The medical elective is an important part of medical training and career. It can also be an exciting opportunity to experience health care systems of different countries and explore areas of medicine that I have particular interests in.

My initial plans are to have the elective placement abroad, ideally in two separate locations. Language is an important factor in choosing the countries as I would like to be able to communicate with the patients and doctors. Out of all the English speaking countries, I think it would be an interesting experience to visit a less developed country or a less developed region within a developed country. The other half of the elective I would choose a developed country and compare and contrast the two health systems.

I want the attachments to be mainly clinical based as I can apply the skills in general medicine and other specialty I have learnt during the two years of clinical training. I would not completely decline the opportunity to mix in some clinical based research, but I am aware that research projects may take some time to organise and may also require extra resources input, such as permission from patients and assistance from other staff, from the destination hospital and institutions.

In terms of safety during travel, although I have travelled to various countries, but I have never travelled or organised travel on my own. Safety in terms of personal belongings, food and drink and personal safety should be put into consideration. If possible, having the placement with a friend would be ideal. As all the 4th year King’s medical students are going on electives this summer, finding a partner going to the same places should be quite possible.

Having just came back from holiday in America, the thought of going back for the elective to have a working experience over in the States appeared quite attractive. The US has a very different health care system compare to the UK. To see their doctors, the patients over in America would need to have private health insurance which can be a very costly payment. It would be interesting to see how the privately funded health system affecting patient experience compared to the NHS in the UK.

America is a big country and this makes choosing the location a bit more difficult. To get an idea about where normally do medical students go for electives in America, I searched on the Elective Abstract System on Virtual Campus. USA seems to be a very popular country for King’s students to go for electives as there is a huge list of hospital and institution for all specialties. The popular destinations are the major cities like New York, Los Angeles, San Francisco and etc. Majority of the hospitals do not accept international students for elective directly, a few smaller clinics do, but the cost is very high and they seem to be very specialised. Feedbacks from students are also mixed, most are happy with their experience, but not everyone had a hands-on experience. Access to patients can be a problem sometimes in some specialty clinics, and most times are spent on observing. Applying to medical schools can also be difficult as a lot of American medical student are also looking for elective placements and the administration fee alone can cost $100 for the application alone.

After those research and further thought, I was slightly put off by the idea of going to the States. Instead of going alone, it would be a better way to travel with a friend. Another King’s 4th medical student was looking for a partner for electives and I have worked with him during my abdominal rotation in 3rd year. he was in the process of organising a research project about respiratory medicine in Singapore which involved some data collection. He needed a partner to work with on the project and we decided to do the elective placements together.

We came across a paper written by Dr Deborah Ng and her colleagues, titled: “awareness of smoking risks and attitudes towards graphic health warning labels on cigarette packs: a cross-cultural study of two populations in Singapore and Scotland”. We were thinking about emulating this study ourselves, looking into the cross-cultural differences between Singapore and London, instead of Scotland. We will use a questionnaire approach to collect the data as oppose to interviews because we want to collect as much data as possible while still working on the clinical side of the placement during the elective period.

We also emailed Dr Ng on further advice about her study and she kindly contacted the head of respiratory department she was working under in Singapore, Professor Sin Fai Lam. Professor Sin agreed to give us 4 weeks placement in Khoo Teck Puat Hospital in the respiratory department and at the same time allow us access to patients for the research project. In order to carry out this project we also require ethics approval and this need to be applied by a qualified doctor. We were told that Professor Sin’s team is rather busy and unable to commit their time for the ethical approval. We are still committed for the clinical placement in Khoo Teck Puat Hospital, and at this stage we are seeking alternative ways to get the ethical approval, possibly from another department or another hospital.

For the second half of the elective, we did not want to travel too far out of the regions. This is partly to save cost and also time spent on travel. So we applied for a few postings in Kuala Lumpur in Malaysia. Hospital Kuala Lumpur kindly accepted our applications for a 4 week long posting in the general medicine department. This would cover a large variety of medicine, and it would be good to have a wide range of experience after a very specialised surgical placement. I can also use this time to get more experience in specialties that we only had limited exposure so far, for example, ENT, dermatology and ophthalmology.

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Career Section

Self-assessment

During my pre-clinical studies in Cambridge, I had very limited exposure to real clinical practice so I kept an open mind about which specialty I would like to pursue for future career. I thoroughly enjoyed learning anatomy in first year of medicine, and particularly the time spent in dissection lab. What appealed to me is that I would read about certain parts of the body and the next day I can have the hands-on opportunity to recap the knowledge to visualise it in real life.

The clinical study offered better opportunities in career exploration. Throughout the various rotations, I found surgery fascinating and I’m always enthusiastic to attend theatre sessions. Although, as a medical student, most of the time spent in theatre is to observe the operations but I was more than keen to scrub in to assist when asked. I also enjoyed the type of team work in surgery where each individual has a clearly defined and unique role in the operating theatre.

Career research exploration and discussions

The Medical Specialty Training website (1) is a good starting point for careers research as it provides information on all specialties within medicine. After medical school, every doctor has to go through two foundation years and apply for specialty trainings, these can be medical, surgical, psychiatry and list of run through specialties. For the surgical specialties, there are two Core Surgical Training years to be completed first. Then there is another application process for the third year (CT3), which is for a sub-specialty, for example, cardiothoracic surgery. The competition information shows that surgery is a highly popular choice, though the competition for other specialties can be equally fierce.

I have also attended the Specialty Fair hosted by Royal College of Medicine. It was aimed for both medical students and foundation year doctors and it had a whole range of specialties on show. Having talked to a number of the doctors from various specialties, orthopaedic surgery particularly stood out for me. It is a surgical specialty concerned with bones, joints and their movement. It covers both injury and other diseases, for example, congenital and degenerative. I think it can be an extremely rewarding career where I can put patients back after severe trauma or restore independence by relieving arthritic joint pain, both can truly transform the patient’s life.

Figure 1. Orthopaedic surgery. From www.sussexotc.nhs.uk

Having not done the rotation for orthopaedic surgery and trauma, I wanted some early taste for the specialty and the 2011 National Undergraduate Trauma Conference provided the perfect occasion. The conference gave great insight into the career options available in trauma and orthopaedic surgery. The workshops lead by experienced doctors in the field also allowed the student to practice some of the skilled involved, for example, laparoscopy.

Using your elective to explore your options

I think the elective period will be an excellent time to explore my area of interest and careers option. For the first half of my elective in Singapore, I will be spending four weeks in the orthopaedic department in a very modern hospital. There are five consultants in the department, all of which are trained in the UK so they will have a pretty good understanding of the level of training I’m currently at and what would benefit me the most during this posting. By this stage I would have done my orthopaedic surgery attachment, and additional exposure in this field will reinforcement and hopefully further develop the knowledge and skill I already have. I should also make the most out of this opportunity to get as much practical experience as possible in learning the basic surgical techniques and management of the common cases encountered in orthopaedics.

For the second half the elective in Kuala Lumpur, although I’m officially posted under general medicine, in reality the hospital is very flexible for the elective students. The consultant who is supervising me during the posting has no problem with elective students making use of the time in Hospital Kuala Lumpur to get a wide range of experience.

Personal reflection on career thoughts/decisions to date

The large career choice medicine offers makes the decision very difficult, especially most specialties requires lengthy training. In order to make a firm decision on which path to take, careful research needs to be done to make sure that I am clear in my goals, changing career path in medicine and restart training can be very tedious. I think at this stage of training it is very difficult to have a clear picture of what I want to do. While learning about the different disciplines in medicine can be quite different when work on them. Although it does give some insight about what it is like to work in that field.

To this date, I am very inclined towards surgery for my future career. Being able to directly see the problem, holding the breakage or feeling the blockage then fixing the problem using your hands is very satisfying. It requires lengthy training and new skills are constantly acquired even after qualification. I always find it exciting to scrubbing-up, operating, or mostly as a medical student, assisting in theatre. There is a vast array of subspecialties on offer, from urology to plastic surgery. Some factors will be common to all specialties, but each will have their own set of challenges and demands.

Orthopaedic surgery is the most appealing subspecialties in surgery, it can be very physical but there are many specialist tools available to reduce the need for excessive force. The on-call schedule is relatively demanding as accidents can happen any time of the day. In contrast with ENT surgery where more of the surgeries are elective with very little emergency work so the working hours can be quite flexible.

Through the course, I am becoming more informed about the different career options and have got a better idea of what sort of career I want, though not confident enough to make a final decision. At the same time I should not become narrow minded and ignore the other areas of medicine, because I may yet discover other new interests.

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Global Health Section

Global health is a discipline in medicine derived from public health and international health. It has been defined as “an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide (2)”. It is a field joins the medical and social science disciplines, including demography, economics, epidemiology and many others. It uses health data such as life expectancy and infant mortality rate to measure the health problems present in an area. It also emphasises on health issues such as HIV/AIDS and malaria that can have a global economical and political impact.

What is equity in health?

Health equity among nations and within a nation or community is a major issue in global health. The promotion of social and economic equity and reduction of health disparities has been a key theme in domestic public health, international health, and global health (2). Equity of health can be confused with equality of health. Health equity focuses on the distribution of resources and other processes that drive a particular kind of inequality between more and less advantaged groups, in other words, health inequality that is unfair or unjust (3).

Not all health disparities are unfair (4), for example, we would expect young adults are healthier than the elderly and men have prostate problems whereas women don’t. However, if the difference arises from immunisation level or nutritional status, then it would cause concern from an equity perspective (3). More recently, Braveman and Gruskin defined health equity as “absence of systematic disparities in health between different social groups. Inequities in health systematically put groups of people who are already socially disadvantaged (for example, by virtue of being poor, female, and/or members of a disenfranchised racial ethnic or religious group) at further disadvantage with respect to their health; health is essential to wellbeing and to overcoming other effects of social disadvantage.” (3)

Financing of health care

Financing of health care is a major factor in equity of health care, it is the activity of raising or collecting revenue to pay for the operation of a health care system (5). The conventional categories for financial sources are taxation, social health insurance, private health insurance and out-of-pocket payments. Depending on the health care system there are many variations in the financing sources, for example, social health care insurance can be implemented on a national level or a community level and it can either be compulsory or voluntary (6). Equity in health care financing is assessed by the degree of inequality in paying for health care between households of unequal Ability To Pay (ATP) (7). Policy makers in various countries seem to be constructing health care financing according to ATP. The Ministry of Health (MOH) in Malaysia subscribes to this strategy by proposing that the nation’s contribution to the new national health financing scheme to be related to ATP (8).

Malaysian health care system

The fundamental principle of the Malaysian health care system is that the accessibility to health care is not to be related to ATP, particularly in the event of sickness (9). The Malaysian health care system has seen great improvement over the past years. During the period of 1990 to 2005, life expectancy at birth increased significantly: males from 69.0 to 71.8 years and females from 73.5 to 76.2 years; infant mortality rate fallen from 13.5 to 5.1 per 1000 (8). Malaysia was ranked at 49 from 191 WHO member countries (10), which assessed the overall health performance against the three objectives of good health, responsiveness and fair financial contribution. Malaysia’s performance at fair financial contribution is relatively low (122-123 out of 191 WHO member countries) compared to the other two objectives (10).

In Malaysia, the public and private health services co-exist. The government provides public health services through public hospitals and health clinics. Private health care complement the medical services provided by the government and its emergence is driven by demand.

The health system overall is predominantly tax financed. The national expenditure showed that government subsidises 58.2% of the funding in public sector whilst the balance of 41.8% is financed by the private sector in 2003 (11). The funding are from five main sources: direct taxes, indirect taxes, Employee Provident Fund (EPF) and Social Security Organisation (SOCSO) contributions, private insurance premiums and out-of-pocket payments (6). Those funds are transferred directly or indirectly to either public or private facilities.

Figure 2. Households’ Financial Contributions to Health Care System in Malaysia. From (6).

Many parameters and techniques are available in the assessment of equity of financing in a particular health care system. Progressivity measures the deviation from proportionality in the relationship between health payment and ATP (12). A progressive system means that the individuals or households with greater ATP are paying more proportionally in financing health care. The Kakwani’s progressivity index (13) is a widely used tool in public finance to assess equity. The value ranges from -2 in the most regressive system to +1 in the most progressive system, 0 means that the system is proportional and health payments account for the same proportion of income, irrespective of the individual’s income (14). A research carried out by Yu et al (6) employed data from Household Expenditure Survey (HES) Malaysia 1998/99 indicated that the five finance sources in Malaysia have produced a progressive system which is regarded as equitable. Malaysia’s Kakwani’s progressivity index score compares very favourably to other tax financed health care systems in both developing and developed countries (6). This finding contradicts the WHO World Health Report 2000, in which an older data source from 1980s was used compared to the 1998/99 figures used in the new report. The two different findings also indicate improvement in the equity of financial contribution in the health care system during this time.

Although the finance of health care can be regarded as equitable in Malaysia, there are other inequities. Many among the poor fail to seek health service due to travel and opportunity costs. The private travel costs incurred to seek treatment have been high and also increased at a higher rate compared to household income (15). The poor also live further from medical facilities and have to spend more to travel compared to the rich (15).

From the case of Malaysia we can see that achieve equity in health care can be very difficult. The country has a very equitable way to finance the health care system but problems remains in the distribution of service. Also the growing proportion of private finance sources will cause an outflow of skill medical personnel from the public sector which will create further access inequities.

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Final Aims and Objectives

Experience health care systems in different countries. The two countries that I’m visiting will have quite different systems to each other and the UK. It would be interesting to see what can be learnt from each and what can we do to improve our own health system.

Practice the clinical skills acquired in the past two years and hopefully acquire some new skills that can be used in the future. This can be a good time to retouch on all the clinical skills which will be needed during attachments in the 5th year and foundation jobs.

Use this opportunity to explore career options. More exposure in orthopaedic surgery will hopefully strengthen my aspiration towards surgical careers. Use the time in Kuala Lumpur to get more exposure to specialties that I haven’t had much exposure, for example, ENT and dermatology.

To conduct the research project, this is still pending on ethical approval. This is an opportunity to practice how to carry out clinical researches, which is a useful skill to have regardless of the specialty I will be entering. If the research is approved and everything else goes well, it can be a good chance to have some work published early in the career.

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Account of Elective Plans

Singapore

Since my elective is split into two halves, I shall talk about each separately. My first destination is Singapore. Officially known as the Republic of Singapore, it is a city state and also an island country. Situated off the southern tip of the Malay peninsula, separated from Malaysia by the Strait of Johor. It is the world’s fourth leading finance centre and the third busiest port.

Figure 3. Singapore skyline at night from www.panorami.com

With a population of just over 5 million and being one of the smallest countries in the world, its population density is the 3rd highest in the world. Only 2.9 million of its population are born locally, 43% (16). Singapore is a multicultural country, the 2010 census (17) indicates that majority of population being ethnic Chinese (74.1%), with 13.4% Malays, 9.2% Indians. There are four official languages in Singapore: English, Mandarin, Tamil and Malay. English is the working language and all doctors are trained in English. The largest religion is Buddhism (44.2%), Christianity and Islam are the other main religions with 18.3% and 14.7% respectively (17).

Figure 4. The Merlion, a symbol of Singapore. This mythological creature is a charming hybrid of a lion and a fish. From www.travelerfolio.com

Singapore has a universal healthcare system where the government ensures affordability. Most care expenditure (68.1%) (18)is provided by the private sector, and the rest is from the government. According to the World Health Organisation (18), Singapore has the lowest infant mortality rate (3 in 1000) and it also has one of the highest life expectancies at birth (80 years). Singapore has “one of the most successful healthcare systems in the world, in terms of both efficiency in financing and the results achieved in community health outcomes” (19). The system uses a combination of compulsory savings from salary deductions, founded by the workers and employers, a means-tested government subsidies for those in financial hardship and a national insurance scheme to cover major and prolonged illnesses (19). Although very successful, this particular healthcare system is “difficult to replicate in other countries”, mainly because the relatively small population of 5 million on a concentrated piece of land, so the planning of the healthcare infrastructure is much easier comparing to larger countries (19).

There are 13 private hospitals, 10 government founded hospitals and a number of other specialist clinics. Khoo Teck Puat Hospital (KTPH) is the newest public hospital in Singapore, built to serve the healthcare needs of more than 650,000 people who live and work in the north of the city. The hospital was officially opened in November 2010, the total cost of development was $674m (20), $125m of which was donated by the late Khoo Teck Puat’s family, who was wealthiest man in Singapore. KTPH is a district general hospital consists of 19 wards with 550 beds, with a six-storey Specialist Outpatient Clinic block, and an eight-storey building housing the private wards and a 10-storey subsidised tower (20). KTPH is also actively involved in medical education and provide clinical teaching to medical students from Yong Loo Lin School of Medicine at the National University of Singapore (20).

Figure 5. Khoo Teck Puat Hospital. From www.flickr.com

Kuala Lumpur, Malaysia

Malaysia is situated in South East Asia, separated into two regions by the South China Sea into Peninsular Malaysia and Malaysian Borneo, also known as West and East Malaysia respectively. The Peninsular Malaysia was known as Malaya, gained independence from Britain in 1975, then united with Sabah, Sarawak and Singapore to form Malaysia in 1963. However in 1965, Singapore withdrew from the federation and formed an independent country.

The total population of Malaysia is just over 28 million (21), Malays and other Bumiputera groups make up 65% of the population, Chinese 26%, Indians 7.1% and other ethnic groups 1% (22). The distribution of population across the country is rather uneven with about 80% living in Peninsular Malaysia (21).

There are 137 living languages spoken in Malaysia (23). Bahasa Malaysia, a standardised from of Malay is the official language. English was the official administrative language before Malaysia’s independence and remained to be widely used, especially in service industries and other work places. So communication should not be an issue during the elective. Islam is the largest and the official religion with 60.4% of the population, Buddhism and Christianity are the other main religions with 19.2% and 9.1% followings respectively.

Figure 6. Map of Malaysia. From www.cia.gov

Kuala Lumpur is the capital and the largest city in the country with a population of 8 million in the metropolitan area (24). The name literally means “muddy estuary” in Malay It has developed from a shanty town housing miners from the nearby tin mine in mid 19th century to be dominated by the tallest skyscrapers in Southeast Asia and flush with the proceeds of international trade and commerce. Kuala Lumpur is a very diverse city in terms of demography, religion and culture with historic temples and mosques sitting alongside futuristic towers. This diversity attracts tourists from all over the world, and I am certain I will have plenty to do and see in my free time.

Figure 7. Kuala Lumpur at sunrise with Petronas Towers dominating the skyline. From kualalumpurhotels.travel

Hospital Kuala Lumpur is the largest hospital in Malaysia and one of the largest in Asia. It is situated on 150 acres of land with 83 wards and 2302 beds. It employs a huge staff of 7000 workers, including 200 consultants and specialists with 500 registrars and house officers (25). The hospital is situated at the centre of the city, and was built in 1870 and consisted of only 3 wards. Since then, it has been constantly upgraded and in 1997 it has completed upgrading its Institute of Radiotherapy, Oncology and Nuclear Medicine (25). HKL also plays an important role in training health professionals. As it is the main teaching hospital for medical students from the National University of Malaysia the staff will be more than capable to provide a worthwhile learning experience and hence it is a very popular choice among elective students. Many 5th students spent their electives in HKL thoroughly enjoyed their postings. As it is a huge hospital there are so many different departments I can visit and most doctors are more than happy for you to join their team for a day regardless the department you are posted under.

Figure 8. The Thean Hou Temple is one of the largest Chinese Buddhist temples in Kuala Lumpur. Officially opened in 1989, it is dedicated to Tian Hou (The Heavenly Mother). From www.flickr.com

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Personal Safety, Health and Wellbeing

For personal safety issues about the countries I am about to visit for the electives, I first checked the Foreign and Commonwealth Office website for some general advice. For Singapore, “there is an underlying threat from terrorism. Attacks could be indiscriminate, including in places frequented by expatriates and foreign travellers” (26).This means there is a low level of known terrorist activity. So from terrorism concern point of view, Singapore is perhaps safer than the UK. FCO also states that violent crime is rare, but travellers should be aware of street crime such as bag-snatching. This kind of activity occurs more frequently in tourist area such as airports, I think I should exercise same kind of caution as I would in all large cities.

The FCO particularly highlighted that “the offences of outrage of modesty (molestation) can result in a fine, jail or corporal punishment (the rattan cane). Travellers are advised to avoid any action that could be interpreted as molestation. Scams involving false claims of molest are thought to exist” (26). This should not be a major concern as most people would exercise common sense not to cause any offence, though this does alert traveller to the country that certain misbehaviours that would be dealt leniently in the UK can lead to very serious punishment in Singapore.

The threat of terrorism is slightly more serious in Malaysia, FCO listed it as a country with “general threat of terrorism” and “some level of known terrorist activity” (26).The FCO also warned against travel to the east Sabah region of the country as there “are indications that both criminal and terrorist groups are planning violent acts against foreign tourists” (26)in that area. The last incidence involving foreign nationals was in 2003 and there are no other reported incidences since. East Sabah is in east Malaysia, far from the capital city Kuala Lumpur, and I have no plans to travel to that part of the country.

In terms of insurance during elective period and other travels that may follow, I have always purchased travel insurance to cover my flights to and from home during the holiday period. I have been with Insure & Go for a number of years, it’s a very reliable company and their annual multi-trip policy is very comprehensive. The insurance package costs £70 per year, which includes cancellation, personal belongings, baggage, documents and whole range of other covers. One important cover I should highlight is the medical cover. As if for any reason I fall sick during the elective or the period spent travelling after the elective, I would be cover for the local health service if it’s needed. The health care systems in Singapore is largely privately founded so the cost it would be quite expensive, and the National University of Singapore requires all incoming elective students to have medical insurance during the elective period. I have also checked with the insurance company that the “medical elective” is covered as part of the travel insurance as it can be a grey area between holiday travel and working travel. They have confirmed that the elective is covered by this policy.

Professional indemnity or malpractice insurance is also required by the placement in Singapore. I have joined the Medical Protection Society since first year of medical school but I have never required their service. If I keep on following the guidance as I have been in the UK during the clinical studies, professional indemnity should not be of concern. I understand the medical practice in different health systems and different culture can vary, patients’ expectation and understanding of the role of medical student can also be quite different. While working with patients, whether on ward or clinic, I should explain my role and make sure the patients understand who I am and what I’m doing. At any point, if I am unsure about the ethical implications of a certain practice, for example, asking for consent from patient for examination, I should consult a senior member of the team and ask for advice for the accepted standard of practice in that particular hospital.

Dengue fever is known to occur in both Singapore and Malaysia (27). There is no available vaccination or medicine to prevent this disease. The best measure is to avoid mosquito bites by using anti-mosquito sprays and creams. There is also a risk of malaria in Malaysia (27), again anti-mosquito measures should be used. In addition, chemoprophylaxis should be u