Supplementary Blog: Post-elective write-up

So this is a write-up report for USM based on a proforma by UEA; apologies for its somewhat note-like format, it was meant to be 800 words shorter than it actually is!!

Post-elective feedback

Name: James Rowson

Elective country: Malaysia

Elective hospital: Hospital Universiti Sains Malaysia, Kota Bharu, Kelantan

Elective dates: 5^th May – 17^th June 2014

Elective department: Neuroscience/neurosurgery

What did you do during your elective?

My elective in Malaysia was split into a sightseeing/cultural holiday with my girlfriend Emma and then the elective proper at HUSM. Emma and I had visited Kuala Lumpur, Singapore, the island of Langkawi and finally the town of Kota Bharu over a 3-week period; I would stay on in Kota Bharu after Emma’s departure, staying with my Aunty there.

Within the hospital, my elective consisted of three distinct blocks: a two-week period of time spent with the neurosurgery team of registrars and consultants, within the ICU and wards and in the operating theatres; a two-week period following the local 4^th year medical students through their neuroscience and neurosurgery posting, including ward rounds, clinics and lectures; and a two-week period of helping my supervisor with a research project, and getting a bit of experience with community rehabilitation teams.

During my time in Kota Bharu I was lucky enough to be invited to a traditional Chinese wedding of a distant family member in the town of Kuantan, two states away, and also to be involved with the local Anglican church which my 8^th Aunty’s family attends, where I volunteered to play piano for the four services I would attend!

What was good about your elective?

It’s impossible to put into words how great I found my time in Malaysia, from cultural enlightenment to learning about the healthcare and education system here. Even though my first couple of weeks got off to a shaky start owing to poor communication between the Medical School and Neuroscience Department, I was accepted into the team of consultants, registrars and juniors incredibly quickly, and where possible allowed to shadow and get involved, even assisting in a craniotomy on my first day!  

The medical students were incredibly welcoming, I had no problem fitting into their group, they invited me to play tabletennis, badminton and even music and a bit of salsa dancing with them – added to the fact I never had to buy my own lunch during that two week period with them!

A good photo with my good friends of USM Year 4 medicine's Group 4

Outside of my time with the neurosurgical team and the medical students my advisor Dr Muzaimi was very forthcoming in helping me achieve the aims of my placement, involving exposure to the community/rehabilitation side of Malaysian healthcare, placing me with a couple of community occupational therapists and letting me spend some time with a group of St John Ambulance nurses (paid) in a nursing home, a rare establishment in the usually family-based care Malaysia.

A morning spent with the St John Ambulance nursing home nurses and patients

What was challenging/eye opening?

My first exposure to Malaysian healthcare was a social call to an old friend of my mother’s with peripheral vascular disease and severe foot ulcers – it was immediately apparent that there was little if no communication between doctor and patient, this poor lady had no idea why she was on her drugs (ibuprofen, gabapentin) and why her ulcers existed, let alone how to cure them! I took her ICE (ideas, concerns, expectations) and following information giving we derived a plan to help her comply with her medications (she’d thought the gabapentin was to replace the ibuprofen) and change her lifestyle to help heal the ulcers (she hadn’t been told to not walk around!).  

Also before my official elective start, I saw my uncle who’d had a sub-arachnoid haemorrhage and then further stroke two years back; he was wheelchair-bound, totally aphasic, and unable to care for himself. I was shocked to find that he’d received no physiotherapy due to there existing no services to bring him to the local centre; also nobody had informed the family about stroke and its rehabilitation! I visited with my cousin (physiotherapist) and girlfriend (psychology masters student) and tried to answer the family’s questions about stroke, and give some tips as to how to communicate and let him develop some sense of independence (he could feed and swallow). We were fully aware that we didn’t want to be that distant relative who swans in and claims “you’re doing it all wrong!” to the full-time carers though.

ANOTHER uncle of mine, during my stay here, had an emergency admission for a strangulated inguinal hernia, which had been grumbling for months beforehand. I was not part of his care initially but with my mother, a retired nurse, simply advised his immediate family to attend A&E immediately should he feel pain and experience nausea. It turned out that he had indeed been experiencing pain and nausea for some time, but did not tell us this: his wife, my aunty, traditionally Chinese educated and more of a believer in mystics than medics (especially Western ones) had dismissed multiple vomiting episodes as “food poisoning” and refused to admit him to hospital. He was brought as an emergency admission to a small district hospital A&E while we were out of the state, and another eye-opening experience of the system confronted us – his receiving hospital was staffed only by general medics/surgeons, the experts were 50km away at USM; he would receive more expert treatment at USM, but apparently there was no facility to transfer him to there, irrespective of the emergency. We could take him there “at own risk” via self-discharge and a car, on the long and bumpy road to Kota Bharu, or he could stay on the emergency operating list at Tanah Merah hospital. We all discussed the options in detail at his bedside, opting to remain at Tanah Merah. He was operated on and made a good recovery, but it took me using my “UK Medical Student” status to get access to his notes before the family were any the wiser as to what had happened and what the future had in store for him.

Within the hospital I was shocked by several things regarding neurosurgery in Kelantan state. Firstly, how many head traumas there are as a result of poor (if any) motorcycling/driving instruction (Malaysia requires FOUR HOURS on-road experience for tests for car or bike drivers, made even easier with a “few extra Ringgit” in the examiner’s pocket), secondly how many of these head traumas are children, often either riding the bikes or sandwiched between parents, no helmets on of course – the youngest I saw was a 6-month old with fractured C3/4 and diaphragmatic paralysis, ventilated indefinitely with a neck brace in-situ. What a waste of life.

I was surprised at the shocking amount of work the registrars have to do – easily over 100h per week, like our old system in the UK before common sense took over; for a state the size of Norfolk there were only two registrars, each covering 1 in 2 on-calls and still working the next day. Just imagine the headlines in England! They were absolutely exhausted, albeit still incredibly friendly and helpful; one of them was suffering from Dengue fever while I was there, coming to work wearing a facemask, with a fever raging. “Life is cheap in Malaysia” said one, forced to choose between attending a new arrival in A&E and an dealing with an emergency patient on the operating table, both with a good chance of living but one would die later solely as a result of staff shortage. The relatives would never sue the hospital or the government for this; the media would never write an exposé.

Post-ward round makan with the neurosurgical team

Negative feedback is still practised in Malaysian education – something that would have British students running to their student union! On asking, they claim they prefer it, as it makes them work hard not just for praise (which is given if deserved) but also to avoid being publicly criticised. “Your presentation was not as good as the last person’s” – met with a stoic nod, acceptance, and the desire to do better next time.

It is interesting to be part of a medical school whose students are simply marked as pass/fail – there is a noticeable lack of competition among the cohort, even though USM is one of Malaysia’s top medical schools! When asked, the students said “we just want to pass” – I don’t blame them; they’re required to do 24h on-calls the day of exams, and complete assignments during assessment weeks, fitting this in between 70-hour weeks (including weekends). We’re very lucky in the UK!

Community and Family Case Studies (CFCS) is a module undertaken by 4^th years here, involving identifying a patient with a long-term illness (e.g. hepatitis) and visiting their home several times to ascertain the patient’s understanding of the condition, and perform steps to improve this and their quality of life. Students make flyers/pamphlets with information, perform information-giving, and even step-in to provide environmental changes e.g. buying non-slip matting, altering the patient’s home environment to make it safer. CFCS is a great way for students to appreciate living with a disease, especially Ideas, Concerns and Expectations, and to get a feel for the lives of those much less privileged than them; however CFCS patients are “tempted” into enrolling via a controversial “Blue Card” syetem, allowing them to receive free healthcare only during the CFCS module, great at the time but then its withdrawal basically saying “that’s what you could have had”.

Malaysian hospital facilities are first-world, despite being in a somewhat "third world" environment; the operating theatre doors were in dire need of replacement, but within the neurosurgical theatre stood a brand new million-Ringgit Carl Zeiss microscope connected to twin HD Plasma TVs within! All the while, cats roamed freely around the general surgical ward, and cracked toilets with broken flushes and flooded floors were shared by staff and patients alike.

"A third-world operating theatre" said one member of staff. Maybe so - but with Carl Zeiss microscopes!

These eye-openers aside, I must reiterate that the Malaysian healthcare system is not a bad one. I would not be afraid to be a patient there, admittedly so long as I wasn't suffering from head trauma on a rainy day. The doctors are highly trained and highly knowledgeable, frustrated with the system but still caring and doing the best for their patients; the nurses are attentive and caring, despite requiring patients' relatives on-hand for 24-hours a day to assist with basic care needs.

What did you learn from the elective, and how will this help in your future career?

The most important thing I learnt on elective was how crucial it is to recognise a patient’s ideas, concerns and expectations, and how imperative it is to communicate well with patients. Medicine in the UK has come a long way in the last few years, with huge improvements in the doctor-patient relationship; patients in Malaysia just say “yes doctor” and do what they’re told, ranging from taking antibiotics (as happened to me following a bout of otitis media) or having potentially life-changing brain surgery. Experiencing this first-hand has made a definite impact on how I will practice in the future, I already believe in the power of ICE and RAV, but this has definitely reinforced such opinions.

I of course learnt about neuroscience and neurosurgery thanks to my 4 weeks with the team, and learnt how lucky we are in the UK even down to having Patient Transport Services available for those hard-to-reach patients in the distant villages.

What were the benefits of your elective to you and the host institution/community?

Academically this elective allowed me to reach my learning objectives stated at the beginning, I learnt a lot about neurology, neurosurgery and neuroscience, and even had extra learning in the form of helping out with research, and some exposure to occupational therapy. I benefited from discovering another country’s health system, and this has reinforced my keenness to not take the National Health Service for granted – it is a phenomenal institution, one that would be criminal to lose. Free at the point of access, yet providing high-quality doctors trained in communication skills as well as detailed knowledge about medicine and science, so the patients can benefit as much as possible from interacting with the service.

Hopefully my fellow students in Malaysia will take away me drumming away about Ideas Concerns and Expectations, I have even shared my UEA Communication Skills notes with them! They had been taught it, they admitted, but a long time ago. I hope that I was a help more than a hindrance to the staff at USM, I helped out on the ward rounds where I could and tried not to get in the way too much! I would have liked to help out more, but hope I did enough. For the community I hope I answered medical questions to those who asked them/needed them answering, including my uncles and my aunty’s friend (who got much better!); I also hope that the church community enjoyed my piano playing for them as much as I enjoyed playing for them!

A great time spent playing music with the band of St Martins Church