This report was written by Ehsan Salim, a 4th year medical student at the University of Dundee, on his experiences during his period of elective study in Melbourne, Australia in Summer 2017. We were delighted to support Ehsan by awarding him the 2017 SCPN student bursary.
For my junior elective this year I went to Australia. After the exhaustive 20 hour plane journey I arrived in the small city of Adelaide, located next to the southern coast of South Australia. I quickly settled into my accommodation which was, very conveniently, in the city centre. The city has a lot to offer including beautiful beaches, national parks, hiking terrain and a large international population which adds a cultural vibe. Travelling around the city centre was really easy; the city has a free bus and tram service in the central district and you can also loan out city council bikes for free daily.
Adelaide, however, is also the largest city in the state and so has the largest institutions which included the Royal Adelaide Hospital (RAH) where I was based. The RAH was the only location in the entire state for many procedures which meant that I often met patients who had taken a flight to make their appointment. With a catchment area four times larger than the size of Britain there was a huge variety of patients coming through the doors; people from a variation of backgrounds, races and ethnicities with issues ranging from animal bites to alcohol abuse.
My elective was on the Gastrointestinal (GI) surgical ward. As the RAH was a teaching hospital, I was placed alongside local medical students which gave me the opportunity to learn more about their education system and its advantages. While on the ward I was able to join in all activities; from taking patient notes to participating (very limitedly) in surgery to attending video conferences.
What really surprised me was the large amount of cases that involved both the prevention and treatment of cancers. In the outpatient clinics, monitoring patients with GORD (Gastric Oesophageal Reflux Disease) and Oesophageal metaplasia was a regular practice. The surgeons would do endoscopy and take tissue samples on a nearly daily basis. Many of the patients were ‘regulars’ who were on a screening list due to their high risk. My supervisor explained the importance of this screening, stating that to treating established oesophageal cancer is not only much more expensive but also much more traumatic. This was something that I had learned in the UK but what I was not aware of was the difference in the challenges to such screening in Australia. On the ward, while taking medical notes from Mrs Cafferty (not her real name) before her endoscopy I came to find out that she was staying in a hotel after having taken a flight to get to Adelaide just for this endoscopy. My supervisor informed me that this was a common occurrence and posed a massive barrier to screening. Not only was the procedure uncomfortable to start with but it consumed a significantly higher amount money and time due to the lack of locally available centres which could do it. This added to discouraging patients from coming in for regular check-ups and Mrs Cafferty informed me that she had missed or cancelled several appointments in the past. The vast distance was not only a barrier to screening but it also resulted in many patients ignoring their initial symptoms until they became more severe – increasing the risk of cancer.
Australia currently has three screening programmes: breast, bowel and cervical screening. However, there are challenges to the success of these screening programmes, many of which are different from those in the UK. For example, when the bowel screening programme was initiated Australia there was a participation rate of about 40% as compared to 58% in England. A key factor that is thought to have caused this difference is the fact that patient and GPs in the UK are all NHS registered which means that centralised health boards can more easily role out policy than in Australia which lacks a similar nationalised healthcare infrastructure(1). Another issue that was pointed out by the Australian government was a low level of awareness about the prevalence of bowel cancer which is a problem in the more rural communities(2). One of the junior doctors informed me that when the government tries to increase awareness about things like bowel cancer or other conditions their campaigns would target mostly major cities and often people living in the more rural parts of the country would not be engaged as much.
I quickly learned that cancer is a major health problem in Australia. It is reported that 1 in 2 men and women will have cancer at some point in their lives by the age of 85 – in 2014 it was the second most common cause of death(3). During my elective I had a chance to spend time on other wards including ENT, Nephrology and Urology specialities. I saw cancer patients and their respective surgeries in each speciality. One of the most fascinating surgeries I observed was that of a middle aged man with oral cancer. The six hour surgery involved a laborious hemiglosectomy – excision of half the tongue – and dissection of the deep cervical lymphnodes in the neck with four specialist surgeons and several nurses on site. This was an incredible amount of resources being utilised simply to prevent the spread of cancer further, which really made the point that prevention is much easier – both for patients as well as healthcare providers.
One case that will stick with me was a patient who was diagnosed with bowel cancer. He had been taken in for surgery and on removal of the bowel section my supervisor was quick to ask me what type of cancer I thought it was. After several wrong guesses he told me that it was a metastatic melanoma cancer. The man had skin cancer that had not been picked up and treated in time. The more concerning issue is that despite skin cancer being the most common cancer in Australia (followed by prostate cancer) there are currently no screening programmes for this. A local medical student informed me that there was an excessive depletion of ozone above South Australia and with temperatures that can go as high as 35 – 40oC during summer the risk of damage was extraordinary. It was quite unsettling to know that just by living in this part of Australia I was automatically exposed to higher levels of radiation. With a majority Caucasian population, skin cancer is an issue that the government is now tackling by increasing awareness both in the public and the healthcare domains.
Another quite unsettling thing I came to realise very quickly was the massive negative impact that westernisation had had on the Aboriginal community. Frequently, as I travelled around Adelaide, I would see young aboriginals intoxicated in public, sleeping on the streets and behaving aggressively. More often than not, the aboriginals were from poorer socioeconomic backgrounds. Their long history of war, exclusion and even genocide (as I came to know of) had resulted in aboriginals feeling disenfranchised by the system. I learned that many lived in isolated communities and refused to engage with local government and institutions. This often resulted in very bad health inequalities in their communities. There was a recent report stating that aboriginal women are 16% less likely to survive breast cancer than their non-aboriginal counterparts. The main reasons for this are not seeking help early enough and another is not sticking with the treatment regime(4) – most likely as a result of the isolation of their community from the wider society. The positive aspect is that in recent history major steps have been taken to engage with the aboriginal population including giving land rights to communities and initiatives such as National Sorry Day.
It’s only fair to say at this point that I didn’t spend the entirety of my elective in the hospital. Australia is a beautiful, vast country with stunning wildlife and landscapes. I had the chance to go on a 3 day road trip with two other locals travelling 1200km from Adelaide to Melbourne along the great ocean road. We repeatedly stopped along the way to take in the natural sites such as tall rocks standing in the middle of the ocean 30 feet from the mainland (Twelve-Apostles) formed over thousands of years. Make sure you don’t miss the opportunity to go to a local zoo or wildlife park – feeding kangaroos and holding a koala bear are experience that you literally can’t have anywhere else. Going abroad for your elective is an experience I would definitely recommend to any medical student. You learn about another healthcare system, it’s challenges, it’s advantages but also about a different culture and community. It is a good idea to get stuck-in and take part in all you can but also make sure you leave time to travel and explore the amazing country. My final week was spent on the beaches of Sydney – sure it was winter but it was Australian winter and I would take that over any Glaswegian summer.
1. Cancer Screening – 5.1 Interpreting current participation rates [Internet]. Cancerscreening.gov.au. 2017 [cited 14 October 2017]. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/rev-nbcs-prog-pt1~inc-part~interp
2. [Internet]. 2017 [cited 12 October 2017]. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/rev-nbcs-prog-pt1~inc-part~imp-part
3. Australia C. [Internet]. Cancer.org.au. 2017 [cited 16 October 2017]. Available from: http://www.cancer.org.au/about-cancer/what-is-cancer/facts-and-figures.html
4. Breast cancer survivor encourages at-risk Indigenous women to get screened for the disease [Internet]. News. 2017 [cited 17 October 2017]. Available from: http://www.sbs.com.au/news/article/2017/10/03/breast-cancer-survivor-encourages-risk-indigenous-women-get-screened-disease