Manipal Teaching Hospital, Pokhara, Nepal Supervisor: Dr Asis De dr_asisde@manipalgroup.com.np Elective Report Personal Learning Objectives and Reflections Elizabeth Boyle 8/1/2013 e.z.boyle@dundee.ac.uk
Objective 1 Through spending four weeks within the team on the General Medicine Ward at Manipal Teaching Hospital, I was able to make progress towards achieving my first elective objective: gaining an understanding of the differences between Nepalese and British Health Care Systems. This placement allowed me access to both patients and healthcare workers within the Nepalese system, which I could compare to my own previous experience of completing placements within the NHS. I learnt that there are many differences between the two health care systems. Both countries have a combination of public and private care. In Nepal however the government run hospitals and outreach clinics provide a basic version of the services available on the NHS. However, they provide the opportunity for those patients unable to financially contribute to their health care cost to access medical attention. With regards to provision, I learnt that the government has additionally made a list of drugs that are available free of charge to patients called the Essential Drugs of Health Post. This is beneficial as even after being consulted by a doctor and being prescribed a medicine it is not always affordable. I think that understanding the differences between the NHS in the UK and Nepalese Health Care Systems is important as a global understanding of differences is important for both personal and professional development. If the opportunity arises later in my career to work in a developing countries, an awareness of the qualities unique to the NHS will be of great use.
Objective 2 The opportunity to experience first-hand the presentation, investigation, treatment, complications and outcomes of diseases that presented on the general medical ward at Manipal Teaching Hospital provided insight into patient care in Nepal. Placement in this department was ideal in terms of achieving this objective. On the ward rounds we saw clinical examinations, history taking and investigations such as imaging and blood test results being discussed in the context of each particular patient. This was good reinforcement of which investigations to order. With regards to this elective objective, I observed and learnt some important differences to the UK. One of these related to the treatment of patients. There were multiple cases were patients were admitted following several attempts at being treated by either traditional healers, or through buying medicines directly from the pharmacist before seeking medical attention. This is because in Nepal you do not need a prescription in order to obtain medicines, you can purchase them without one. In some instances this simply delayed their presentation but had no worse effect. On several occasions however, this practise complicated the care of the patient. One lady presented with a Urinary Tract Infection which was resistant to many antibiotics following taking antibiotics from the pharmacy in the community, all of which failed to clear the infection. Issues surrounding the development of Multi Drug Resistant Tuberculosis are relevant in this scenario of self-medicating. I also learnt that there are many diseases common to both Nepal and the UK e.g. COPD and diabetes. This was interesting as you saw familiar histories, symptoms, examinations etc, despite being in such a different setting. Implications upon future practise regarding this objective is that I now feel more confident regarding the variety of diseases that can present in any setting. This therefore means that the patient care I saw in Nepal, even when this was for tropical diseases are beneficial for work in the UK. Secondly, as a 5 th year medical student and further onto a junior Doctor, I will also feel more confident in my examination skills after completion of this placement.
Objective 3 This objective was focussed upon increasing my awareness of the main practicalities, rewards and problems of working in a developing countries health care systems, as I hope to spend a part of my career working in a developing nation. Being placed in Manipal Hospital, for this length of time, and integrated into the ward team provided great experiences with regards to this. I had the opportunity to speak to local and foreign Doctors all with different background and perspectives on their experiences of working in a developing health care system. Secondary to discussions that I had, and my own observations, I leant a vast amount regarding working in a developing country. This regarded practicalities, problems, and rewards that I would likely encounter. Examples of what I leant include: In the community outreach clinics I learnt that one of the problems in practising medicine is having to base clinical decisions on history taking and clinical examinations only, as getting investigations and results can be a complex process. It can be difficult to organise this type of work independently from large organisations, however this can be the best option in some instances, giving you more flexibility and personal choice. Therefore, as a result of my experiences and leaning on this placement, I now feel more certain that spending a period of my career working in a developing country is something that I would like to achieve. However, work that I still have to complete is deciding where and when to do this, whether to do it through an organisation such as Medicines Sans Frontiers or independently.
Objective 4 This objective was concerned with gaining an understanding of the impact of the Nepalese culture - whether that was social behaviours, economic problems or political policies- on the health of the population. The experiences that I had related to this objective included both ward based (taking histories and ward round and discussion) and small group teaching sessions. This provided a range from specific patient cases, to public health issues throughout the country. This gave insight into the range of ways in which the culture impacted on health, as well as specific examples of this. I leant that the intricate ways in which culture impacts upon a patients experiences of poor health, presentation, patient care and public health beliefs is complicated but explicit. Examples of this is that I have experienced relate the high prevalence of COPD in Nepal. We were taught that a large contributing factor to this was a lack of government and public health action on smoking cessation. This is reportedly because the government receives substantial taxes on cigarettes sold and therefore does not want to dissuade the population from smoking. Secondly to this, smoking is not perceived in the general public as unhealthy, as it is in the UK. The implications of this learning objective is that it has acted to reinforce my knowledge that assessing a patient within their societal / cultural context it is vital to fully understanding and appreciating their condition. Without this you cannot provide the best patient care. Therefore further to the impactions of being told this, it prompted me to seek more information on this topic and read into the government policies in further detail.
Objective 5 This objective was concerned with developing my clinical skills, for example becoming more confident in eliciting clinical signs upon examination. The experience that I had in relation to this was excellent. The opportunity to examine patients on the ward round, receive constructive feedback from consultants and elicit signs rarely seen in the UK greatly improved my confidence in my clinical skills. Part of the reason that this experience was as valuable is that generally in Nepal, patients tend to present later than in the UK. Unfortunately as the disease process may have progressed further due to this, there is therefore often classical or advanced clinical signs. This however did provide the opportunity to see signs that I had not seen before e.g. fluid thrill, or barrel chest and abdominal breathing. During our first week on the ward we also were able to see the Manipal Final Year Students sitting the OSCE on the ward. Through this experience I learnt the importance of having confidence in your examination findings and the implications that these have upon your differential diagnosis. I have also learnt that should you choose to, there are plenty of opportunities on placements to ensure that you remain confident in your clinical skills. The implications of this experience, and what I have learnt is the value in remaining confident in your clinical skills. Therefore as a result of this I will ensure that I keep on practising examinations and other practical skills such as procedures on the wards, specifically on my medical and surgical shadowing blocks. A good way to assess how effectively I have done this will be through the feedback that I receive for both DOPS and mini CEX exercises.
Pictures from Travelling Phewa Lake, Pokhara Annapurna Base Camp, Himalayas, Nepal