European Studies Placement Report

Violeta Tafilaj European Placement – Madrid 2016 Hospital de Rey Juan Carlos European Studies Placement Report The European Options programme was o...
Author: Geoffrey Rice
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Violeta Tafilaj

European Placement – Madrid 2016

Hospital de Rey Juan Carlos

European Studies Placement Report The European Options programme was one of the reasons I applied to Manchester Medical School. I had studied Spanish on and off for six years and did not want those years to go to waste. It would mean a few extra hours of studying each week, and a couple of extra exams each semester but the reward would be a placement at a Spanish hospital at the end of fifth year. Of course this was an exciting prospect but was, at the time, very much in the distant future and it was hard to imagine myself being a final year medical student in a Spanish hospital, speaking Spanish only, with the level of Spanish I felt I knew at the time.

Arriving in Madrid In January this year, I arrived in Madrid a few days before my placement was meant to start and I spent those days travelling around Madrid, seeing all the attractions and getting used to the metro system. My accommodation during my placement was in a district called Villa Verde Alto, where I lived with the family of one of my Spanish friends from Manchester. Their English was very limited so there was no other option than to speak Spanish with each other. Both by friend’s father and his partner were elderly and retired and had worked governmental jobs, and were highly intelligent people and very keen to have me around. They were very adamant that I would make the most out of my time in Madrid and improve my Spanish as best I could and were therefor very strict with my Spanish, correcting every single error I made. This was, for obvious reasons, very frequent in the beginning but has everything to do with why I now, at the end of my trip, feel so much more confident with my level of Spanish. They were both also interested in films and we spent most evenings during the week watching Spanish films, but also regularly watched the news together and a Spanish comedy show called ‘Ilustres Ignorantes’. I was more exposed to the Spanish language than I would have been if I would have lived alone or with other Erasmus students. Admittedly, it was exhausting at first. I was invited to family reunions and visits to relatives in Toledo, Aranjuez and Rozas de Puerto Real where I met some incredible people and where I was constantly put in unfamiliar situations and where speaking English was not an option. However daunting it felt in the beginning, living with locals is something I would highly recommend to other European Placement students if the opportunity would arise. My hosts also gave me all the information I needed with regards to public transport, which is essential for anyone living and working or studying in Madrid. It costs £20 per month for anyone younger than 26 years old, and £72 for every else. I belonged to the latter group but still thought it was worth paying for since it covers all types of public (bus, trams, trains and metro). My route to the hospital involved a train and a tram and cost me a total of £6 per day, £120 for one month of placement, excluding the costs of transport during the weekend or in the evenings during the week. In order to obtain it you will need to bring your ID, along with

Violeta Tafilaj

European Placement – Madrid 2016

Hospital de Rey Juan Carlos

a paper copy of your ID, to one of the bigger train stations where there will be a specific office dealing with these matters, and you will leave with your transport card in hand. My hosts also arranged a phone contract for me under their tariff during my first week, which meant I was able to make national phone calls but also had access to internet on my phone, and therefore access to google maps, which makes life a lot easier when you are in a new place.

Reflections on the differences between UK and Spanish health care systems I spent most of my time in a general district hospital called Hospital de Rey Juan Carlos, where I did placements in general medicine, neurology and paediatrics. The doctor: patient ratio was very low (usually two students per placement) and so there were therefore a lot of learning opportunities. Anyone registered to work in Spain and make national insurance contributions have access to state-run healthcare. There are also many private options, but most people still use the public health care system. In my experience, it was a very well-run system. The general district hospital I did my placement in only opened its doors four years ago and is a beautiful modern hospital where every patient has their own room. They do not have any wards; instead they have floors, eg. stroke unit floor, on which each patient has an individual room, which made it a lot more comfortable for family to spend some quality time with the patients. In general, the standard was very high and the patients very well looked after. My first memorable impression was how friendly and calm they all were. This obviously helped make my experience a very enjoyable one, but it also made me wonder why this was the case. Some of it had to do with the fact that this was a new hospital, only four years old, and was full of new young doctors (as well as senior consultants), whose dayshifts took place between eight am and three pm, sometimes a couple of hours later. All the medical information in the hospital, including all the patients’ notes, was digitalized and updated into the computer immediately after the ward round. This was also something which the students helped with. Despite what it might seem like, that leaving your notes until the end would just allow it to accumulate, it was very efficient because it was easy to update/add to and later reduced the time it would take to write referral and discharge letters or any other transfer of information. All of the patients’ notes were reviewed and discussed in the morning, which was a very good learning opportunity for us medical students, because we got a better understanding of the patients’ histories while we simultaneously looked at imaging and test results, with opportunities for discussion and for asking questions. This was not disruptive as the medical students were encouraged to participate. I discovered many differences between the Spanish and UK medical school training after speaking to the medical students on my placement. Their medical degree lasts for six years and is heavily based on theoretical teaching. They certainly knew a lot of medicine but had much less practical experience. For example, myself and other medical students were asked

Violeta Tafilaj

European Placement – Madrid 2016

Hospital de Rey Juan Carlos

to perform a neurological examination on a few patients and their examination technique was different, more basic, than the one taught at Manchester Medical School. Their obligatory final exams are strictly theoretical while the practical ones are voluntary, and not skills they have to show they are capable of doing in order to graduate. Then, about eight months completing their sixth year, they all write an exam called El MIR (Médico Interno Residente), where the results places them on an allocation list which eventually will determine which residency job they will get. It is similar to how we in the UK apply for foundation training posts, but they go straight into speciality residency strictly based on the result of el MIR. The results are released on the same day across the entire country and students find out their queue place (their allocation number), and the student who gets the top score of all the other students gets to pick and choose their speciality right there and then before everyone else, of the ones that are available in the country, and then it’s the runner up’s turn and so on.. So if you happen to have number 550 and want to be a paediatrician, you would hope that the other 549 medical students have not filled up all of the paediatric posts that the country has to offer at the time. I spoke to the doctors at the hospital about this method of allocating jobs and they all described it as a very stressful day, especially since their families would often be waiting outside and hoping that their family member managed to snatch their dream job. I discussed with one of the Paediatrics consultants about the advantages and disadvantages of this. My point was that I did not feel that it was a method which included all other aspects of an individual which make them better qualified for a particular position. The students were not even interviewed before receiving the job offer. Also, they had very limited experience of the speciality (especially the practical aspect), something which is very necessary to have in order to make a decision about your future career within medicine or surgery. For example, another of the paediatric consultant told about her experience of finding out her results and waiting in the queue to choose her speciality and noticed that there were not many paediatric positions left and the girl in-front-of her chose one of those positions strictly based on where it was located in the country and not because she had much interest in paediatrics, perhaps robbing someone with a true vocation of the opportunity. The consultant understood my point of view but also insisted that it was a good and fair method because it was a standardised objective method and that other methods are too subjective and could easily be manipulated. I also understood his point, but I still do think that people should be allowed to be hired by their employer for both objective and subjective reasons, as they know their team well and can make a decision about that person from the point of view of how well they would work within the team, or at least have had some evidence of their clinical experience from previous jobs.

Hospital placements My first few weeks in the hospital were difficult because I was still adjusting to medical Spanish and needed to build up a confidence in my abilities to speak Spanish. I slowly started to become more confident even though it was still difficult to communicate with patients,

Violeta Tafilaj

European Placement – Madrid 2016

Hospital de Rey Juan Carlos

especially if they were partially deaf and where breathing through a mask. I was constantly placed in situation where communication could be difficult but quickly started to pick up on the medical vocabulary relevant for the placement and did my best with communicating with the patients. It was occasionally frustrating because it felt that my personality did not come across as it does when I speak English, and because it was difficult, and it has somehow made me feel more relaxed when I now approach patients in a UK hospital, that sense of relief of being able to freely and confidently communicate with someone. I spent two weeks in internal medicine/infectious medicine which consisted partly of daily morning ward rounds (where we saw a mix of patients, most of them elderly with chest infections), which were very rewarding since they included most often just another doctor and I, which meant I was given a lot of time to ask questions and room for discussing patients and briefly examining them. During two mornings per week I attended infectious disease clinics (which included patients with Chronic infectious disease such as Hepatitis and HIV), and once a discharge clinic. In the afternoons I review patients on the computer system, familiarizing myself with the medical language and abbreviations. Occasionally I was given a task, like for example: revise the causes of SIADH and tell me why you think this patient has got it? ..or, go through this patient’s notes and find out why he’s having a CTPA for a PE when he is on anticoagulation and has an appropriate INR? I spent three weeks on this placement which was a sufficient amount of time for me to feel comfortable with doing examinations on my own, which was my main learning objective from the previous placement. I learnt from the excellent doctors on the ward (who were all friendly and very happy to teach) as well as the other Spanish medical students, and could in the end perform a complete but basic neurological examination on my own in Spanish by instructing the patient with simple commands. Stroke patients may present with different types of focal and/or global signs and I have seen a vast range of them on the wards of the stroke unit. It has been interesting but also a very good learning experience to interact with these patients, as well as discuss the link between CNS anatomy and focal or global signs. I feel more confident in my neuroanatomy knowledge and how disruptions in certain structures cause specific signs and symptoms. There was also opportunity to watch Carotid Dopplers and Angiograms both in ICU and on the wards (with the doctor explaining the relevant anatomical structures and any possible associated pathology), as well as discussions of CT and MR imagining results. Overall, a very comprehensive neurology experience, tying together very well neuroanatomy, neurophysiology but also important psychosocial factors related to patient rehabilitation, their families and the complexity of managing certain high risk patients. My final placement was in the paediatrics department of the hospital. My placement was divided into three parts: 1) Paediatric clinics, 2) Neonatology and 3) Paediatrics accident and Emergency. I only spent a couple of days in clinics. My role there was both passive and active: the doctor explained the patients’ medical history briefly and we would later examine the patient together, leaving room for questions and discussions between each patient. It was very similar to my time in Accident and Emergency, where the setting was very similar to

Violeta Tafilaj

European Placement – Madrid 2016

Hospital de Rey Juan Carlos

consultations but the patients had more acute illnesses and injuries and would either be admitted, discharged with medication and advice or asked to stay for a few hours for monitoring, in case of i.e. respiratory distress and bronchodilators were prescribed.

I had a much more active role in neonatology: my morning would start with going through the list of patients and then marking them as ‘new-borns’, ‘review’ or ‘discharge’ as well as visiting the patients in NICU. The new-borns would be seen last, a job which was divided between myself and another final year student from Spain. Our task was to review the medical and obstetric history of mother and new-born, present that history to the consultant and take turns in performing examinations of the new-borns, as well as document our findings in the electronic notes afterwards. Dr Ares, the neonatology consultant, would also ask us to read about certain neonatological disorders afterwards which would be discussed over coffee during the following day. By this point my Spanish had improved and I felt much more confident with speaking to the patients and understood everything that doctor was saying. In the paediatrics clinic, the patients we saw ranged from neonates to pre-teens and presented with physical as well as functional disorder, mostly gastrointestinal. The latter was of particular interest to me since it is something I have not been exposed too much before, and it was interesting and useful to watch the communication between doctor and parents in these cases. I particularly enjoyed neonatology because I had a much more active role here. The student I was paired up with was very helpful and after a few days of shadowing her I was able to complete the task from start to finish on my own, which consisted of reviewing the histories and laboratory results and learning to pick up on relevant pathology and complications in order to perform a proper case presentation later, perform the examinations and complete the notes afterwards. Performing examinations of the new-born has become second nature as I did at least three per day.

Self-arranged GP placement I arranged a GP placement with Dr Patricia Rodriguez Garcia-Calvo. I wanted to experience primary health care in Spain, and was put in contact with Dr Rodriguez Garcia-Calvo by my Spanish friend, whose family I have been staying with in Madrid. We agreed that I should spend Thursday afternoons/evenings in the health care centre and spent a total of six Thursdays (4-6 hours each time) with Patricia, after my hospital placements had finished. I had a both active and passive role in the practice: each patient would enter the office (15-20 patients each time) and I would introduce myself, or be introduced. The doctor would explain the patients back ground, there would be room for me to ask more questions, we looked at radiography and analysis results together and examined the patient together, followed by short discussions about the patient, certain conditions, and their medications whenever possible, as well as made a couple of house visits.

Violeta Tafilaj

European Placement – Madrid 2016

Hospital de Rey Juan Carlos

I wanted to do this placement in order to experience primary health care in Spain as well as gain more experience and increasing my vocabulary in history taking and examinations. Dr Patricia Rodriguez Garcia-Calvo was very good (and patient) with making sure I learnt all I could from each patient, despite her long and busy days. Simply talking about medical conditions and medication in Spanish has been an achievement on its own. My vocabulary has improved and attending these consultations has been good for general revision of both common and uncommon disorders. Most of the patients had upper or lower viral or bacterial infections. A couple of patients had to be sent to the hospital; one girl with a potential DVT who presented with a sore swollen legs and some symptoms of phlebitis. The other patient was an elderly overweight man who presented with fever and severe headache and the family reported several brief moments of confusion. Even though it meant my Thursdays were very long, spending time in a primary health care setting very much completed my experience of the Spanish health care system.

Madrid life My experience of Madrid was heavily influenced by the people I lived with. Luis, the retired gentleman who I was staying with, whose full name was Luis Felipe Garcia Calvo, used to be the general director of the public sector of Castilla la Mancha. He had previously worked as a University lecturer of Civil Rights. When he was younger his father had been one of Franco’s main generals, and a fascist, who lost contact with Luis during several decades because Luis considered himself a communist and was incarcerated four times during the Franco era for political reasons. The dinner table conversations were for many reasons endlessly interesting. As a thank you, and to feel more part of the family, we agreed that I would be responsible for cooking the Sunday dinners. They were curious of my Swedish and Albanian origin and so I attempted to introduce them to typical Albanian and Swedish food. The grandparents were often invited and Sunday’s quickly became my favourite day of the week. Luis’ son Manuel, and my friend from Manchester, came to visit and introduced me to all of his favourite bars in Malasaña. The drinking culture in Spain involves eating a bowl of cheese, crisps, ham or olives along with your drink, and was often served for no extra money. When I explained the commonly used phrase ‘Eating is cheating’ amongst UK university students to my new Spanish friends, they struggled to get their head around the idea of drinking without food. The Spanish certainly know how to enjoy themselves and they seem in general much more relaxed as a population. It was often difficult to tell a Tuesday night from a Saturday night since the city centre was always filled with people enjoying their late evening dinners, followed by late night events aimed towards entertaining the younger crowd. It was easy to meet new people. Initially, social gatherings were difficult, mostly because it took some time for me to feel confident in my Spanish, and to get over my frustration of not being able to express myself as freely as I was used to. The reward of trying came afterwards, when it suddenly became easier and it felt that my language improved at an exponential

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European Placement – Madrid 2016

Hospital de Rey Juan Carlos

speed. After all those years of learning Spanish, it all finally came together and if the improvement of my Spanish was the only outcome of my European Studies Placement than it would still be worth it. It was difficult at times, and could sometimes get lonely, but my little temporary life in Spain, doing a placement in a Spanish hospital and GP practice and living with a Spanish family, was definitely a once in a lifetime experience which I will always remember. It was better than I could have imaged it would be. A large part of that is because I was lucky to meet these incredible people, but also because Madrid is very welcoming and endlessly fun: a grand summer city that carries its history and displays Spanish culture so beautifully. I have already made plans to go back.