, we looked out for good deals for the legendary Broadway musicals. Our efforts paid off when we bought The Phantom of the Opera tickets at 50% off at a TKTS Booth and got very decent orchestra seats! But the ultimate coup was winning the Wicked Lottery, where 12 pairs of US$200 tickets for the blockbuster musical Wicked were sold for US$26.50 at a lucky draw! I couldn’t believe our luck when we won the Lottery!

I often pondered the reasons for Hopkins’ success while I was there. And I concluded that the most important ingredient in this success story is the human factor. The men and women at Hopkins are all stars in their own fields. I see in them motivated individuals who are constantly innovating and collegial team players. From residents to the most senior professors, I see humility and respect for others. One slogan which I saw on the walls of the hospital is “Sweat the small stuff for your patients” – encouraging the staff to go the extra mile for their patients, because it is this extra bit that touches the human soul and creates the positive experience for both patients and staff. This positive attitude is what makes their delivery of healthcare so effective and working at Hopkins such a pleasant experience. I see many similar practices between Hopkins and the Singapore hospitals, and I am justifiably proud of Singapore’s healthcare system for we deliver universal healthcare to Singaporeans at world-class standards, but at a fraction of what the US spends on their healthcare system. Just imagine what we could do if we spend like our Americans friends do!


Overall, the two months had been a wonderful eye-opener for me. I was given so many opportunities to develop myself both professionally and as a person, entrusted with significant responsibility in patient management, and enjoyed myself so tremendously, I would not have traded the opportunity to learn at Johns Hopkins for anything. This trip would not have been possible if the Yong Loo Lin School of Medicine had not selected me under the affiliated universities exchange programme and if the MOHH Division of Clinical Manpower and the NHG Manpower Team had not supported my educational trip financially. I am greatly indebted to all who have given me this opportunity of a lifetime.

Ng Chew Lip
Year 3 Medical Student
Yong Loo Lin School of Medicine

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My Elective at Kibosho Hospital


Kibosho against Mount Kilimanjaro Kibosho against Mount Kilimanjaro


“We start as fools and become wise through experience.” – Tanzanian Proverb

I had the privilege of being attached to Kibosho Hospital in Tanzania, Africa, from 13th May to 2nd June under Dr Tan Teng Kok. Even though my elective was severely cut short by the travel restrictions during the initial phases of the H1N1 influenza outbreak, the experience that I gained during my short stay there opened my eyes to a different world. It is difficult to put what I have learnt from this trip in words but I shall try.

About the hospital

Kibosho Hospital, located 1200m above sea level in Moshi, North-eastern Tanzania, has come a long way since it started as a dispensary in 1929. From the hospital, it is possible to catch glimpses of the beautiful Uhuru Peak, the top of Mount Kilimanjaro, Africa’s highest mountain. It is a government hospital that is run by the Catholic Diocese of the region. The main building houses 14 rooms which hold about 180 beds. The hospital is also equipped with 2 operation theatres, a casualty room (a small and basic emergency room), a new obstetric wing and a building with outpatient clinics and a laboratory. There is also ongoing construction for a building specialized for the treatment of patients affected by HIV.

People travel long distances from faraway places to Kibosho Hospital because it has a reputation for offering good clinical services. Besides seeing patients within the hospital compound, Kibosho hospital also sends outreach teams to numerous neighbouring areas, providing clinical services such as eye surgery and dental care.

Kibosho also receives a fair amount of support from various overseas organizations particularly from Germany which used to rule Tanzania as a colony.

Applying to Kibosho

I have always had interests in working for an international medical relief organization even before I applied to study Medicine. I thought patients in 3rd world countries are perhaps the patients that need the most help. Hence, I really wanted to see how it is like to practice Medicine in a 3rd world country. I went on to find out more.

Professor Low Cheng Hock and seniors who have been to hospitals in Africa also told us that it is a golden opportunity to experience Medicine in a dramatically different way. I was told that there will be plenty of hands-on experience and there is an incredible wealth of clinical material in Africa. They also told me that it is extremely inspiring to see how the healthcare workers in Africa treat their patients with the limited amount of resources they had.

I was lucky enough to have Professor Low introduce us to his good friend, Dr Tan Teng Kok, who was willing to take us on an elective in Kibosho. Dr Tan is a general surgeon by training and has worked in Africa and various other countries for more than the past 20 years. He graduated from the National University of Singapore in 1970 and obtained his fellowship in General Surgery (FRCS, Gen Surg, Edin) in 1976 and (FRACS, Gen Surg) 1977. Seniors who were attached to him before spoke of a man of great patience and love for life. He was someone who was very willing to teach students and show us the sort of Medicine that he has been practicing.

As I did not want to be of financial burden to my family, I started saving to finance my own elective. I am extremely grateful for National Healthcare Group (NHG) Manpower Division which relieved part of this burden my granting me the Medical Elective Travel Award (META). Without this award, travelling overseas would be a lot more difficult than what it was. I am also very grateful for Dr Tan and his wife who was so generous in sharing with us their home, food, time and so much else. That made our attachment so much better than it could have.

Regarding Clinical Posting in Tanzania

In the mornings, we would join Dr Tan or other doctors in the hospital for ward rounds. We would also join in the discussion for the diagnosis and management of the patients. The common conditions in the hospital include HIV, chest infections, malaria, soft tissue and bone infections and other infections. There are also numerous oncological cases, including cancers of the stomach, breast and oesophagus. With the improvement of sanitation and quality of life, the people are there able to live longer and hence also suffer from conditions that commonly plague the developed world such as diabetes mellitus, heart failure, and hypertension. As such, it can be said that they suffer a double whammy.

With the aid of a phrase book and nurses who acted as translators, we were able to take very basic histories from the patients even though many of the patients only spoke Swahili. The patients also had a considerable number and variety of clinical signs. It was in Kibosho that I palpated the biggest spleen and liver that I have ever encountered. As patients present very late in the course of the disease, they develop complications and clinical signs that we can only appreciate in textbooks back in Singapore.

The scarcity of sophisticated, high-tech investigations also reminded me how important and useful clinical evaluation of the patients is. Many times, the only tools that the physicians over there had to diagnose their patients’ conditions with were their five senses and their clinical knowledge.

We also saw interesting conditions that will never be seen in Singapore. An example is jiggers (chigoe flea or Tunga penetrans) infection which infects the feet of farmers who work for long hours barefooted in soil fertilized with animal manure. The parasite penetrates the skin and propagates in the soft tissue in the feet where it may ulcerate and cause a great deal of itch. It is said that the itch can be so bad that the patients can go crazy, thereby causing “jiggers psychosis”.

Treatment of the more complex conditions is also severely limited. For example, patients, provided they could afford it, had to travel to the largest city of Tanzania Dar Es Salaam, which was a day’s travel away, for chemotherapy and radiotherapy.

Almost all the doctors there are truly general physicians and are able to handle all sorts of problems, be it medical, surgical, paediatric, obstetric or gynaecological. Before I left, a doctor whom I spoke to about the trip asked me if this was a good or bad thing. I think one of the few bad things is that the doctors are perhaps unable to specialize and become a true expert in treating specific types of diseases. However, I feel if doctors, especially the primary care providers in Singapore, are able to work like that, the need for referral will be much less. Patients will not be treated like organ systems and can be treated as a whole. Patient-physician relationship will be improved. The number of patients requiring tertiary level of care will be less and perhaps healthcare costs can be lowered.

We went to the operating theatres every Tuesday and Thursday. We mainly only had an observational role because there were new trainees who needed the hands-on training. Also, because our elective was cut short, we were less familiar with the workflow and hence the risk of us getting a needle-stick injury was higher. This was a little disappointing as all of the students that were there before us had many opportunities to assist in surgeries.

The common operations performed include appendectomies, cholecystectomies, colectomies, prostatectomies as well as obstetric and gynecological procedures such as hysterectomies, caesarean sections and myomectomies. There were also thyroidectomies which were introduced to Kibosho Hospital by our very own Professor Low Cheng Hock!

Even though the facilities in Kibosho are very basic, the local surgeons were still able to perform large number surgeries fairly competently. They used ether as their anaesthetic and only had a manual ventilator. Their operating theatre was not air-conditioned and at times there are even flies flying into the theatre. Interestingly though, the number of post-operative infections and complications is not high.

It was also fascinating to see how the locals had creative and cheap solutions for problems that we face. I thought it was ingenious when they stuck a piece of string on patients’ nose to monitor their respiration rate during surgeries. They also boiled water using mirrors and solar power.

Other activities that we took part in included clinical meetings (much like our grand ward rounds and clinical teaching sessions) on Monday and Thursday mornings.

We also visited the Kilimanjaro Christian Medical Centre (KCMC), a much larger hospital located in Moshi Town, on a few occasions and joined the medical students there for ward rounds, lectures and tutorials. The bed situation at KCMC is what my friends and I will describe as a “war zone”. The dark and narrow corridor is packed with beds on both sides. However, because it is a larger and a more well-equipped hospital, it is able to take care of more complex cases.

In the evenings, Dr Tan would give us tutorials at his home late into the night, going through some of the clinical problems and diseases that we saw during the day. We would come up with differential diagnoses for the more complex cases we saw in the day. Besides Medicine, Dr Tan also shared with us many lessons about life – including issues such as family, doctoring and religion.

Regarding the people in Kibosho

Tanzanians are well-known to be friendly and we experienced the full extent of their warmth. Everyone in the community, from the nurses to doctors to the random man we met in the street, were very friendly to us. They often greeted “jumbo” or “habari” (their version of “how are you?” and “hello”) and many stopped to chat with us and even invited us to their homes.

Poverty is also very evident in their community. Most of the people there are farmers and many still live in houses made from rocks and mud. There was one particular incident that struck me. We came to know a senior nurse who is also trained to give anaesthesia as well as take care of psychiatric patients. He is usually very neatly dressed in his white coat in the hospital. During one of our evening walks in the residential and farming areas around the hospital, a man in a dirty, tattered and torn red pullover greeted us. He looked familiar but I thought he was only one of the farmers who lived there. It was only after about 5 seconds that I recognized he was the senior nurse who we have seen so many times in the hospital! I felt ashamed of myself and sheepishly greeted him back.

In fact, I was told the hospital staff, including the nurses and even some doctors, is so poorly paid that besides performing their hospital duties, they also need to grow their own food at home or take on second jobs.

However, one can still see the dedication that the doctors and nurses put into caring for their patients. The entire community in and around the hospital is a like a gigantic family and everyone knew and took care of one another. The quality of care far exceeds what one may expect, given the level of poverty in the area.

For us, it is difficult to imagine how the people there live in those conditions every day and one can perhaps only truly understand the extent of their poverty when one sees it for oneself. We are very lucky to be living in a country like Singapore.


 

Regarding Medical Education in Tanzania

The structure of Medical Education in Tanzania is very different. There are a few routes to become a fully qualified doctor. One of the ways requires graduates from Form 4 or 6 (equivalent to our Secondary 4 or Junior College) to take a 3 year course involving mainly knowledge in nursing and clinical subjects. After which, the students graduate as “Medical Assistants” and function like the nurses in our wards. The Medical Assistants can then take a 2 year course (while working) to train to become Assistant Medical Officers (AMOs) and upon graduation they are expected to take care of patients in the hospitals (much like our House Officers or Medical Officers) with the guidance of senior doctors. From there, it is another long and tedious process of approximately another 4 to 5 years after which they will graduate with a MD degree from the university. The alternative is a direct entrance from Form 6 to the MD course which takes a much shorter time.

The result is that many of the AMOs running the wards are able to carry out instructions but have a lot of difficulty dealing with clinical problems because they have not received structured training in the core subjects such as physiology and pharmacology. On the other hand, being put through such hands-on “training” means that if they go on to graduate with the full MD degree, their practical clinical acumen and skill is usually very good. A newly graduated MD would be able to perform surgeries independently. Even the medical students there are able to stitch better than many of our doctors (even registrars) here.

Singapore obviously cannot regress back to such a level of clinical care and also cannot take such a long time to train a single doctor. However, I cannot help but think if I had even only one-tenth of the hands-on training they had and with the proper guidance, I would be so much more confident of handling practical clinical problems by the time I graduate.

Regarding foreign aid to Africa

At both Kibosho Hospital and Kilimanjaro Christian Medical Centre, the doctors told us about the problems they face regarding the issue of foreign aid. One may find the above statement counter-intuitive. Shouldn’t they be thankful that they are receiving support from overseas organizations?

However, the reality is that not all aid is useful. Some organizations send sophisticated equipment without considering that the local people may not know how to operate them. As a result, many of this equipment lie in the dark storerooms of these hospitals and are never utilized.

Many organizations also “donate” expired medication or broken-down machines and vehicles. Worse, the African hospitals are often requested to endorse these “donations” which are often inflated by the organizations that donate them. One can only infer that these organizations are merely looking for a quick way to reduce their taxes and at the same time jettison whatever “old but still usable” equipment.

The other probably unexpected but highly undesirable side effect of having foreign aid is that the local people have come to believe that they are unable to make any progress without foreign aid. One of the doctors who I spoke to even bluntly said, “the best way to help is to not help at all.”

From a totally utilitarian point of view, it may also be argued that a significant disease burden is created from treating chronic debilitating diseases especially if these health services cannot be supported by the patient or the country’s economy. As such, treating such conditions may do more harm than good.

On the other hand, I have seen how a few people, like Dr Tan, with his training and knowledge, can make such a big difference to the healthcare of an entire region. I think it is not unreasonable to say that thyroid surgery would have reached Kibosho much later if Dr Tan did not go there.

Diseases are also becoming increasingly global in nature, such as in the case of infectious diseases. I notice that many times when the physicians are unable to diagnose the type of infection that is affecting the patient, they prescribe a concoction of anti-virals, antibiotics, anti-fungals and anti-parasitic drugs. I cannot help but think that this sort of prescription pattern will only breed multi-drug resistant super bugs that are ready to be unleashed to the rest of the world. Hence, it may be for our own preservation that the first world countries lend a full and strong helping hand to the healthcare systems of the third world.

Conclusion

There is a Swahili proverb that says “Elimu maisha si vitabu” which means “Education is life not books”. There are many things in life that cannot be learnt from books and can only be experienced. Many things that we take for granted in life, even things like the alcohol hand-washing solution at the foot of every bed, are a scarcity in places like Kibosho. Dr Tan’s love for his patients, students Medicine and life in general even at his age is something I would like to emulate. I am afraid if we do not allow ourselves to break out of the shelter and comfort of Singapore and go out to see the rest of world, we will become myopic “mountain tortoises”, insensitive to the storms around us.

This was truly an experience of a lifetime and it would not have been possible without the generous support of Dr Tan Teng Kok and the National Healthcare Group (NHG) Manpower Division. The invaluable insights that I have gained from Dr Tan and my short attachment will follow me for the rest of my life.

Ho Quan Yao
Year 3 Medical Student
Yong Loo Lin School of Medicine

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