Sunday, August 31, 2008

A visit to The Royal Infirmary of Edinburgh.

My first visit to Scotland, and Great Britain. It was months ago when I decided to participate in the three-week 'English for Medicine' course offered at the University of Edinburgh's (pronounced 'yeh-dinbra') Institute for Applied Language Studies (IALS), and what made me do so was that I wanted to see the Division of Community Health Sciences and meet a professor named Dr. Raj Bhopal there to seek some advice about how I should pursue my area(s) of interest. Having interest in family medicine and public health with a clinical taste, I also wanted to take a look at how general practitioners (GPs) work and get a general idea of the health care system there.

As in other countries as well, the U.K. has both public and private hospitals, the former of which is run by the National Health Service (NHS), a non-profit organization funded by the government but independent from, paper-wise. Now, in Japan, patients have the freedom to choose the hospital or clinic they wish to visit. Whether it's your local clinic or a university hospital or the cancer center, it is basically up to you to decide where to go, however, this is not the case in Great Britain. If you become ill and wish to see a physician, unless you have a contract with a private health insurance company, which will allow you to have access to a private hospital, there are only two ways you can see a physician: see your GP or end up in the accident and emergency department (A&E). GPs are allotted a certain population in an area, meaning from the patient's point of view, you are automatically determined who your local health care provider is depending on where you live. Only when your health problem cannot be solved at the GP or A&E clinic that you first have the chance to see a specialist, in the form of referrals written by your GP.

A GP has two major roles: an expert in general medicine providing primary medical care, and a gatekeeper of resources. The former role includes not only the clinical part (inside the clinic and also visiting homes), which includes pediatrics, maternal health, referring patients to specialist hospitals, and follow-up of patients with chronic illnesses, but also a variety of other tasks for community health, such as prevention and health promotion, and sex education and family planning. But in reality, most of the GPs in populated areas only have time to do the clinical part, which can be understood from the fact that patients are made to wait an average one week from when you make your phone call to the point of your appointment. No wonder an increasing number of patients, who can afford, are choosing private hospitals. If you're referred to a specialist, it will likely add more weeks or even months to that.

The GPs' latter task, as a gatekeeper of resources, is in two perspectives. A GP has to prevent inappropriate use of treatments and 'control' the patients' demands, thereby saving financial resources, and also guide the patient to the right care they need, as in referring to the appropriate specialist, thereby saving human resources. However, because of this, there are many GPs who face a dilemma, as they are also the closest health care personnel for the patients, and speaking out for them is the basis of a GP's job.

So, when I had an opportunity to follow Dr. William MacNee, a consultant physician and professor of respiratory and environmental medicine at the Royal Infirmary of Edinburgh (RIE), I wanted to focus on not only how he interacts with the patients but also how he communicates, or exchanges information with the patients' GP, system-wise, as good communication is vital between the specialist and the GP as well in a health care system like the U.K. Oh, how do I know him? Well, Dr. Patrick Barron, the passionate professor in charge of the International Medical Communications Center (IMCC) at my university, kindly introduced me to him.

In a typical medical consultation here, the physician only jots down notes, instead of scribbling on the official medical records, which makes reading them a decipherment for others. After the patient leaves the room, the physician will read aloud and record on a tape what he wants written in the official records. The tape will then be duplicated, with one copy going to the patient's GP and the other to the physician's (or the department's) secretary for transcription on to the electronic medical records. The one going to the GP is labeled urgent (red) or not (blue). This system saves a considerable amount of time for the physician, though that means more work and some medical knowledge needed for the secretary.

The RIE is a specialist hospital, so there are no GPs, except for those in the A&E. Tracing its roots back to 1729 as the oldest voluntary hospital in Scotland, it was incorporated into the NHS scheme in 1948, and the current facility, located south-east of the city, was completed in 2003 for 190 million British pounds and boasts 900 beds. Due to its location, it also serves Midlothian and East Lothian. Adjacent to the hospital is the medical school of the University of Edinburgh, which the hospital has maintained close ties with for years. Some noteworthy features of the facility include a 24-hour A&E unit, the Simpson Centre for Reproductive Health, giving birth to 6,000 babies each year (largest in Scotland), and the Scottish Liver Transplant Unit. In the hospital's main hall are banks, eateries, a general store, a bookshop, a barber, and the patients' information center. Brochures and pamphlets covering a variety of topics, from information of diseases to informed consent, or self-help guides, such as how to deal with stress, can be found here and the good thing is all are free for the patient to take home. Very useful and interesting.

Finally, I would like to share some phrases and expressions I heard in the patient-physician interactions, especially from Dr. Gourab Choudhury, who is Dr. MacNee's registrar. I spent the morning following him on the day I was at the RIE. When a patient kept on complaining over and over about how her dyspnea was so severe, he used the phrase "Oh dear." several times. It's sometimes not easy to think about how to react when your patient keeps on complaining, and I thought this was a nice and simple way to express sympathy. Another phrase is "Let's take it on from there.", which he often used when he was finishing up the medical consultation. I often find it difficult to find an appropriate phrase to end the conversation with a patient, but here it is, a simple, convenient expression with a positive-thinking meaning and a touch of sympathy. :-)

Sunday, August 10, 2008

Oban and the Isle of Iona.

On a weekend in August this summer during my stay in Edinburgh, I had a chance to see the Scottish outskirts of the Highlands and Islands. That is when I visited the town of Oban and the Isle of Iona.

Built on a crescent-shaped bay on the Firth of Lorne, Oban is an important base for those who wish to explore the West Highlands and the islands of the Inner Hebridges in the western part of Scotland. It is a typical Victorian holiday town and has a lively nightlife scene throughout the summer, with good pubs and ceilidhs (pronounced 'kay-lees'), which is traditional Scottish dancing. A picturesque small town, and I mean small that you can virtually become familiar with all the nice cafes and restaurants in one day. And providing the weather is favorable, the view of the bay from the waterfront at sunset is simply beautiful.

On a morning, together with my friends, we walked down from our modest accommodation in Oban to the port, where we caught a ferry to haul us to the Isle of Mull. Our bus came with us too. Upon arriving on the relatively large piece of land, we hopped on the bus for a bumpy ride to Duart Castle, situated on the east side of the island. Home of Clan MacLean, it was built in the 14th century and went through several military conflicts like many other Scottish castles before being abandoned in 1751. It was restored in 1911.

After touring through the castle, we traveled down to the southwest tip of the island where another ferry was waiting for us, though this time the ship was small and the trip was short. Leaving the bus behind, we crossed the body of water over to Iona, an island regarded by many as a very special and sacred place because of the arrival here of St. Columba in 563 AD. Columba came from Ireland and was a descendant of the country's kings and queens. He established a Christian church here and soon began to convert the heathen Picts of Scotland to the Christian religion. Soon, Christianity spread throughout the land and its strong position was confirmed when Columba was granted the power to crown Aidan as King of Dalriada, establishing a royal line of kings and queens of Scotland. Simply said, Iona is the birthplace of Christianity in Scotland.

But even without considering that, Iona feels like an island that has a special something. I personally do not follow any particular religion, however, the island is so beautiful and peaceful that it truly calms you down and refreshes your mind, though of course, only if you have the weather with you. Sea water is so transparent here that you can see the ocean bottom from the deck of the ferry upon approaching the island's sole port. There is one village on the island which everyone calls 'The Village'. A few shops and cafeterias, the compact but sufficient port, and houses make up the village, though the island's Abbey is located five minutes from here by walking. The villagers say that until a couple of years ago, cars didn't even exist on the island. It is so small that you can walk to any corner. Roads wind between fenced but large pieces of hilly grassland, where sheep bask and graze in the sun. When you are walking, you feel as if time has stopped. Magnificent, beautiful, spectacular... it seems like any word fits to describe in some sense, but doesn't in another.

Oban and Iona... truly places I would like to visit again sometime in my life. :-)