Elective in Liverpool – Experience Report – Neurology

1. Februar 2018 at 09:47

by Vineet Dhery

Vineet Dhery

Introduction and History

My elective placement took place at the NHS Trust Royal Liverpool Hospital in the city of Liverpool in England. Liverpool lies in northern England on the Mersey River and is the administrative capital of Merseyside county. It is located approximately 50 km from Manchester.

The Health System

Healthcare (NHS= National Health system) in the United Kingdom is managed separately in England, Northern Ireland, Scotland and Wales, each having their own systems of publicly funded healthcare, funded by and accountable to separate governments and parliaments, together with smaller private sector and voluntary provision. As a result of each country having different policies and priorities, a variety of differences now exist between these systems. Despite separate health services for each country, the performance of the National Health Service (NHS) across the UK can be measured for the purpose of making international comparisons. The total expenditure on healthcare as a proportion of GDP in 2013 was 8.5%, which is below the OECD average of 8.9%. These 8.5% are considerably less than the percentages spent by comparable economies such as Austria (10.1%), France (10.9%), Germany (11.0%), Netherlands (11.1%), Switzerland (11.1%) and the USA (16.4%).

A big difference compared to European hospitals is that the NHS is working with a target based system e.g. over 90% of the patients visiting the Accident and Emergency (A&E) unit should be seen and treated within 4 hours. If a hospital trust cannot reach these targets, it will be fined by the health ministry. Another difference is that the hospitals are organized as trusts and work separately from other hospitals unlike the Wiener Krankenanstaltverbund (KAV) in Vienna, my home city, where all hospitals have a common budget und have to follow policy-based directives. Every patient who is a legal resident in the UK has free of cost access to the NHS, which is solely tax funded unlike Austria.

Due to the ageing population, cuts of health funding as well as recruitment difficulties, the NHS is nowadays under considerable strain, especially in the winter months, where hospitals are confronted with high numbers of patients. There is fear (Labour party) that the NHS will be taken over by private companies in the future.

The Beatles statue

Registration

As this elective was part of my ERASMUS semester, I had to apply via the International Office at the Medical University of Vienna. As there were only 4 placements each year, the slots were distributed primarily on base of university grades/achievements in the previous year. The European commission supported me via the ERASMUS program with approximately 330 €/month.

 

My Placement

My elective placement was in the NHS Royal Liverpool University Hospital. The hospital is a purely tertiary healthcare institution, rendering specialized and highly specialized services to medically referred patients. However, the hospital also contains an Accident and Emergency (A&E) department which receives acute emergencies from the nearby area of Merseyside, which is a metropolitan county in North West England compromising five boroughs (Knowsley, St. Helens, Sefton, Wirral, and the city of Liverpool), and according to hospital sources is the biggest of its kind in the UK.

During the elective period I spent four weeks in the neurology department and four weeks in the AE (general) medicine department. During each of these placements I joined one of the consultants or professors.

My accommodation was a privately rented terraced house 1 km from the hospital. The rent for my single room was around 350 Pounds for one month. In total, I spent around 800 Pounds for these 4 weeks excluding costs for travel like my flight tickets (cost Vienna-Manchester 200€). I shared the house with fellow students from Austria, Germany as well as one Bulgarian IT student. I made very good friends with these students and also learnt a lot about the culture in Bulgaria, as well as how medical education differs. Outside of working hours we also spent time together exploring the UK.

(c) Vineet Dhery – House we rented

The system of medical education at Liverpool University is slightly different to that of my home University in Vienna, Austria. Final year students on each ward split the patients between each other and are expected to attend the ward each morning, visit their patients, write follow-up notes and find blood/investigation results from the previous day.
The registrar/consultant then does a daily ward round. If any further investigations are ordered, it is the responsibility of the intern (Foundation Year I doctor = junior doctor who just graduated from university) and the student to see that these took place concisely and that the results are delivered to the patient’s file in a timely fashion. Generally, it can be said, the IT systems in comparison to Austria, Switzerland or USA are quite old fashioned and outdated (use of Windows 99/2000 on many computers).

Being responsible for your own patients is something which I had never fully experienced in Austria before as a clerkship student. It was very rewarding and very captivating as well, as I became truly involved in patients´ care. I also began to feel a sense of companionship with the patients, many of whom I saw every morning for many weeks (especially e.g. those with Guillain Barre syndrome or meningitis).

Practice presentation of patients on ward rounds

Medical students in Liverpool are very integrated with their respective clinical team and actively participate in patient care. I was given many opportunities to present patients on ward rounds in front of consultants and professors.

This experience boosted my confidence and I now feel more able to present and make valued contributions to ward rounds and ultimately contribute to the overall care of the patient.

Practice helps to improve competency of neurological examination

View of Birkenhead skyline across the Mersey river

There was plenty of opportunity for me to practice my examination skills under the supervision of registrars and consultants. It was interesting to see different techniques used for eliciting certain signs such as the Babinski reflex. At the end of my placement I also sat the neurology practical examination with the UK students and received excellent feedback on my performance.

My experience in the UK has shown me how examination of the patient is an art which must be practiced thoroughly. One must gain years of experience to elicit certain subtle clinical signs. Being taught and being able to practice clinical examination of the neurological system by the professor of neurology Dr. Pietkiewicz at Liverpool Walton Centre was a particular highlight for me, and it was very enjoyable to watch a master at work.

Practice Lumbar Puncture

In Austria I have had little opportunity to perform a lumbar puncture. For this reason, I decided that a good goal for my elective would be to perform a number of lumbar punctures. I mentioned this fact to my registrar on arrival and gave him my mobile telephone number. My registrar or nurse practitioner then rung me on a number of occasions, firstly to simply observe him conducting lumbar punctures and then to perform them myself. I now feel competent in performing lumbar puncture independently and am aware of the indications and contraindications of the procedure. I am also more able to interpret the results of cerebrospinal fluid analysis.

As well as lumbar punctures, I also practiced several other procedures which will be useful for me as a medical student and future doctor. These included phlebotomy and venous cannulation, catheterisation as well as ophthalmoscopy & arterial blood gas sampling.

Conclusion

Liverpool on the Mersey River from Birkenhead

My elective was an extremely enjoyable and educational experience. I feel that I have learnt a lot about medicine, but also a lot about myself. I have experienced not only a different health care system but also a different culture and way of life. I feel this has broadened my horizons and made me more knowledgeable about the world. As a doctor I will meet people from all over the world, and my experiences on my elective have whet my appetite for this opportunity.

Unfortunately, our group of 4 students from Vienna will be the last students coming to Trust Royal Liverpool Hospital: Due to the Brexit decision both universities have decided to cut their ties as the ERASMUS program will most likely not be available for the UK after 2019.

Interesting websites


Here you can download the experience report as PDF file.

If you are interested in working abroad as a medical student or doctor, click here for more information.


Published in GI-Mail 02/2018 (English edition) and 05/2018 (German edition). Sign up for GI-Mail here.  

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