陳炳元 IFMSA-SCOPE (Standing Committee of Professional Exchange)

研習期間：97.07.01~97.07.31
研習學生：醫學院 醫學系 陳炳元
研習地點：以色列
研習類別：IFMSA-SCOPE (Standing Committee of Professional Exchange)

Since my official exchange program was for a one-month clerkship in the Chaim Sheba Medical Center in Tel Hashomer, Israel, my main focus here will be on my time spent in a general surgery rotation in the largest medical center in Israel.

I arrived the Tel Hashomer campus, located about 40 minutes by public bus from downtown Tel Aviv, on 2008/7/1 as initially stipulated in my contract. Finding the hospital was not simple due to bus stop signs only listed in Hebrew. However, a local female soldier (men serve three years; women one year compulsory service in the military) was very helpful and guided me onto the correct bus. Upon arrival in the “medical center”, I was simply overwhelmed at the sheer size of the complex: there were 3 on-site markets, 2 malls, several cafeterias and a full service hotel within the campus, about a 30-minute walk from end-to-end. After about an hour’s asking around I finally checked into my room in the nursing dormitory. I was the third to arrive; my roommate was not expected in until the 3rd. After settling in and grabbing a simple hummus sandwich, I reported to my assigned doctor, Professor Amram Ayalon, chief of the General Surgery B department (GS was divided into B and C departments). I was told to report the following day for morning meeting at 8 am.

Morning meeting was similar to ones held here in our Chung-Ho Memorial Hospital, with residents presenting surgical cases with subsequent discussion by the attending physicians and other residents focused on pinpointing issues worth learning from and requiring future improvement. These morning meetings typically lasted an hour and occurred every Monday, Wednesday and Friday. Tuesday and Thursday morning meetings were conducted in conjunction with the imaging department highlighted one or two special cases in which imaging modalities could have been of greater assistance in the pre-operative work-up, also similar to meetings held here in our hospital. However, since the meetings were conducted in Hebrew, it was very difficult to understand what was being discussed with the exception of the occasional medical terminology uttered, “blah blah blah… left hemicolectomy… blah blah blah… virtual colonoscopy.” Luckily, there were a total of eight students undertaking a clerkship in general surgery B at the time; two from Mexico, four from Hungary, one from France and myself, with the former six fluent in Hebrew and thus able to translate for the Frenchman Mikheil and I in intervals.

After morning meeting, Mikheil and I were assigned to a first year Italian resident named Gil with whom we would shadow in the following weeks on ward rounds. Two points were of great interest to me when observing these rounds. First was the use of portable laptop computers when doing rounds so that updated patient information could be readily accessed while instantaneously keying orders or procedures that needed to be performed on the patient. One such station is pictured to the right. While paper copies of the patient’s files could be found at the nursing station, all relevant tests, results, diagnoses, treatments, and responses could be easily retrieved with these electronic cart-stations. The second event of note that I witnessed was the performing of necessary procedures as the patient was checked on. For example, on the first day a patient was in need of central venous catheterization and after keying into the computer, materials were prepared and the procedure was performed then and there, without further delay. The only setback from such actions was that a typical ward round of just our assigned resident’s patients (average, twelve) lasted between three and four hours.

We first entered the operating room (OR) on the 3rd day of our rotation. Of note were the very advanced and complete equipment in their ORs. For example, their surgical tables were fully detachable so that the patient entered the OR on the “bed”, which could be “slid” onto the central bed stump without the patient being physically moved from the gurney. Also, the sheer size of the operating rooms was impressive. The photo to the right of me standing in the OR provides an idea of this. However, unlike many television shows where operating theaters are equipped with observation galleries, no such rooms existed here. Similar to the situation encountered in the morning meetings and ward rounds, the surgeons spoke predominantly in Hebrew and thus many of the fine details to the procedures being performed were incomprehensible. The attitude of the surgeons varied greatly, with one doctor very willing to explain the step-by-step approach he took during surgery, while the vast majority gave the impression that they’d much rather prefer if us students weren’t even present.

My greatest comment about what I observed in the operating rooms was the sheer lack of aseptic method by the nurses, residents, and surgeons alike. Similar to in our hospital, the circulating nurses are extremely vocal about students taking extreme care in observing sterile zones. However, unlike the situation I observed in our ORs, at least the nurses themselves abide by their own words. In Israel, on many more than one occasion I observed circulating nurses brushing up against “sterile” Mayo trays and the like. However, the most deplorable sight was watching nurses and surgeons both walk into the operating rooms without surgical masks and speaking openly. Only after noticing that students were in the room would they lift their scrubs to cover their mouths!! In addition, many nurses and surgeons would physically remove the 2 bottom straps on the surgical masks due to “discomfort”; however, this resulted in a taut covering over the nose with the mask completely loose over the mouth. In other cases, surgeons would simply only cover their mouths leaving their noses completely exposed. It was such a shame to see such well equipped operating rooms with such negligent operators.

All in all my 30-days in the Sheba Medical Center were a very good experience. Medically, I observed several surgeries that are rarely seen in Taiwan such as pilonidal cyst resections. In addition, I witnessed diseases that are also rarer in Asian populations such as Crohn’s disease.

Similarly, the number of hepatology patients was much less than in Taiwan. It was also interesting to note that I observed no oncology surgeries due to the presence of an entire oncological ward elsewhere in the medical center. This is in stark contrast with our oncological surgery ward in our hospital which basically focuses on port implantation and chemotherapy regimens. Also of interest is the fact that while Sheba consists of an extremely large campus, there are only a total of 1,700 beds as compared to the 1,600 located in our Kaohsiung Medical University Hospital! Nevertheless, it was a great learning experience to witness first-hand the distinctions in two medical systems both based on Western medicine. I strongly believe that any student or physician that has the opportunity to partake in such an exchange should do so for both self-improvement and continued development of his/her own hospital.