Impressions of Cambodia
Lindsey Jones - medical student from Sydney Medical School, won the Carl Jackson Scholarship in 2015, and undertook an Elective from JanuaryFebruary 2016
The Sydney Medical Program Elective Term is an exciting time for many students – a time for travel, personal growth, and education. I was very honoured to receive the Dr. Carl Richard Jackson Scholarship in 2015-16 and began planning my trip to Cambodia almost immediately.
My first placement was at the National Paediatric Hospital in the heart of Phnom Penh. The professors were extremely keen to teach and the medical students were very welcoming and eager to share their knowledge while practicing their English. Furthermore, the patients and their families were grateful for the medical attention despite the sometimes-desolate conditions in which it was delivered. With my time split between respiratory, gastroenterology, and surgery, I was able to see a wide variety of cases and was often offered hands on experience. Some of the most notable cases included the surgical and medical management of third degree burns, an alveolar bone graft for the repair of a cleft palate, and multiple incidences of Osteogenesis Imperfect.
My second placement was also located in Phnom Penh at a medical clinic run by One-2-One Cambodia. One-2-One is a NGO that focuses specifically on providing for the poor and vulnerable populations of Cambodia. Furthermore, One-2-One has a holistic approach that attempts to address all determinates of health by providing educational programs, dental programs, vocational programs, and physical movement programs. My four weeks with One-2-One was an eye opening experience in that the majority of clinics were conducted in the alleyways of the slums of Phnom Penh. Hygiene in this setting was a major barrier to effective delivery of health care. Nevertheless, the mobile clinic came armed with generous supplies of masks, gloves, and anti-bacterial hand-wash. I was fortunate enough to fully engage in parallel consulting via the help of a volunteer translator. Unfortunately, the care we could provide is such setting was rudimentary at best. Referrals to further services were often ignored due to lack of time, lack of transport, and lack of money. While many of the inhabitants of the slums presented with malnutrition, anaemia, and poor dentition, three of the most interesting cases for me were 1) a case of untreated, chronic uterine prolapse and 2) an undiagnosed case of cerebral palsy in a two year old boy with a known ten minute post birth hypoxic event and 3) a severe case of domestic violence in which a young boy was brutally whipped.
Before setting out on the elective, I had made a personal goal of immersing myself in the local culture and seeing as much of the country as possible. I’m happy to report that I was able to achieve this goal, although it made for a jam-packed schedule. I learned of the tortuous history of Cambodia by visiting the Killing Fields and Toul Sleng Genocide Museum and was even privileged enough to talk with survivors of the Khmer Rouge about their experience. I became friends with the owner of my guesthouse and with my tuk tuk driver, learning about their culture and religious beliefs and the struggles of living in a poverty stricken country. I visited the Phnom Tamao Wildlife Sanctuary where I fed wild animals while hearing stories of poachers and illegal animal trading. I made daily excursions to the local markets, honing my bargaining skills and experiencing new foods, such as the Cambodian 20 day salted egg. I visited the beautiful beaches of Sihanoukville and enjoyed a boat trip out to the island of Koh Rong. I travelled to Siem Reap to experience the wonders of Angkor Wat and toured the floating villages on Lake Tonle Sap. I also visited my local pagoda, Wat Ounalom, where I chatted with a monk about Khmer Buddhism and life inside the monastery.
As a 2015-16 recipient of The Dr. Carl Richard Jackson Scholarship, I cannot begin to express my gratitude to the Jackson family for providing me with such a wonderful and enriching opportunity. I want to thank the entire Jackson family, especially Mrs. Jackson, for all of their support, advice, and interest in my life and my future career.
Lauren Smith - medical student from Sydney Medical School, undertook an Elective in Cambodia in 2014-15
The two months that I spent at the Children’s Surgical Centre (CSC) in Phnom Penh changed my perspective of medicine and taught me more than I ever thought possible in such a short time. I saw pathology that I would never have the chance to see at home. I also saw common pathologies through a new perspective, which no doubt enhanced my knowledge and broadened my ability to manage cases in Australia. However the exposure to disease and how it is dealt with in Cambodia was not the area in which I learnt the most. Working with limited resources, effective leadership, decision making skills, the necessity of continuing education, and the politics of international aid were all areas that I felt my elective benefited immensely. I also gained an appreciation for the culture of medicine in Australia.
Cambodia has faced immense challenges over the last several decades. The genocide perpetrated by the Pol Pot regime targeted the educated, leaving a medical system which is still heavily reliant on international aid today. CSC has been in operation for over 16 years, offering free care to poor Cambodians and training Khmer staff. In the two months I was there, there were at least five international teams that came to assist through operating and training. The centre takes maxillofacial, burns, reconstructive plastics, ENT, ophthalmology, and complicated orthopaedics cases. They also facilitate other specialist cases when international volunteer surgeons are available.
The most challenging aspect of my elective was coming to terms with some of the unexpected cultural phenomena in Cambodia. It was also difficult to see cases that could have been prevented if they presented earlier, or which would be treatable in Australia but not Cambodia. Certainly I was filled with frustration with how little I could contribute as a student, and this renewed my vigor to study medicine, that I may be more helpful the next time I go.
During my time in CSC I got to know many of the staff and appreciate how hard they work and how desperate they are to make their country better. The doctors work long hours and often train overseas away from their families, many of the scrub nurses are at medical school on the weekend, and yet they went out of their way to include me in patient care and make sure I got to see other parts of the country while I was there. I would highly recommend this placement to anyone interested in surgery and international medical aid.
I am extremely grateful to the Jackson family for making my elective experience possible through the Dr Carl Richard Jackson Scholarship. This family’s generosity and commitment to Cambodia has provided me with an invaluable medical education.
Christine Lim - medical student from Sydney Medical School, undertook an Elective in Cambodia in 201415
The two months I spent in Cambodia were eye-opening, heart-warming and provided a great outlook on human life and how medicine integrates into it. Poverty is rife in Cambodia, their lives are tough and people make do with what they have. There were countless times during my stay where I felt incredibly fortunate to be born in my family, live in Australia, study Medicine and have the opportunity to complete an elective in Cambodia. I am immensely grateful to the Jackson family for their generous scholarship (Dr Carl Richard Jackson Scholarship) that allowed me to gain an incredible experience and insight into Cambodian healthcare and its people.
One of the key cultural lessons I will take away is that the successful practice of Medicine is different in different settings. Cultural sensitivity is of utmost importance as a foreigner in order to gain a patient’s and colleagues’ trust. Health is perceived differently in different parts of the world and differently by individuals. In order to be attuned to their patient’s health goals, a doctor needs to have cultural sensitivity to gain a better understanding of their patient. Seeing how Medicine is practiced in a developing country has taught me to be open to new perspectives to the practice of Medicine.
The practice of Medicine in a resource-limited setting such as in Cambodia teaches you
the importance of clinical medicine. The doctors taught me to rely on basic medical principles/ signs, clinical experience and good judgment to treat patients. The limitations placed on these doctors also provided an avenue for innovation. Their resourcefulness was something I really admired about them. For example, I saw how they recycled plastic water bottles to be used as spacers. Despite these limitations, the doctors were always able to use humour and laughter to relieve their pressures. With their smiles and welcoming nature, I always felt like a part of the team.
The biggest challenges for me were the different standards of Medicine I witnessed there to what we are used to back in Australia. Compromises have to be made due to resource limitations. It was heartbreaking to see children presenting with advanced presentation of diseases due to fear of Western medicine and lack of financial support. Malnutrition and communicable diseases (dengue, parasites, etc) were common presentations. I was lucky to have spent 4 weeks in an NGO (Angkor Hospital for Children) – which provided free treatment, had better funding and could support more expensive investigations and treatment, and 4 weeks in a public hospital (National Paediatric Hospital) – patient-funded unless they came from low income families. This allowed me to compare and contrast the different systems. It highlighted how valuable the role NGOs play in the healthcare system in Cambodia.
There were times I felt out of my comfort zone, due the unfamiliarity of environment, language barrier and challenging medical situations however the medical students and doctors were always ready to help translate or lend a hand. It was great to see their dedication to their work and how they did their duties to the best of their abilities with what was available to them.
I would once again like to sincerely thank the Jackson family for this fantastic opportunity to experience Medicine in beautiful Cambodia and to all the Cambodians I met for all the wonderful memories.
Kate Hulme - medical student from Sydney Medical School, undertook an Elective in Cambodia in 201415
I had a wonderful experience in Cambodia and I would definitely recommend the country as an invigorating and unique elective experience. During my time at the National Paediatric Hospital, my most valuable medical experience was during my infectious disease rotation. On the medical wards of this hospital, one must rely almost solely on clinical examination and history taking skills alone. There are next to no investigations available except for a routine blood count. This meant that, under the guidance of locally trained Professors, I needed to diagnose and manage sick children using only my examination skills and the brief history that could be translated (in broken English).
Due to the very late presentations of disease I became familiar with a number of eponomous signs that I had only read about in a text book and also saw uncommon paediatric infectious diseases such as Measles and Typhoid fever, rarely seen in Australia. Unlike Australia, Cambodia also has a number of tropical diseases such as Dengue Haemorrhagic Fever that made up the majority of our patients. In my time at NPH I became very familiar with the diagnosis and management of these diseases and certainly had to thoroughly practice my history and examination skills. This was even more challenging given the often frightened sick children and anxious parents who usually speak only Khmer.
Understanding the attitudes of the local people towards western medicine was one of the most important cultural lessons that I learnt. As I spoke with my medical student colleagues it became clear to me that western medicine is not widely accepted, nor is it readily available in Cambodia and most parents believe that unless their child has a cannula and fluids running, regardless of the illness, that this meant the doctors didn’t care about their child. It was also important for me to show respect to my supervising Professors by always introducing myself formally and asking relevant questions when I could.
However, at times, asking questions and understanding the answers was very challenging as only a handful of doctors and students spoke English and my attempts at Khmer were often laughable. This language barrier also meant that there were few situations where I felt comfortable to perform a less familiar procedure because often I couldn’t understand the supervisors very well. As a result, I often communicated with staff through food as they brought me new fruits or dishes at lunch and patiently taught me their names. I am very grateful for the kindness and patience shown to me by all the staff at NPH and it was their small gestures of friendship that made my elective unforgettable.
For students who are keen to visit Cambodia on elective in the future, I would also recommend investigating the other NGO hospitals in Cambodia such as Kanthabopal and the Angkor Hospital for Children in Siem Reap.
Sally Plunkett - medical student from Sydney Medical School, undertook an Elective in Cambodia in 201314
It is difficult to imagine what the people of Cambodia have endured in the country's most recent history - from the genocide at the hands of the Khmer Rouge during the 1970's, to the extreme poverty people continue to suffer from. It is with great gratitude that I thank the Jackson Family for awarding me their incredibly generous scholarship, offering the opportunity to undertake my elective placement in Cambodia and to gain insight into what healthcare and life is like in this developing nation.
My first placement was based at Helen Bonner Health Centre, part of a growing non-government organisation called New Hope Cambodia (NHC) which offers free education and healthcare and sponsorship to poor and underprivileged people in slum villages on the outskirts of Siem Reap. Part of my work in the clinic involved taking a history and examination with a translator, before patients were seen by the clinic doctors and prescribed free medicine for their illness. The most common clinical presentations I saw included checkups for hypertension, diabetes, thyroid disease & gastritis & reflux symptoms, in addition to acute upper & lower respiratory illnesses. As access to diagnostic investigations were limited, I found this a great opportunity to practice my history taking and examination skills, and also develop skills with working with a translator.
My favourite experience at NHC was being able to visit patients while they were in hospital and then following them up in the village after being discharged, gaining an insight into both how the public hospital system works and the extremely poor living conditions in the community. During my placement there were many other volunteers in the clinic, social outreach program and school which meant I was able to make lots of new friends. Thanks to my family and friends back home, I set up a fundraiser page and we were able to raise some funds for the NGO. Without a doubt, I would highly recommend undertaking a placement at New Hope to prospective students doing elective in Cambodia. Other placements I considered in Siem Reap included Angkor Children's Hospital and the Lake Clinic Cambodia (although you need to get in early).
My second placement was based at the government-run National Pediatric Hospital (NPH) in the busy, capital city of Phnom Penh. I spent four weeks in the surgical department and was able to see many interesting congenital cases in general & orthopedic surgery in the operating theatres, on the ward and in outpatient clinics. Some examples of cases I saw in theatre include orthopedic fractures, ano-rectal malformations in a newborn, biliary atresia, meningo-encephalocele and spina bifida, in addition to a theatre entirely dedicated to cleft palate and lip repair, which I was able to observe and at times assist in surgery. Clinics were also very interesting and worthwhile attending including a general outpatients clinic everyday, and weekly orthopedic, abdominal and cleft palate clinics.
Unfortunately doctors in the public hospitals are paid a very minimal monthly salary, and as a result many choose to work in private practice in the afternoons, meaning placement hours are limited to the mornings. Sadly patients have to pay for their surgery and care whilst in hospital, different to Australia where care in our public hospitals is free. Amazingly, almost all equipment in the theatres was re-sterilisable - from the gowns, drapes, and surgical tools, again very different to that seen in Australia. Overall it was a great insight into the public hospital system in Cambodia. The staff in the surgical department were very welcoming and all the surgeons were able to speak English and were very good at teaching. I'd definitely recommend 4 weeks of placement in the surgical department at NPH.
Placements aside, it was a great opportunity to travel and learn much about the rich ancient and modern history of Cambodia from the Ancient temples of the Angkorian era, to the horrific Pol Pot regime in the 1970's where it's estimate 2 million Cambodians died at the hands of Pol Pot from torture, murder or extreme malnutrition.
Once again, I'd like to sincerely thank the Jackson family for the amazing opportunity to complete my elective placement in Cambodia, with thanks to the generous financial support of the Dr Carl Jackson Scholarship. I hope that one day I will be able to return as a qualified doctor to offer whatever help to the poor and underprivileged people of Cambodia. I have had many memories from my elective placement which will stay with me forever.
Loren Besley undertook an ILA with the National Pediatric Hospital, Cambodia in 201314
Cambodia has a recent dark history that has directly affected a large portion of the current population. Despite this, the locals welcome you into their country with a warm smile. There is a strong sense of hope and community and they are passionate about rebuilding their country and moving towards a bright future. In the midst of regenerating itself, Phnom Penh is a city of diversity. In one direction there are children playing with rubbish in the muddy river banks and their parents fishing for their next meal, while a glance on the other side shows pristine new hotels and restaurants brimming with tourists and wealthy Cambodians. Motorbikes are family vehicles (with as many as 6 people on one bike) and it is quite normal to eat a fried cockroach or tarantula from a roadside vendor.
The years of repression during which Pol Pott and his followers killed a majority of the doctors in the country have had a huge detrimental effect on the health system which is now beginning to recover and show promise with a flock of doctors passing through the training program who are eager to assist in any way they can.
My time spent at the National Paediatrics Hospital in Phnom Penh was filled with mixed emotions. I spent my time in the general surgery, infectious disease and neonatal wards. It was heartwarming to see cleft palate repair surgery on a 4 year old girl and a neonate discharged from hospital following recovery from beri beri. On the other hand it was incredibly saddening to meet a child with nephroblastoma who had presented to the hospital too late due to a lack of awareness and whose parents were unable to afford treatment. I learnt that this is quite a common occurrence in Cambodia. I was able to sit in on orthopaedics team meetings in the morning and join ward rounds as well as classes focused on relevant topics such as Dengue fever. Although the language barrier was challenging at first, I quickly learned that many of the training medical students know some English and are eager to practise their skills.
I am grateful to have been given to opportunity to attend a series of baby screening clinics in the rural countryside in which Professor Vuthy (the head paediatric surgeon at the NPH) directs a program which aims to provide training to local nurses for an efficient and thorough physical health check of newborns and young children. The screen is to assess for congenital defects such as spina bifida and microcephaly, and other conditions such as malnutrition and rickets that unfortunately still commonly occur in Cambodia. Rural areas in particular still suffer from poor access to education, sanitation and clean water and resultantly the health of Cambodians living in these areas is much less than in the cities. With limited resources and a lack of money for diagnostic tests (Cambodians do not have health insurance provided to them), doctors must rely much more on their physical examinations and histories taken from their patients and their intuitive skill has inspired my future practice.
Thank you so much for the incredible opportunity to experience a country so rich in culture and gain an insight into a medical system which is scarce in resources but which they make up for in passion to make a difference. It was a humbling and enriching experience that will impact my practise as a doctor in the years to come.
Elissa Calderwood - Sydney Medical Student, undertook an Elective in Cambodia in 201314
I completed my elective term in Cambodia, with the kind assistance of the Dr Carl Richard Jackson Scholarship from the Jackson family. The first four weeks was at the National Paediatric Hospital in Phnom Penh. The second four weeks was in the rural province of Takeo, working with an NGO called Women’s Health Cambodia.
The National Paediatric Hospital is a large children’s hospital, originally set up by World Vision and a number of other charities, but now funded and run by the government. All the doctors are Khmer, and there are a lot of local medical students. The doctors and students all speak some English, and were very keen to practise it with us! We were warmly welcomed, especially by the surgical department, where I spent two weeks and learned the most. My other weeks were in the HIV/AIDS ward and the Neonatal ward.
I learned a lot during my time at NPH, mostly about the differences in healthcare and medical training in Cambodia compared with Australia. There is a distinct lack of resources there, which showed itself in many ways. One example is the wards and theatres had limited amounts of equipment and supplies that we are used to having in Australia, such as gloves, hand sanitiser, oxygen saturation monitoring, and electronic IV fluid pumps. It was interesting to see how they functioned without these things. The medical training is also a bit different- for example it is all in French! The medical notes were written in French as well which made things interesting. I saw many interesting clinical cases, especially in the busy orthopaedic clinics. Cases that stand out include bone tumours, hip dysplasia, cleft palate repairs, hernias and hydroceles, traumas, oesophageal atresia, phimosis and dilatation, and HIV/AIDS opportunistic infections.
In the second half of the elective term I went from the crazy pulsating chaos of Phnom Penh to a quiet sleepy village in Takeo province. It was a welcome relief to get out of the city, which can be quite demanding for tourists, and into such a laid back and friendly little town. I felt like I was in another world, with cows wandering down the streets, people living in bamboo huts on stilts, riding everywhere and carrying everything on their bicycles, and surrounded by rice fields on every side. I was living with the translator, driver and cook from the NGO. The local food that the cook whipped up for us every day was delicious! We were a happy little team, and managed to get on well even though the translator and I were the only ones who spoke English! I did manage to pick up a little bit of Khmer by the end.
The translator and I spent the mornings at the small hospital (Prey Kabas Referral Hospital), where I saw a mix of the maternity ward, the clinic, and the inpatient ward. The common presentations seemed to be chest infections and gastroenteritis, TB, and some traumas. Anything major was transported to the bigger hospital at Takeo Hospital or Phnom Penh. It was a privilege to be present in the first moments of some tiny babies’ lives, but also challenging to see how the management of labour and childbirth is quite different and not up to the standards we would expect in Australia.
Most afternoons we would go in the back of the tuk tuk out to the surrounding villages to do home visits with new mothers and babies. It was an amazing opportunity to get a real insight into the way people live there. There is still a lot of superstition and old wives tales- for example putting pepper or the ash from incense in the baby’s umbilical would help it “heal”! The families loved having us visit, and often the room would fill up with all the cousins, neighbours kids, aunts and grandmas. On one visit there were five older ladies and fifteen kids watching!
Living in Cambodia was challenging and exciting, and I learned about living in another culture and what it means to be a foreigner. I had many experiences on elective that I will never forget, and I was stretched in ways that I would not have imagined. I would recommend going to Cambodia if you are up for a challenge, for being immersed in something completely different to everyday life, and for getting a real insight into people’s lives and healthcare in this fascinating part of the world.
Joshua Serov - medical student from Sydney Medical School, undertook an Elective in Cambodia in 201213 on a Dr Carl Richard Jackson Scholarship
The two months I spent in Cambodia on Elective were the most challenging and eye-opening months I have experienced in medicine. Seeing and experiencing the country in and outside of the hospital gave me a new appreciation of the challenges faced in delivering universal health care. My hospital placements at Preah Ket Mealea Hospital, in Phnom Penh, and the Angkor Hospital for Children, in Siem Reap provided me with two different experiences into health care in Cambodia. Spending two months in this vibrant and complex country had a lasting impact on me which I will carry throughout my career.
My first experience of Cambodia was flying into Phnom Penh. For the first 24hours I was in a constant state of bewilderment. It is as beautiful as it is eye-opening. Considering the terrifying traffic, crowded markets, bustling tuk tuks and newly built sky scrapers, it is a city of contrasts. My time spent in Phnom Penh was a crash course in Cambodian culture. I was lucky enough to have locals show me the surrounding temples, palaces, markets, countryside and riverside. Seeing the varied ways in which the population lives allowed me a glimpse into Cambodian culture. The most memorable visits were to the Choeung-Ek Genocide Museum and the Tuol Sleng Genocide Museum; both provided a vivid account of the time when the Khmer Rouge were in power. The lessons I learned while living in Phnom Penh were important to my time in the hospital as they gave context to the patients I saw and spoke with.
Phnom Penh: I spent four weeks at Preah Ket Mealea Hospital organised by the Rose Charities. The majority of my time was spent with the fantastic Maxillofacial Surgical Team. Days at the hospital began with attending the morning consultant meetings and hearing the important cases of the day. Following this I would attend surgeries in the maxillofacial department or in the general hospital theatres, where I could watch urological and neurosurgical procedures. Outside of these hours I was able to attend numerous private polyclinics, the Rose Charities Rehabilitation Centre and the Rose Charities Sight Centre. This enabled a very informative and important look at the various levels of Cambodian health care.
Siem Reap: The last 4 weeks of my elective I spent at the Angkor Hospital for Children. (AHC) AHC is a non-profit paediatric hospital in Siem Reap run in cooperation with the Cambodian government. It has about 50 beds, depending on the season; the emergency department can see over 400 patients each day. At AHC I undertook three rotations, in the inpatients department, emergency and critical care unit. Most of the staff spoke English which meant I could have full involvement in patient care. The senior doctors taught in English and the junior doctors were extremely welcoming. It provided a huge amount of experience, with a large amount of late presenting conditions, and was an excellent model on how to provide the most health care with limited resources.
My elective experience in Cambodia was a very eye-opening and humbling one. The interaction with patients and doctors in the hospital showed me a side of medicine I hadn’t seen before. The disparity in resources and healthcare between Australia and Cambodia was a good lesson to learn at this stage of my training. To see how well the doctors were able to treat their patients despite the limitations inspired me to make sure the skills I learn in Australia are transferable to a situation with limited resources. I think the time I spent in the community was invaluable to the whole experience. Understanding the social situation assisted immeasurably with my understanding of the patients' conditions and presentations. Endless thanks to The Dr Carl Richard Jackson Scholarship and the Jackson family for their support and to all the doctors and students who shared their experiences and country with me. It was an amazing and life changing experience.
Tom Morley – medical student from Sydney Medical School, won the Carl Jackson Scholarship in 2012, and undertook an Elective from January–March 2012
As a fortunate recipient of the Dr Carl Richard Jackson Memorial Scholarship, I completed my medical elective term in Cambodia over the summer of 2011–2012. Conveniently, I had previously been involved with two Australian non-governmental organizations (NGO) operating in remote and rural areas of Cambodia. Although my elective was completed as two separate placements over a total of 12 weeks, I’ve chosen to reflect in depth upon the broad experience of the working in the health services in Cambodia. Describing and reflecting upon the two experiences with such radical word limitations would do no justice to the experience of what I have witnessed and had the privilege to be involved in.
Kampong Speu is one of the 24 provinces in Cambodia, situated to the west of the well-known urban epicenter of Cambodia, Phnom Penh. Famous for its production of palm sugar and palm wine, the province is rapidly developing to house some of the country’s many expanding industrial and manufacturing facilities. It was in a humble village within this economically booming province that the first of my placements was completed under the guidance of the Australian NGO LifeOptions. This organization identifies itself primarily as one concerned with health education, committed to responding to the requests and requirements of local community health workers. By working with a Khmer partner NGO, LifeOptions aims to collaborate with the workers’ understanding of the health related issues affecting their own communities.
In stark contrast to Kampong Speu province, the second of my engagements took place in the tropical villages surrounding Battambang city, located in Battambang province in the north west of Cambodia. Known by many as the rice bowl of Cambodia, Battambang is the main region of the country that remains to be affected by landmines. The city is home to uncountable NGOs concerned with safe disarmament of the area, such as the Mines Advisory Group (MAG), as well as many providing relief to land-mine victims, for example the Italian Emergency hospital. Facilitated by the Australian NGO Hope for Cambodian Children Foundation (HfCCF), this placement saw me visiting varied settings from the ill resourced Battambang referral hospital, district hospitals and health centers to the exorbitantly priced private clinics.
There were very few aspects of my clinical experience that left me feeling disappointed. As I had attempted to prepare for, there were numerous clinical and non-clinical events that left me cringing, just as there were many that left me in awe. An example of the latter is the resilience of health workers to often function with inadequate training, inadequate support and inadequate resources. Attempting to perform in the conditions under which these staff work led me to appreciate that the practice of western medicine, with the privilege of almost unlimited resources, is of very little preparation for the practice of medicine in developing countries. The ability to consult, diagnose and treat with either no laboratory investigations, or limited options that were prohibitively expensive and delayed, was astounding. Having trained in a western system that places immense emphasis on evidence based medicine and defensive practice, the game of trial and error with patient health was a one that I was uncomfortable playing. The rules of this game seemed to be very much up to interpretation by the caregiver, with grave consequence for a poor performance.
the time that I spent working in the health services in Cambodia, there is a unbelievable number of events that have had a profound impact not only on my understanding of the practice of medicine, but also on my understanding and appreciation of the vital importance of public health. Of the many realizations I had throughout my time working in what I can only describe as challenging conditions, by far one of the most significant was a newfound appreciation of the incredibly intertwined nature of clinical health services, public health practices and socio-economic development. Although not an easy task, extrapolating and adapting the theoretical study of international public health and development from both university curriculum and independent study has been one of the most enriching experiences of my education to date. Moving from theory to practice is a challenge in clinical medical education and is in no way different for public health. I feel that no extent of preparation through theory can compare to the firsthand experiencing of these critical situations.
Louise Greenup – medical student from Sydney Medical School, won the Carl Jackson Scholarship in 2012, and undertook an Elective from January–March 2012
Thank you very much to the Jackson Family for the opportunity to undertake my elective in Cambodia over the Summer of 2011/2012. I spent time both at the Children’s Surgical Center (CSC), Phnom Penh and the Helen Bonner Health Clinic, Siem Reap. This experience will hopefully prove to be the beginning of an enduring relationship of myself with a fascinating nation; plagued by decades of unthinkable torture yet strong, optimistic and determined to regain its footing on the world stage.
I was first based at the Children’s Surgical Center, Phnom Penh, a hospital which provides free rehabilitation to disabled and very poor Cambodia children and adults. Clinical specialties at the Children’s Surgical Center include ophthalmology, orthopaedics, plastic and reconstructive surgery and maxillofacial surgery and I was fortunate to be spend time in each of these areas. A key aim of mine was to gain surgical experience and I was able to assist with surgeries for repair of congenital malformations, e.g. cleft lip/palate, club foot, release of constriction bands; reconstructive orthopaedic surgery; hip replacements; vesico-vaginal fistula repairs; flexion contracture releases and tumour excisions.
Between surgeries, I thoroughly enjoyed time in the wards with the children. The children were delighted with the paper, pens and stickers I had taken with me to entertain them during their hospital stay. Even the adults were keen to get involved and we found many budding artists amongst the patients.
During my time in Phnom Penh, I also visited several clinics attached to the Children’s Surgical Center, for example the Cambodian Acid Survivors Charity which was established to rehabilitate survivors of acid burns through physical and occupational rehabilitation, pressure garment manufacture and psychological counselling services.
In addition to an eye-opening and inspiring clinical experience, my time in Phnom Penh afforded me a fantastic social life and times of relaxation. Most of all, I enjoyed getting to know the people of Cambodia. I became friends with many locals and had the unique opportunity of learning from many of them how the Pol Pot regime affected their lives.
My second placement was at the Helen Bonner Health Clinic, Siem Reap, a part of the Non Government Organisation, New Hope. In addition to the health clinic, New Hope consists of a school, training restaurant, farm and outreach centre. In the four years since New Hope’s inception, the health of villagers has vastly improved in this time though many challenges remain.
My placement coincided with the volunteering of several Australian doctors which was fortunate for me as I was able to benefit from their supervision and teaching. The clinic was a great opportunity for me to develop history and examine skills. We were fortunate to have interpreters to make the language barrier less of a challenge. One of the most valuable aspects of my placement was being part of the medical response unit team. This team consisted of a social worker, a doctor, a translator and a driver and was called out to attend emergencies in the surrounding villages and market places and to undertake outreach services. The emergencies not only provided me with practice of primary and secondary surveys in a community setting with limited resources but also demonstrated rather significant problems with the health system in Cambodia, including corruption and lack of resources.
Thank you again to the Jackson family for their generous scholarship to help medical students complete a placement in Cambodia. The value of this scholarship in nurturing a genuine interest in the health of Cambodia should not be overlooked and its potential role in aiding the long term provision of medical services to this great nation should be congratulated.
I spent six weeks at a non-governmental organisation (NGO) hospital in Phnom Penh known as the Children’s Surgical Centre (CSC) which provides free surgery to disabled Cambodian children and adults.
It almost goes without saying that an elective at CSC is suited to students who are interested in surgery as it is a small hospital that focuses on orthopaedics, plastic surgery and ophthalmology. In fact the hospital is mainly just four rooms – the operating theatre with 3 tables next to each other, the small recovery room, the ward and the consulting room. I was expected to scrub for almost every operation and most of the time I found myself much more actively involved in the surgery than I would be back home. The main conditions we operated on were fractures and associated complications, acid burn contractures and cleft palates. From an anaesthetics point of view, I learnt how to perform intubation as well as epidural and spinal anaesthesia. There were also some visiting anaesthetists from the USA and the UK who came for a few weeks each to teach the local staff and I learnt quite a lot from both of them. One of them even organised for myself and 2 other medical students to run a teaching session on advanced paediatric life support for the medical and nursing staff.
Overall, my time at CSC was a mixture of emotions - at times it was sad and frustrating and at others it was enjoyable and satisfying. For example, it was immensely satisfying to watch cleft palate repairs yet really sad when young patients with bone tumours had no access to chemotherapy because they couldn’t afford it. Seeing patients with acid burns is always shocking no matter how many different cases you see, yet it was nice to see the patients smile after the plastic surgeons performed skin grafts to improve their function and appearance. It was frustrating seeing patients with relatively simple problems that were presenting at more serious and advanced stages because they had tried Khmer traditional medicine or couldn’t afford the trip to hospital. We saw countless patients with complications such as Volkmann’s ischaemic contracture that resulted from inadequate treatment of simple fractures. Despite such frustrations, the positives certainly outweighed the negatives and every Cambodian patient I met was very appreciative of the free high quality surgical care they received at CSC.
The staff at CSC speak English and they are all very friendly and welcoming. I forged many memorable friendships with the staff and my respect for them has grown after I began to understand the challenges involved in providing complex surgical care in Cambodia. I was very impressed with the efficiency of CSC as an organisation and the ability of its staff to get the job done despite its relatively limited resources. For example, I observed several complex scoliosis surgeries that were not only done on patients with particularly severe scoliosis but the surgeons had to use a mixture of older generation equipment because it’s all that was available. Another example was when I joined a weekend medical outreach clinic in Kratie - a rural province approximately 5 hours away from Phnom Penh. Whilst we were there we set up a temporary clinic in a school to provide primary care, eye care and women’s health services to people of all ages. Importantly, there were also areas devoted to health education and provision of basic health supplies and multivitamins. The trip was unexpected and it turned out to be one of the highlights of my elective. It was hard work, starting at 7am and in scorching heat with very few resources – just clinical acumen and a range of medications. I feel that these experiences of practicing medicine with fewer resources are valuable and indeed one of the benefits of doing an elective in a developing country.
My time in Cambodia turned out to be a fantastic grounding experience as the people are incredibly stoic and often very poor - many live off less than a dollar a day. At this level of poverty, many of the patients had poor access to so many things we take for granted including clean water and adequate food and shelter let alone the opportunity to travel to Phnom Penh to seek medical care. I certainly gained a new perspective on life and a new found appreciation for what hardship really means. Cambodia, and its smiling people, has found a place in my heart. I will return.
Andrew's placement was supported by a generous donation from the Jackson family in the form of the Dr Carl Richard Jackson Scholarship.
Alana Lessi – medical student from Sydney Medical School, undertook an elective at the National Paediatrics Hospital in Cambodia in 201011.
My first impression of the National Paediatric Hospital (NPH) was one of diversity. On my first day I began on the respiratory ward, where Dr Cheung was in the middle of conducting a teaching ward round in English, French and Khmer all at once! He was interactive and the students were clearly enjoying being pushed to come up with on-the-spot hypothesis for their patients’ states of disease.
Patients at the NPH ranged from financially comfortable locals of Phnom Penh to extremely poor families from distant provinces. I observed that these different socio-economic groups responded differently to disease and the help at hand. Local families were more likely to have sought medical help before presenting at hospital, and seemed more confident in the treatments offered at NPH. On the other hand, families from the provinces often presented as a last resort. Presentation had often been delayed because the family had been unable to identify the difference between an every-day injury or illness and a potentially life-threatening situation. In addition, the notion of illness as a form of punishment hindered such families from taking measures in disease prevention. The disparity in education, and the role of public education in population health became very apparent to me.
As more Sydney elective students arrived, we realised that the key to learning at NPH was finding a student or resident with good English. This obviously benefited my history taking, understanding clinical discussions etc, but it also allowed me to offer something in return. Thanks to my fellow-student translators, my knowledge of orthopaedics, tropical diseases and infectious diseases has vastly increased. In return we were able to provide them with an approach to learning about a clinical – and back it up with information-seeking from reliable sources.
Finally, any elective student visiting Phnom Penh should attend the annual Mekong Sante Conference, held in January. 2011 was the second Mekong Sante conference, and delegates included surgical, medical and public health consultants form all over Cambodia and several international presenters. Mekong Sante provides an insight into the current targets of local public health efforts and the difficulties of administering healthcare in a country where basic population data is only now becoming available.
I came away with a strong sense that in healthcare at least, international efforts are not in vain, and that progress is certainly being made. I would most sincerely like to thank the Jackson family for assisting me to undertake an elective in Cambodia – a place that I am already making plans to return to, contribute to and to learn from.
Alana's placement was supported by a generous donation from the Jackson family in the form of the Dr Carl Richard Jackson Scholarship.
Costa Boyages – medical student from Sydney Medical School, undertook an ILA at the National Paediatric Hospital in Cambodia in 2010-11
"Doing an ILA placement through the Office of Global Health at the National Paediatric Hospital in Cambodia was inspiring and humbling in equal measure. I was attached to the surgical team under the guidance of Dr Yuthy - an American trained surgeon who, unlike many doctors of his generation, had survived the Khmer purges of the professional class.
Cambodia is still achingly poor, riven inequity. This leaves little money for health in a state hospital like the NPH. The difference between medicine at the NPH and western hospitals is stark and largely a result of the discrepancy in resources: doctors at the NPH are more generalist, less reliant on expensive diagnostic techniques and mostly very young given the population explosion in Cambodia and policies in the 1970's which tried to turn Cambodia into a self-sufficient peasant agrarian society.
As first year medical students, we were conscious not to overstep our capabilities. We would observe procedures and consults. We were able to give back in small ways for example assisting young doctors (mostly trained in French) to write notes in English. Despite the learning environment being quite different, we all learned a great deal over the three weeks of our placement. Dr Yuthy and his team had an impressive range of clinical skills and would very generously take the time to translate and explain the presentation/pathology to us in English between consults.
Clinically, the cases were as varied as they were exotic including a gastroschisos surgery. Clubfoot, motorcycle accident trauma and scholiosis featured in the orthopaedic presentations very often. It was humbling to see the stoicism and cheer with which many Cambodians approach life. Equally, the resourcefulness, good humour and fighting spirit of Dr Yuthy and his team was impressive. "
"The doctors I worked alongside in Cambodia are the most inspiring I've ever met. In a system where there simply is no money for medicine, I watched as the surgeons joked with each as they made traction devices from cardboard and bandaging, as they used garden-shed pliers to remove pins, and wooden mallets to carve out bone and correct foot deformities. They never complained, quite the opposite, theatres were always filled with laughter and good humour, and they made me feel like part of the team. To me this felt like real medicine, using clinical experience and good judgement to treat patients, where resourcefulness is the greatest commodity you have. Many of these doctors had survived the Khmer Rouge, many of their patients were suffering the sequelae of a country torn apart and the massive loss of resources, especially health resources, that followed.
From the doctors I learned so much, the best way to perform a cleft palate repair, how to approach the diagnosis of congenital deformities, surgery from the bread and butter of hydrocele repair all the way up to treatment of Hirschprungs disease. I learned about diseases that I'd never heard of, and I saw the heartbreaking consequences of an ill-equipped ICU. I learned just how lucky we are in Australia to have our health system - Cambodia is still heavily reliant on NGOs to help a lot of their citizens. Best of all, I learned how to maintain good humour in any situation. With a lack of resources, extremely ill patients and burning heat, Khmer doctors, indeed Khmers in general, are always ready for a laugh, and are almost never without a smile. As a future doctor, the perspective this elective gave me, on medicine, and life, is something I will take with me forever. The good humour and resourcefulness of my mentors will make me a far better doctor than I would have been without this elective. They say that Cambodia changes you, and whoever they are, they are right.
I'd like to thank the Jackson family for the for the Dr Carl Richard Jackson Scholarship and for amazing opportunity they provided, and I highly recommend the National Paediatric Hospital to anyone considering an elective term."
"Coming into the Sydney Medical Program I set out to push myself beyond my comfort zone and experience as much as I could. I selected the Cambodia ILA because it was unlike anything I had undertaken in my first degree and it would enable me to experience healthcare in a developing world environment. To be honest at first I didn’t spend much time considering how I would be able to give back as much as I thought about what I could gain. That is what most first year medical students think about, also the opportunity to perform duties beyond our capabilities, because let’s face it, at this stage we all just want to cut, suture, inject or withdraw something from our patients. For my sake and the sake of my patients I was glad that the National Pediatric Hospital, Phnom Penh is a large teaching hospital. I certainly didn’t get to perform outside my capabilities but I did manage to learn an incredible amount in my 4 weeks.
I spent the whole time in the surgical department, watching mostly orthopaedic procedures on deformities we just don’t see in Australia. Things like osteotomies on children suffering Rickets, triple arthrodesis surgery for talipes equinovarus and hip surgery for children who had congenital hip dysplasia but weren’t picked up until well into their childhood. I grappled with the many reasons why such preventable deformities would still be happening, but after visiting cultural sites like Tuol Sleng (S21 prision camp) and Choeung Ek (the Killing Fields), I realized this small nation, including their medical system, is in the process of being dragged back into the 21st century after the Khmer Rouge regime sent it hurtling back to an agrarian society only 30 years ago.
My supervisor, Dr Vuthy is a man with such a passion for his work. I got to spend a weekend away with him and his family visiting the area he stayed in as a child during the Khmer Rouge regime. We even found the family which housed and protected him. It was such a moving experience. In my time at NPH I felt like I took a lot (the essence of being the dreaded ‘medical tourist’), but by chance my time coincided with a visiting American surgeon, Dr Gabriel. Dr Vuthy had saved up all of his ‘difficult cases’ for Dr Gabriel to consult and operate on. I had my Canon digital SLR camera with me at the hospital so Dr Vuthy asked if I could document, step by step the surgeries Dr Gabriel was performing for teaching purposes. I looked at this as my chance to leave a ‘positive footprint’, to give back in a way that will hopefully serve the future doctors of Cambodia for many years to come."
Adrian’s placement was supported by a generous donation from the Jackson family in the form of the Dr Carl Richard Jackson Scholarship.