Max Elwig

I wanted to go overseas during my elective period as I wanted to gain insight into both the differences and similarities in healthcare in the developing world. I had originally planned to spend my placement in Sri Lanka, which my friend and I had organised independently. But the plans fell through at the last minute due to in-country circumstances that were beyond our control.

We contacted Work the World and they managed to quickly put together a placement in The Philippines for us with only two weeks’ notice. In hindsight, I’m so glad it worked out the way it did because I think we had a much better time than we would have.

The fact that Work the World organises the finer details of hospital placement and have relationships with local hospitals is reason enough. The team on the ground knows the placements inside out and that helps you settle quickly so you can start getting the benefit of the clinical experience straight away.

All the hospital staff know who you are before you get there and they’re all enthusiastic about you being there. They’re all keen to get you involved as well, and I don’t think that’s necessarily something we’d have experienced had we ended up on our independently organised placement.

Another big benefit was that the Work the World planning experience was totally stress free. Independently organising our original placement took months. There were long periods of back and forth, waiting for approval and sign off of different aspects of the hospital experience we were looking for. There was none of that with Work the World — we put our interest in on the Thursday, had a phone call with someone from their UK office on the Friday, and we were on a plane two weeks later.

We just wouldn’t have been able to do something like that without the contacts Work the World has on the ground.

It wasn’t until we were boarding the plane that it really sank in that we were going to The Philippines for our elective. But the inductions and orientations start right away, so pretty quickly you feel confident in your new surroundings.

In the hospital

We had our hospital introduction, and that was a case of meeting the people we were going to be spending time alongside for the next few weeks. That helped us establish the relationships that ended up helping us get more from the clinical experience than we otherwise might have.

I went into the hospital with an open mind as I didn’t really have any expectations as such — I hadn’t had much of an opportunity to build any up given that my placement was organised on such short notice. And to some degree I wasn’t surprised by what I saw because the only expectation I had was that things would be different.

But there were things that struck me throughout the placement. When I was in the outpatient clinic for orthopaedics, we saw a real lack of privacy. In the UK we would see patients in separate rooms, whereas in our placement hospital in The Philippines there were patients anywhere and everywhere.

We spent some of our placement in surgical theatre as well. The scrub in protocol was a lot more lax than we’re familiar with in the UK. Back at home we are extremely thorough and the scrub in areas kept incredibly clean. This wasn’t so much the case in our placement hospital in The Philippines.

The other major differences were in the kinds of cases we saw and the stages at which they presented. A lot of people rode motorcycles — both bikes and tricycles and drink driving is much more common in The Philippines than it is in the UK. So there were a lot of RTAs resulting from bike and trike crashes. We saw plenty of fractures and other injuries resulting from these crashes.

There’s also a far greater number of diabetes patients in The Philippines. Especially late-stage cases where the condition hadn’t been treated, to the point where amputation wasn’t all that uncommon. Again, this is not the norm in the UK.

I spent time in ENT as well, and we saw some quite late-stage throat cancers and skin cancers on the face. In the UK these would have been treated long before they got to the stage we saw them at in our placement hospital.

Some of the conditions we saw were very directly related to culturally specific behaviours. One example was tongue cancers that were caused by chewing ‘betel nut’, a kind of nut that’s sliced and chewed across the country. It gives a boost of adrenaline, so people use it as a pick-me-up. Obviously this wasn’t something I’d seen back home.

I also had the chance to scrub into an ENT theatre that conducted minor procedures. We assisted under supervision and got the chance to use a nose endoscope to examine the patient. It was a great opportunity.

There was one patient who had tongue cancer, which we suspected was caused by smoking and chewing tobacco. We saw them in the clinic, and the next week we observed the operation for that same patient. It was great being able to follow this particular case because I hadn’t seen a tumour like it before in terms of its size. We couldn’t quite believe how long it had been left before being treated.

The operation itself was a huge procedure. They even had to go as far as doing a neck dissection to clear the lymph nodes. It was a 6 - 7 hour procedure. In the UK it would have likely been a much shorter surgery as the cancer would never have reached that stage to begin with.

A lot of these delayed presentations seemed to come down to money. Government insurance does cover some of the cost of treatments in The Philippines, but if the costs go past a certain figure, patients have to foot the bill themselves. The patient I mentioned above had obviously just lasted as long as they could until it affected their quality of life so much that they had to just go and get it sorted.

One other thing to note is that in The Philippines, there’s very little in the way of primary care. People can’t just pop to their GP to get a referral, they usually have to go straight to hospital. It’s a very different process.

People in the UK are quick to criticise how the NHS is run, and take issue with things like waiting times. And to a large extent they’re justified in their opinions. But when you go somewhere like The Philippines you really get to appreciate how lucky we are here in the UK.

The other bit of perspective I gained was from the doctors’ point of view. In the UK, doctors have to pull long shifts, and that has been a bone of contention for some time. But in The Philippines, I saw staff regularly throwing down 24-hour, sometimes 36-hour shifts with scarcely a break in between. One of our supervisors worked four days back to back, and for three of them she was on call for 24-hours. This was all due to staff shortages.

There’s so much more I could say, and the whole clinical experience really opened my eyes and has changed the way I’ll approach practice.

Outside of placement

The experience in the Work the World house was great. I think this is what makes Work the World so much better than organising something yourself. When we first got there, there were 20 of us starting at the same time — 7 American nursing students, 4 Canadian medical students, my friend and I from the UK and 6 physio students also from the UK.

It was a good mix, and at its busiest the house had over 40 people in it. We had radiologists, midwives — there were so many students from different disciplines. Meeting people on different healthcare courses was great and we learned a lot from each other while we were all in the house together.

The social experience in general was really what sold Work the World to me. Our first few evenings we explored the city to get our bearings. The staff in the house gave us plenty of tips too. There were plenty of hotels with swimming pools we were able to use. Of course we went to lots of different bars and restaurants in the evenings. We even found a driving range, which was good fun if you’re into that sort of thing.

During the weekends we got out of Iloilo and did some bigger trips away. The first weekend we went to Boracay, which is an island off the coast. Twenty of us stayed in the same hotel, and it was a bit of a hassle to organise but it ended up being exceptional fun. We all got to know each other really well.

The second weekend we travelled to Cebu and swam with whale sharks, went canyoneering, swam in waterfalls, went snorkelling and saw sea turtles… We really packed the adventure in.

We got to see a lot of the country, and there was so much to do it was difficult to know what to spend our time on.

I spoke to friends who chose to stay at home rather than travel abroad for their electives and this perspective shift is something they’ve missed out on.

I think the biggest takeaway from the experience was a greater appreciation of what we have in the UK. When you’re working hard and faced with the trials of practising day in, day out in the NHS, it’s so easy to forget what the system is good at. I spoke to friends who chose to stay at home rather than travel abroad for their electives and this perspective shift is something they’ve missed out on.

You can imagine what it’s like, but you’ll never really know until you’re there seeing it for yourself.

I can certainly say I gained more confidence in my ability through the experience too. Being able to ask local doctors good questions and demonstrating my skill and knowledge helped me understand the breadth and depth of what I could and could not do.

Discovering that I could navigate a healthcare system in which English isn’t the first language was another big confidence booster. Getting this kind of experience is critical in a profession like mine where you’re working with patients all day. Being able to understand and deliver information is an enormous part of the role, so being able to do that non-verbally is a great test.

If you’re feeling hesitant about whether or not you want to travel for your placement, I’d just say that travelling with Work the World is the best way to do it. You get such a good introduction to the country and then to your placement hospital. Everything is so easy, and you can feel confident from the start knowing that you can ask a member of the in-country team any question at any time — they’re from the country and are a treasure trove of wisdom.

I should also say I do still feel like we had plenty of autonomy. There was lots of help available, but it was never overbearing and we were free to explore our independence.

And again socially, the atmosphere is brilliant. You’ll meet so many different people who are in exactly the same boat as you. No one had done a trip like this prior to doing it with Work the World and so we were all on the same footing. Even if you’re travelling alone, you’re not going to be by yourself.