An Elective in South East Asia

Alastair Yap

Hong Kong

Queen Mary Hospital

Obstetrics and Gynaecology

Background

My 4 weeks in Hong Kong were spent working within the Department of Obstetrics and Gynaecology
at the Queen Mary Hospital. Queen Mary Hospital is the main teaching hospital of the University of
Hong Kongs Faculty of Medicine.

Daily Activities
My time at Queen Mary Hospital was very interesting and my timetable involved attaching myself to
a firm of local final year Medical Students who were undertaking their Obstetrics and Gynaecology
rotation however there was some flexibility to move between groups within the firm.

With 1,400 beds it is one of the biggest hospitals in the territory and is a tertiary referral
centre for the whole of Hong Kong and beyond.
The Department of Obstetrics and Gynaecology handles 8,000 admissions each year.
The department performs almost 4,000 gynaecological operations throughout the year and
handles 3,500 deliveries per year.
The department is also the tertiary referral centre for the whole of Hong Kong.
The purpose of spending time in Obstetrics and Gynaecology was to gain some more experience and
to observe the different attitudes towards healthcare compared to the UK.

Time was mostly split between Surgery and Clinics with more time being allocated to
Clinics. As a public hospital, and a tertiary centre, the department was a very busy one.
The local Medical Students really were at the frontline when it came to Clinics and were
given the responsibility of clerking each and every patient and then succinctly presenting their
findings before the patient was seen by the Consultant.
This proved to be great practice for all and absolutely necessary given the amount of
patients that were waiting to be seen.
Efficient clerking skills were a must and this was very well done, allowing the Consultants
to quickly gain a full picture of the patients history.

Key Differences
All the teaching of Medicine and the recording in the notes was done in English but history taking and interaction with patients was more of a challenge.
The patients seen in Queen Mary Hospital were from a variety of backgrounds and spoke a variety of mother tongues. Most of the local population speaks Cantonese Chinese as their first language
whilst a large proportion of patients had come down from Mainland China to receive a perceived better standard of care and all their consultations were done in Mandarin Chinese.
Whilst I have a fair conversational level of Cantonese and a basic working level of Mandarin, I nevertheless found myself having to spend the first week or so learning some of the medical
vocabulary since the female anatomy is not something which often crops up in conversation with family members or in language lessons!
I was very impressed by the local students abilities to take comprehensive medical histories in a variety of languages under considerable time pressure.
Whilst I was able to struggle through some history taking in Cantonese with a little help and encouragement from local colleagues and could just about follow most of the consultations in
Mandarin, I couldnt help but feel in awe at the fluency in three languages of the local students and perhaps even a little inadequate at times!
Fortunately my chance at redemption came when I was able to help out when a native Spanish-speaker from South America arrived in the Clinic and I was able to provide some translation.
The healthcare system in Hong Kong is different from that of the UK and is not free at the point of delivery. There two major grades of care; general class which is subsidised and is available to
all eligible residents and private class which is available to all at a cost. Most people, where possible, prefer to undergo private treatment, as it is perceived to be superior.
It was something of a culture shock to me, as having grown up with the safety net of the NHS, the concept of having to pay for things such as childbirth seemed slightly alien to me.
The costs of such services were not insubstantial with a General Class delivery amounting to hundreds of pounds and a Private Class delivery ranging from 6,000-10,000.
However one should bear in mind that levels of tax are rather low in comparison to the UK but this does mean that most people have savings as a contingency should they require medical treatment
although there are provisions for those who cannot afford to fully contribute towards their care.
Attitudes towards healthcare are consequently slightly different from those in the UK. The consultations are far more paternalistic. Patients come into the Clinic expecting to be told exactly whats
wrong with them and will readily take any medication prescribed with few questions.
There are also cultural differences when compared to the UK as attitudes in Hong Kong remain relatively conservative socially and some things remain a taboo, which brings its own set of unique
problems.

Traditional Chinese Medicine

There remains a significant proportion of the population who hold a strong belief in traditional
Chinese medicine and this can bring its own difficulties. When taking a medical history in Hong Kong,
when taking a Drug History, one must also remember to ask whether the patient is taking any traditional
or herbal remedies as these can have a variety of effects and alter blood results.
Herbs which promote the thickening of the uterine lining include: Perilla stem, fennel, and Radix
Achyranthis Bidentatae (Niu Xi- ). Conversely the root of the cotton plant Radix gossypium (Main
Hau Gen- ) may serve to thin the uterine lining.
Chinese herbs which may increase the levels of oestrogen include: black soybean, Chinese rhubarb
and red sage root amongst many others. The herb Artemisia anomala (Liu Ji Niu- ) can lower the
levels of oestrogen.

Reflections on my Experience
Overall my time in Hong Kong was enjoyable and rather different from what I am used to.
For the first time I started to think about the consequences of each test that was ordered,
whether it was necessary, and what it might show as each investigation would have to be
paid for by the patient or their insurance albeit often at a subsidised rate.
The paternalistic nature of healthcare in Hong Kong was also different, with patients
preferring to be guided in their treatment rather than discussing with the Doctor to create a
plan of treatment.
The experience made me think more about peoples beliefs and attitudes as well as social
and societal factors which can have profound effects on patients and their outcomes.

Singapore

Plastic Surgery
Background
I spent the remaining four weeks of my elective in Singapore. Singapore General Hospital is the oldest and
largest tertiary acute hospital in Singapore. It is one of the flagship hospitals of Singapore and has been in
existence in various forms since 1821, moving to the current site in 1926.
It is a government owned hospital with over 60% of its 1,600 beds allocated for subsidised patients.
Rather than a typical model of public hospitals, SGH is operated by a government-owned corporation
which is responsible for the running of the hospital.
The department of Plastic, Reconstructive and Aesthetic Surgery deals with a mixture of patients,
some of whom come from different parts of Asia to receive treatment.
The department also incorporates the Burns Centre which is the only specialised facility managing
burn injuries in Southeast Asia.
A major factor behind wanting to explore Plastic Surgery was the multidisciplinary nature of the work.
A wide variety of procedures were performed within the department each requiring different skills and
detailed knowledge of the local anatomy ranging from delicate skin grafting and flap closures in the burns
unit to breast reconstruction and facial microsurgery.

Daily Activities
Upon arrival I was issued with a detailed timetable which was well balanced and allowed us to observe and
experience a broad range of cases and procedures.
There was also the opportunity to sit in on some of the Private Clinics as well.
There were quite a number of other students on elective from all around the World working within the
Department of Plastic Surgery but there were no local students although we sometimes came across them in
theatres throughout the course of the day.
The range of cases was wide and varied and aside from the Burns theatre where skin grafts and flaps were the
bread and butter, there was no such thing as a typical list.
One particularly interesting morning list saw particularly long cases including breast reconstruction after
mastectomy and gender reassignment surgery.
Further to the timetabled activities, I was also offered the opportunity to learn some advanced suturing skills
on models.

Key Differences
All of the teaching was in English as were most but not all of the patient consultations. The majority of the local population in Singapore is ethnically Chinese and Mandarin is one of the official languages and so it is not
uncommon for consultations to take place in Mandarin or other dialects of Chinese if the Doctor is fluent and confident in the language.
Singaporean patients in general prefer a paternalistic system although the large (mainly European) expatriate population resident in Singapore prefer to have a detailed discussion in a manner we are more used to in the UK.
Singapore has universal healthcare system where the government ensures affordability of healthcare within the public health system, largely through a system of compulsory savings, subsidies and price controls.
Like the UKs National Insurance, Singapore's system uses a combination of compulsory savings from payroll deductions to provide subsidies within a nationalized health insurance plan known as Medisave.
Within Medisave, each citizen accumulates funds that are individually tracked, and such funds can be pooled and shared by families. The vast majority of Singapore citizens have substantial savings in this scheme.
One of three levels of subsidy is chosen by the patient at the time of the healthcare episode. Further to this, there are also additional subsidies subject to means testing.
A key principle of the Singaporean health system is that no medical service is provided free of charge. Even at the highest level of subsidy, a small charge is levied. This is intended to reduce overutilization of healthcare
services.
As a result of this many Singaporeans have supplemental private health insurance to cover all eventualities. This is sometimes part of the benefits package provided by employers.
The system appears to work with Singapore enjoying the joint lowest infant mortality rate in the world and among the highest life expectancies from birth.
Furthermore, government spending on healthcare amounting to 3-4% of GDP which is small compared to the 8.5% of GDP spent in the UK.

Traditional Chinese Medicine

As in Hong Kong, in Singapore there is also a great proportion of people
who hold much faith in the virtues of Traditional Chinese Medicine.
The demand for TCM is great enough that SGH set up a TCM clinic within
the Hospital in order to offer consultations and treatments to their patients.
The advantage of having an in-house TCM clinic is that when a patient
presents with a history of having tried TCM, it is easier for the Doctor to find
out exactly what has been taken and Physicians and Patients can be assured
of the quality of the ingredients used.

Reflections on my Experience

It was a valuable experience to be able to learn more about Plastic Surgery which is barely touched upon at Medical School. Although
clearly the techniques used are similar to those used in other surgical specialties. The variety and intricacy of the work undertaken was
certainly illuminating.
It was interesting to experience a different method of implementing a Universal Healthcare system. I felt that there is clearly some
merit to the system used in Singapore and the levying of a charge to discourage abuse of the system is interesting; however the worry is
that it may discourage those who genuinely need help from seeking it. Having said this, the health outcomes in Singapore would suggest
that this is not a major problem.
The implementation of a TCM clinic within the hospital itself is a rather neat solution to addressing the demand for TCM remedies
whilst also ensuring that there is a degree of quality control and record keeping which allows Doctors to find out what herbs and
remedies have been taken and avoid any adverse outcomes.