medicine – Page 2 – ToewsTravels

healthcare in israel

soroka hospital, beer sheva, isreal
where i attend medical school

israel has an excellent socialized healthcare system for its citizens, arguably one of the best in the world. early zionism was very idealistic and socialist, and quality and universal healthcare has always been a central theme. the current system uses an interesting model – it is single payer (the government), but there is an element of competition as well. there are three not-for-profit “sick funds” which receive a set monetary amount from the government for each citizen who is insured with them. the government requires that these funds provide a “basket” of medical services and treatments for their enlistees. for the most part, the basket includes what would be considered the standard of care in the western world. it generally does not include things such as procedures or treatments for aesthetic reasons or overpriced or experimental new drugs. typically only the generic version of a drug is covered as part of the basket if it is available. generous allotments for services like physiotherapy are also included in the basket. the lump sum payment to the sick funds for each patient, termed “capitation,” provides incentive for the fund to invest in preventative measures for its patients, as if they can keep them out of the hospital or prevent them from becoming sick in the first place then significant money can be saved. each fund receives money for their patients according to the same formula (age, gender, medical conditions, disability, area of the country in which they live, etc). in addition to the required basket of services and drugs, the funds can provide additional services as well to attract more patients/customers. citizens can choose their sick fund and can switch between funds at any time without penalty, and the funds cannot refuse to insure a patient. the funds are also the operators of the hospitals and clinics, which technically keeps the government out of the business of healthcare though there is obviously close collaboration.

though required healthcare is free for the citizenry, targeted fees are permitted that aim to reduce inefficiencies. for example, due to the universal problem of overuse of emergency rooms for minor issues, a fee was introduced for emergency visits that are not either first referred by a primary care physician or do not result in a hospital admission. likewise, a large levy exists for those who call an ambulance but are not subsequently admitted to the hospital. these efforts of course sometimes result in further inefficiencies, such as people feeling the need to first contact their primary care physician when they should probably just go straight to the emergency department, or doctors admitting patients when they medically don’t need it to help them avoid the fees. overall though it is a very fair balance that allows everyone to get the healthcare they need without having to go bankrupt to do so, and attempting to limit unnecessary overuse of the system.

of course, socialized care has its limitations. while it is excellent for the poor, the rich do not appreciate waiting in line, getting a generic drug rather than the brand name one, or not being able to hand-pick their surgeon. thus, over the last few decades a robust private healthcare system has developed in parallel with the public one. the merits and drawbacks of these two-tiers are beyond the scope of this blog post, but private healthcare has become a major sector of the israeli economy and a very contentious issue for all involved.

prioritization of the family is a major focus. things like maternity leave and government transfer of money to parents is a priority, as it is a strategic goal of the government to keep the birthrate high. so much so that invitro fertilization for all israeli citizens is free, at tremendous cost to the state.

emergency medicine and disaster response are huge in israel. due to everyone spending required time in the military, most people have some training in responding to emergencies, and many have firsthand experience from wars they have fought in. israel also sends medical teams to major worldwide disasters, either privately or as a military delegation, and are world leaders in this regard.

it must be noted that healthcare benefits extend only to israeli citizens – not to asylum seekers living in israel or to palestinians, except official east jerusalem residents. still sounds pretty good though, right? israel has its huge problems, but overall i’d say healthcare is one of its gleaming achievements.

match result!

“match day” – the most infamous day in a medical student’s life – was in march, and in june i’ll be moving to philadelphia, pennsylvania for the next three years! for those who don’t know, the match is a computer algorithm that correlates the rank lists of applicants and residency programs. the process starts with applications, and then (hopefully) interview invitations to specific residency programs in the fall, which one then ranks in order of preference. on match day, every residency applicant finds out at the same time via email where they matched for residency. the mathematicians who developed the algorithm won a nobel prize for their efforts! it usually works out for the aggregate best, but there are never any guarantees that one will end up at somewhere near the top of their list or of matching at all for that matter.

i am absolutely thrilled that i will be doing my residency in pediatrics at my first choice, st. christopher’s hospital for children, which is the pediatric teaching hospital for drexel and temple universities. the hospital is in north philadelphia, in the heart of the “poorest zipcode in america.” the patient population is predominantly african american and very underserved, which is tremendously attractive to me, as on the whole i will much prefer the inner-city to dealing with upper-middle class suburban anti-vaxxers. also thrilled to get to move to the great city of philadelphia! it is a better residency program than i deserve objectively speaking and i am so very thankful to God for this opportunity! all are most welcome to come visit!

geriatrics: never again

i’m back in israel. the last few months of medical school we’ll be doing four “selectives,” each being two week sections in different subspecialties. my first was geriatrics, which thankfully i will never again have much to do with in my life professionally. still good to know about on a personal level i suppose. the first week was in beer sheva, but the second week we were relocated to a wine-growing paradise between tel aviv and haifa called zichron yaakov! and the school payed for four of us to stay in a nice hotel! (that’s definitely the most generous thing my medical school has ever done for us). we were at israel’s largest geriatric facility, and got some great teaching. the israeli healthcare system is extremely well integrated and it is very impressive to witness the spectrum of the various levels of care within a multidisciplinary facility with the broad mandate of caring for the elderly.

an interesting sequela of israel’s status as a jewish state is how much say rabbis have when it comes to healthcare law. at the geriatrics hospital there was an entire building devoted to mechanical ventilation. in the rest of the developed world, people might be placed on a ventilator at the end of life, but if they are deemed to have lost brain function and the family agrees then they will typically be disconnected with little ethical equivocation. in israel however, once someone is intubated and placed on a ventilator, it is illegal to disconnect them for any reason if doing so would lead to respiratory distress, regardless of the patient’s prior wishes or the those of the legal proxy (also irrespective of the patient’s religion, despite this being an esoteric religious intricacy rather unique to judaism). what this means practically is that many elderly – basically just bodies – in vegetative states with no likelihood of a return to consciousness are kept alive on mechanical ventilators for indefinite periods of time. literally, this only happens in israel. an entire building of long-past brain dead elderly on mechanical ventilators, at tremendous cost to the state, for no reason other than that the rabbis say it should be so. this after watching otherwise healthy toddlers die preventable deaths in the philippines because the hospital doesn’t have any ventilators. after just returning from the philippines, i find it fascinating how this specific contrast could literally not be starker between any two other countries in the world.

the best part of the week was an inclusive breakfast at the hotel, with 30 types of cheese and made to order americanos on demand! my friend kady and i averaged about five americanos each every morning. also spent some good time in the hotel’s hot tub (a true rarity in israel)! we had a day off for the israeli elections, and a number of my classmates came up for some wine tasting organized by my friend jenna. we went to two unique wineries in the zichron yaakov area, israel’s wine heartland. also patronized a super-gourmet restaurant called uri buri’s in the seaside town of akko – i would never spend that much on a meal unless ladies made me do it but i must admit it was a gastronomic pleasure! it was match week so we deserved it:)

pediatric inpatient medicine – eastern visayas regional medical center

we spent half our time in tacloban at the regional tertiary care hospital – i spent the time in the pediatrics ward. interestingly, pediatrics in the philippines is the most challenging and draining rotation for medical students and residents, with malignantly harsh professors and the strictest of expectations. this is in sharp contrast to the general culture of pediatrics in the west. we had to sign in and out every day to make sure we were there for all of the required hours. the interns work 32 hour shifts every third day (q3 call) without any weekends or breaks, which is insane. we did these overnights sometimes but thankfully they didn’t make us do them every three days. then, in the morning, the young doctor’s verbal presentations were picked apart and absolutely destroyed by the attending physicians and director of the department, often with unveiled and unnecessary personal insults.

and this was one of the least sad things about the pediatrics ward. the place was grossly underesourced. not a single person used gloves the entire time i was there. there were often 10 or 20 patients and their families in a room, and privacy was nonexistent. when a patient died the family would be told and left to mourn in a room full of onlookers. while technically there is a government payment scheme that most in the area belong to since being struck by the typhoon, not much was covered. little things like caps for intravenous catheters or bigger things like certain drugs had to be purchased by the parents in the streets outside the hospital. in the pediatric intensive care unit when babies went into respiratory distress (which happened on a daily basis) they asked the parent if they could intubate, using the english term without any explanation of what that meant. sometimes the parent refused, nothing was done, and the baby promptly died. the parent almost certainly said no out of ignorance or misunderstanding. in the west, lifesaving interventions for children are done even if the parent does not give permission. in tacloban, even when the patient was intubated, there were sadly no ventilators. so the parent was expected to manually ventilate their child with a bag. no one from the hospital staff had the time to relieve the parent, and often there was no support to bring them food or water. so what would typically happen is that the parent would bag nonstop for 24 or 36 hours without food or water, and then give up, and the child would die. completely preventable deaths. and this happened almost every day. it is terrible.

one interesting program at the hospital was for rehabilitation of malnourished children. the program was funded by unicef. one mother brought in her infant who was obviously starving to death, and told us that she had been feeding him exclusively watered-down rice water since birth. the program pays for children like this to stay in the hospital until they are deemed rehabilitated enough to return home. the problem is, the issue will undoubtedly recur when the patient does go home. the family only earns one dollar or so a day and has 11 other children to feed. even the parents were subsisting off just rice. it’s a rough world when you don’t have resources. i suppose that is the moral of this story.

mayorga

i was assigned to another rural health unit for a week, this one in mayorga, two hours south of tacloban. the commute was a bit rough, squeezed into the back of a lurching hot, sweaty jeepney with 20 other commuters for four hours each day. the town is having a big push for “zero open defecation.” an obvious problem from a public health perspective is that people defecate in open areas when they don’t have anywhere else to go. so a big ngo brought in a bunch of toilets to install. now every house has a toilet, but without running water they aren’t as useful as they could be. the town actually employs inspectors who roam the villages looking for human excrement, and the villages lose out on funding if it is found. another cool public health initiative in the town are free regular zumba classes for everyone!

my commute each day brought me past the historical site of the leyte landing, which is where u.s. general macarthur first came ashore during the liberation of the philippines from the japanese at the end of world war two. the site is commemorated with bronze statues of the americans – wearing aviators – wading onto the beach. interestingly, tacloban was actually the capital of the philippines for a few short months at the end of the war, until manila was liberated.

we were invited a birthday party feast one afternoon in mayorga, one of many feasts thus far, which has been great. the hospitality is wonderful, but i’ve got to say that the food here is as unhealthy as you can imagine. filipinos eat white rice for every single meal. if they have the money, the addition will be pork; the fattier the better. at a more impressive meal, the rice will be supplemented with other empty carbohydrates, such as white wonder bread, chow mein noodles, rice cakes, and cooked cassava (for the uninitiated, similar to a baked potato except drier and with less flavor). the fatty pork will be supplemented with an alternatively flavored selection of fatty pork, fried chicken, and fried fish. absolutely never vegetables, which is disheartening. though the fruit is amazing, it is enjoyed by the average person as a rare delicacy maybe just a couple times per year. little wonder pretty much everyone here that is middle aged and older has rampant hypertension, diabetes and kidney failure.

while on the topic of food, i will end with a couple of the few bright spots. one is halo-halo, literally “mixture.” it is shaved ice soaked in sugary milk, topped with various selections of jello, ice cream, pieces of fruit, red beans, yellow beans, taro jam, crème de leche flan, and corn flakes. another is belut, a 14 day old chicken or duck fetus that is still in the shell. the fetus is killed when the egg is boiled, and the belut tastes best immediately afterword, doused with vinegar. seriously, it is delicious!

tanauan: hardest hit

i spent last week in the town of tanauan, about one hour south of tacloban. tanauan was the hardest hit area during typhoon haiyan, which occurred just over one year ago. a 20-foot storm surge, or sudden increase in sea level secondary to wind and profound changes in barometric pressure, swept over the town. it killed somewhere between 5% and 10% of the population. no one really knows how many people were killed, as there were many undocumented workers from other provinces who had moved there for informal work. the storm surge came in very quickly, moving one kilometer inland, demolishing everything in its path. the water moved back out to sea much more slowly, leaving rubble and dead bodies behind in the ditches. after a few days the dead bodies began decomposing and blew up like balloons. they were buried in numerous mass graves along the side of the road – many of the bodies never identified. some graves are marked with touching memorials; others are unmarked and will likely soon be forgotten. one mass grave is beneath the town square, which is now being revitalized as a basketball court. the town’s new official slogan is “every day is a better day in tanauan.”

i was assigned with the local interns, but their schedule was different this week than most. a massive medical mission was being held in the newly built civic center, led by a group of 40 volunteers from california. dr. gabriola, an internist at stanford, was in charge. five physicians from california and 15 from the philippines (as well as tim and i) saw 5000 patients over four days at no charge. most of the american volunteers were ethnically filipino, wanting to give back to the country of their youth.

though missions like this were clearly necessary following the typhoon, a critic could rip holes in the ethics of continuing to hold these types of events over a year later, when the local healthcare system is already back in full swing. we’re way past post-disaster medicine now; access to healthcare is now about the same as it was before the typhoon, and missions like this lack sustainability. critiques could include that a mission like this undercuts the livelihood of local healthcare professionals. but the interns enlightened me, telling me that the patients who attend these free missions are a completely different demographic than can afford to pay a physician. another critique is that many patients depend exclusively on these missions for issues they should be seeing a primary care physician for. for example, we saw numerous patients who experienced strokes, only to wait weeks for the next free medical mission to see a medical professional. of course, without the missions, some would see a doctor sooner, and some never would. undoubtedly, many of the patients were feigning “cough,” in an effort to procure free amoxicillin, believed here to be the ultimate cure for everything. and most of the legitimate medical concerns we saw were chronic in nature (hypertension, diabetes, etc), meaning that being seen by a different doctor every few months at a mission isn’t really doing any good.

dr. gabriola did actually have a very nuanced perspective on global health. she waxed poetically on the pros and cons of a major mission like this with tim and i, and it was quite inspiring. ultimately, in some contexts, perhaps such as this, the benefits of this type of mission may overshadow the drawbacks. but it should always be done as collaboratively as possible, and with the goal of strengthening the local system instead of competing with it. tim and i got name tags that said “dr” on them, more autonomy than we’ve ever had before, and tried not to give out too much amoxicillin.

the week ended with a good-bye party held by the town for the american volunteers, and we were invited. we traveled to the event hanging off the back of a jeepney; others were sitting on the roof of the speeding, swerving vehicle watching movies on their laptops. in what would appear to be filipino-american fashion, at the opulent event there were two full hours of speeches, followed by a presentation of a certificate to every single volunteer, all before dinner. the dinner was worth waiting for, though, as it included lechon, an entire suckling (hence fattier) pig cooked on a spit. then there was dancing, complete with dance instructors. i was unable to elicit who was paying for all this extravagance – the american volunteers or the town. it was unequivocally over the top for some people who volunteered for a few days. oh well, parties are always fun!

wild west(ern samar): torpedos, coconut wine and vote buying

i spent last week in the rural region of paranas, which is about two hours north of tacloban on the western edge of the almost entirely undeveloped island of samar. there is one town, but paranas is a vast municipality, roughly equivalent to an american county. it is the type of place where foreigners are required to meet with the mayor and the legislative assembly upon arriving, where mayors walk with limps because of past assassination attempts, and where the mayor hasn’t even been to some of the villages in his region because they are so inaccessible. yes, if you’ve noticed, everything is about the mayor.

after a refreshing hair-tousling ride from tacloban in the back of a pickup truck, i was ushered before the municipality’s legislative assembly for formal introductions. the dozen or so politicians sat in one of the only air-conditioned rooms for miles, on ornately carved hardwood thrones (a status symbol in these parts), and referred to themselves as “the honorable____”. that was just the legislative branch; next i needed to meet the mayor, who seemed like a great guy. later i learned that he payed everyone who voted for him in the last election the equivalent of $10. the guy he was running against payed $40 per vote. the municipality offers identity cards, but only those who voted for the current mayor get one. exclusively those with these cards are eligible for free municipality-sponsored raffles for televisions and new cars – all this in a place that claims not to have the resources to buy an ambulance.

while we were small-talking with the mayor a woman was brought in who had a bulging eye and desperately needed to travel to the nearest city for a ct scan. the mayor agreed to pay for it, presumably pending future favors. he peeled the required cash off the huge wad of bills that he pulled from his pocket. no one knows for sure if this is the town’s money or his personal benevolence; he’s doing a great job of giving folks the impression that it’s the latter.

the mayor spent an inordinate period of time assuring all present that the safety of this foreigner (me) would be sacrosanct. apparently western samar is home to some leftest rebels who may be interested in kidnapping a caucasian, or as the mayor put it, someone with such a “pointy nose” (to raucous laughter). he told me that i would not be allowed to to the barangays (villages) in the “hinterlands.” that is where we were panning to spend most of the week, so after the meeting i petitioned him to let me go and he relented.

the next day four great local interns (mel, jc, christine and karen) and i, along with a very flamboyant male nurse and a midwife hiked for two hours through the mud and waded through a thigh-deep river to an isolated barangay (village) called tipul, where we stayed for two nights. rubber boots were required, as the area has endemic leishmaniasis. part of the way i got to ride a carabao, or local water buffalo. the village’s dwellings were constructed of thatched palm and elevated from the ground on sticks. the village was full of of naked kids, stray dogs, roaming pigs and blaring taylor swift (they did have electricity). we stayed in the home of the barangay captain (the village political leader), where we slept on the floor on banana-leaf mats and pillows filled with rice and ate exclusively rice and fish broth for each meal. apparently they brought in the fish just because we were there, the implication being that all they usually eat is rice. even the rice was donated, as unfortunately the village has had a really tough time recently with their crops (predominantly rice and coconuts). according to the interns, the food we ate in the three days may have been the family’s food for the next month. we justified our sustenance by requesting more food aid for the village from the mayor upon our return. i carried in my own eight liters of drinking water, and it ended up being a good idea as there were plenty of folks with gastroenteritis from the village water source. all that water filled my backpack, so my only clothes were the ones on my back. gotta love putting on the same disgustingly sweaty clothes each day. no running water either. nothing makes you thankful for cold showers like no showers at all. the hospitality of the family who hosted us was profoundly humbling.

we held a medical “consultation” in the town square, dispensing an extremely small selection of medicines from the one box we had carried with us. most of the complaints were pediatric upper respiratory issues secondary to everyone having wood fires for cooking in their homes, and skin infections. everyone seems to believe that amoxicillin will solve any problem, including muscle pain and rhinorrhea. i got to see patients myself, with expert interpreting from the nurse. patients continued trickling in throughout the nights, and late one night some local men caught us some huge frogs, which we devoured in their entirety as part of a spicy coconut-based soup.

basically nothing is known about the health status of this community. no one knows what the leading causes of morbidity and mortality are, so part of the mission was to sign up and teach some new local health volunteers to fill out surveys to that effect. also to plan for emergency health events, which require the villagers to carry the sick in a hammock across the river and through the mud to the nearest road, at which point they need to send a messenger to send for transport as there is no cell phone service in the area. most everyone is illiterate – though there are teachers assigned to the village school, it takes them days to get there each week, such that classes end up only being held one or two days per week. one of the more concerning medical cases was an elderly woman with suspected pulmonary tuberculosis. this should be aggressively treated to prevent the infection of others, through direct observed treatment (dots). but the woman was too weak to walk to the clinic to get tested, and would not have the resources to stay for treatment. there is not currently anyone in the village who can administer dots, and there are even bureaucratic obstacles to collecting a sputum sample, so the case remains untreated. not cool.

we also held a clinic in the town of paranas. doctors (and everyone else) around here love to spend their afternoons drinking the local coconut wine, called tuba. a red bark is added to give a slightly bitter taste and a red hue. interestingly, it takes three years to grow a coconut, and while coconuts remain on the island of samar, none remain on the island of leyte (where tacloban is), as they were all destroyed by typhoon haiyan. in practical terms, in addition to more pressing concerns, this means no alcohol for the common man for the next couple years.

i stuck around samar for the weekend, and on saturday we took an excellent excursion two hours up a river in a “torpedo,” a 25-foot long narrow boat. there are three people manning the boat – one to drive it, one at the front to help steer, and a kid whose job it is to continuously bail out the accumulating water, as the boat leaks and also the entire trip was whitewater so we were constantly being soaked! at a point in the river there were some huge rapids, and we needed to disembark while the boatsmen expertly guided the boat through the rapids, using a pulley system set up for that purpose. we were able to do some swimming in the rapids as well! tula, the barangay (village) that was our destination, was heavily hit by typhoon ruby late last year, demolishing many dwellings and taking down lots of big trees.

after docking the boats, we still needed to wade through another river with knee-deep mud to get to the village. we brought along some vaccines, so i got to hone my baby-poking skills, just because we happened to be there! there was also a child there with hydrocephalus and an untreated meningomyelocele, issues i am very familiar with after a stint volunteering with a pediatric neurosurgeon in kenya prior to medical school. the required (partially corrective) surgeries would be free in the city, but his family doesn’t have the money for transport and accommodation once they’re there, so no surgery. he’ll probably die soon; profoundly sad.

this epic week ended with a saturday night trip to the local city, catbalogan, to our attending physician’s house, to sing non-optional late-night karaoke and to spend the night. everyone wanted me to sing until i started, then they wanted me to stop. i got off easy, as apparently when some people mess up a karaoke performance in the philippines they get lynched (multiple deaths after bad renditions of frank sinatra’s “my way”). we were fed the classic karaoking snack – sigsig, fried pig brains. an outrageous end to and outrageously amazing week!

filipino approaches to rural community health

the medical school we are rotating at here, the leyte branch of the university of the philippines, uses an interesting model. it has a special mandate to train primary care phyicians to work in rural communities. all its students complete a fifth year of medical school, one more than other medical students in the philippines. this year is spent as an “intern” in an assigned rural community, and major focus is placed on becoming an integral member of the community as opposed to just its physician. to attract students, medical education at this school is subsidized by the government and provided free of charge to the students, provided they pay back the time working in rural areas. prior to typhoon haiyan last year the school was based in the nearby town of palo, but the campus was completely destroyed, so it was moved to some buildings in tacloban which survived the typhoon.

this week all of the local class of interns returned to tacloban from their work sites to attend a training session on how to train community health workers. we were priveleged to be able to attend as well. the village units in the philippines are termed “barangay,” and it is at this level that many decisions are made, as government in the the philippines is in general rather decentralized, thanks to geographic isolation and countless disparate ethnic groups and languages. the intern’s focus is on developing good relations with the mayors and other leaders of the barangays, in an effort to address some of the social determinants of health – a preventative effort at the community level as opposed to simply dealing with individual’s acute health needs. the training session focused on how to give good presentations and effectively run a meeting while remaining cognizant of the best interests of all stakeholders. icebreakers and frequent dancing were a major theme. also discussed were strategies for identifying public health issues and how to go about fixing them using the community’s ideas. this was primarily in english, which all educated filipinos speak, thanks to the history of american occupation. often however, talk will trend into “taglish,” a combination of english and tagalog, the national language which almost everyone speaks. filipinos love acronyms, indeed even more than americans do. the medical system here, at least at this school, is profoundly non-hierarchical. the faculty and school leadership attended the training, and if we didn’t already know who they were we could never have guessed, as they were following orders and joking around just as much as the interns. get a group of filipinos together and there will be a joke told at least every 30 seconds, and everyone will laugh even at things which aren’t meant to be funny. people here love laughing, and its great!

6 month tour of ‘murca!

i came back to the glorious united states from the end of june until the beginning of january. on the schedule were four month-long fourth year medical school electives. first i did pediatric emergency medicine at morgan stanley children’s hospital, which is at columbia university’s new york presbyterian hospital in washington heights, at the northern tip of manhattan. i rented a room close to the hospital in the heavily dominican neighborhood, and frequently ran back and forth across the george washington bridge at night for awe-inspiring views of the manhattan skyline. this as well as the next elective were sub-internships, meaning that i was expected to assume the responsibility level of a first-year resident, which was a huge (but great) learning curve and kept me extremely busy. that first month i also took the clinical skills (cs) portion of step 2 of the united states medical licensing exam (usmle), which is a practical test in which you enter a series of exam rooms with actor patients who simulate a variety of medical scenarios.

my next elective was in baton rouge, louisiana, at our lady of the lake hospital, where i was on the pediatric wards basically 15 hours every day.

next i made a quick stop at home in alberta to pick up my car, as living in the south for a month without a car really reminded me of the value of wheels. then, to rady children’s hospital at the university of california – san diego for a month of pediatric endocrinology (and many long runs on the beach)! thanks to friends from the past kimberly and brian for being so welcoming! san diego was truly amazing, and i stuck around for a couple weeks after my elective to go to mexico and also to attend the american academy of pediatric’s (aap) annual conference, whose attendees included, among others, hillary clinton.

then i drove quickly back across the country to new york city, where i did an elective in dermatology at mount sinai – beth israel hospital in midtown manhattan, commuting daily from the cheapest place i could rent in caribbean brooklyn. then, i drove all around the country for a little over a month, attending residency interviews! they were quite fun. special thanks to all the people who helped me out by hosting me, like mrs breckenridge in san diego, will in phoenix, mayaan in western mass, isaac and camille in south bend indiana, ryan and jess in minneapolis, joel in chicago, mr and mrs burns in cincinnati, and a potpurri of motel 6s. even made the impromtu decision to go to kenya for a week for a family reunion! finally, it was home to canada for christmas, with about 30 000 more kilometers on my college-era honda civic.

obstetrics and gynecology, psychiatry and surgery, beer sheva

finally in about february i started my first clerkship of the year “at home” in beer sheva! i really loved obstetrics and gynecology. long nights of adrenaline. our soroka hospital in beer sheva has more births than any other hospital in israel, about 13 000 /year. the boss of the clerkship is one of the more iconic physicians in beer sheva and an extremely humorous individual -a type of person i’d like to become more like. except jokes like his would never fly from physician in the u.s. or there would be lots of lawsuits. but in israel the doctors have a lot more latitude for levity. after pediatrics ob-gyn was my favorite specialty.

the next clerkship was psychiatry. this was at a mental health center on the outskirts of the beer sheva. i must say the state of israel does phenomenally well when it comes to taking care of the mentally ill. i was fortunate enough to be placed in the inpatient adolescent ward. one day we watched the film “silver lining playbook” with all the kids; they already knew what bipolar disorder is all about. holocaust memorial day also happened to be while we were there and they had a very touching little ceremony, only with some of the interruptions one would expect in a mental hospital. the clerkship was dominated by a teen who was convinced she was demi lovato and could fly (off furniture and stuff). death threats. ethical discussions on forcible confinement. electroconvulsive therapy supervised by a guy with a big, greasy mustache. good times.

the final required clerkship of my third year of medical school was surgery, at soroka hospital in beer sheva. i am not a huge fan. i was also studying very intensively for the clinical knowledge portion of step 2 of the united states licensing medical licensing exam (usmle), which i took at the end of the clerkship, so admittedly that was more of a focus for me than the stuff going on in the operating room. then, all of a sudden, third year was over, and i headed back to the glorious united states for fourth year electives!