Elective Report: Julius Bruch (Queens College)

Singapore and Sarawak (Malaysia)

Summer 2010
My reasons for choosing an
elective in Singapore and
Sarawak:
I wanted to split my elective in two
parts to experience two contrasting
healthcare environments. In
Singapore, I wanted to experience
technology intensive medicine in a
much more business oriented
system. I also thought this
opportunity would be ideal to explore
two fields in medicine further that I
am especially interested in:
Neurology and Neurosurgery. In
Sarawak, by contrast, I wanted to
experience healthcare provision with
more limited resources and a
different disease spectrum.

Singapore Neurology and

Neurosurgery at the National
Neuroscience Institute, Tan
Tock Seng Hospital

promoting open cultural events,

performances and the arts with the
effect that one is guaranteed never
to get bored.
Medicine in Singapore:
In Singapore, the richer people use
the purely private health care
facilities which are dotted around the
centre. The state care system
integrates private health care with
state subsidies that are matched to
every persons income. However,
when it comes to accommodation,
you still get what you pay for: The
poorer patients stay in C wards
which are essentially large halls with
no air conditioning. The richer
patients stay in A wards and have
single rooms with their own sofa and
TV. As South East Asias centre for
medical tourism, one definitely is
sure to see a great variety of
interesting cases in Singapore.

Singapore as a destination:
Singapore is a very exciting city state
which has the small-scale feeling and
grandeur of Monaco mixed with the
flare of other oriental cities such as
Shanghai or Hong Kong. In order to
rid itself of the image of a sterile and
authoritarian enclave the countrys
government is now actively

The intraoperative MRI suite at SGH.

Skyline of Singapore Financial District by night.

My elective experience in
Singapore:
The first week I spent in the
neurological ITU where I learnt a lot
not only about care of patients with
critical neurological conditions but
also about all aspects of ITU
medicine. They have a lot of trauma
cases, brain tumours and abscesses.

The level of technology employed far

exceeds UK levels everything
charts itself onto computers from
the body temperature that is
monitored via wireless abdominal
probes to the intracranial pressures
and the standard observations. There
is a dedicated laptop for every
patient (replacing the bedside notes)
and every doctor. Even the food gets
delivered via a kitchen robot (which
is quite brutal and is known to have
rolled over peoples feet in the past).
Neurosurgical procedures also benefit
from capital intensive technology,
such as the intraoperative MRI suite.

The National Neuroscience Institute entrance

In Neurology, the National

Neuroscience Institute offers a wide
variety in specialist clinics and
investigations that are very
interesting to watch. One thing that
requires getting used to is that
Neurology in Singapore is defined a
lot broader: Two of the most
commonly seen conditions are
headache and stroke, both of which
UK neurologists only have very
limited contact with. Teaching
opportunities are at about Cambridge
level.
Ward life in Singapore is quite
different. Junior doctors work much
longer hours and the consultants are
generally much less present on the
wards. One doctor complained to me
that she only got four hours sleep a
night, which did concern me. The

working atmosphere between junior

doctors is really good, but
Consultants do scald their juniors
quite regularly and more outright
than we would be used to from
England.
Overall elective impression:
I would definitely do my elective
again in Singapore. I really got to
love the city and it certainly helped
that I got to know lots of friends
there. Singapore is a great
alternative destination to the USA if
you want to experience some
technology intensive and business
oriented medicine. I would definitely
recommend it!
Best way to organise the
elective:
Go to
http://itumed.nus.edu.sg/scesp/welc
ome.htm. This has all the
information required. You can
organise the elective directly with
some doctors but you will not legally
be allowed to touch patients unless
you go through the official NUS
application route.

Sarawak, Malaysia General

Medicine and Neurology
Sarawak as a destination:
Sarawak is one of the two Malaysian
states on the island of Borneo. About
half is covered by jungle which is
under great threat due to
deforestation and oil palm
plantations. There are numerous
national parks, an Orang-Utan
sanctuary and the opportunity to
stay overnight in a Dayak longhouse!
A random fact is that Borneos jungle
is thought to still contain the greatest
undiscovered repertoire of natural
pharmaceutical substances.
Medical elective in Sarawak:
If you want to experience tropical
medicine in the jungle, this is the

place to go. Sarawak offers the

perfect combination of exotic medical
conditions, great signs, decent
healthcare in the cities and the
opportunity to go into the depth of
the jungle to experience medicine in
some of the remotest villages and
towns. Kuching is the states capital
and most students start off with an
attachment at Sarawak General
Hospital. Dr Wong is the doctor there
who organises the electives. Once
you have arrived, he can organise
attachments at several other
healthcare institutions across the
state. I would particularly
recommend going to Kapit and the
village clinics.

Tropical diseases are common, such

as malaria, melioidosis and dengue
fever. The doctors there were very
friendly, letting us do antenatal
ultrasound scans and other
procedures.
The village clinics take place about
every two weeks over the weekend.
With three jeeps few (one or two)
doctors, several medical students
and helpers drive into some of the
most remote villages along the
Indonesian border. If youve lost
your enthusiasm about clinical
medicine in stage II and pathology,
you definitely regain it here as you
can hold your own clinic with a
translator and every help is actually
greatly appreciated. Since the village
population generally cant reach a
doctor, this is the only opportunity
they have to get help. However, I
also got a disturbing feeling when we
had to leave some villagers behind
with chronic, treatable conditions
(such as Parkinsons) for which the
village clinics dont carry the
medication.

Medical ward in Kapit Hospital

Kapit is a small town in the centre of

the state. It is surrounded by jungle
and is not connected by any roads.
The only way to get there is by a 180
km long speed boat ride up the great
Rajang River from Sibu. The hospital
there is staffed by five medical
officers who need to work without an
anaesthetist and many other critical
medical services we take for granted.
Casesarian sections are done under
spinal anaesthesia as epidural blocks
are unavailable. If, for example,
there is an accident at a timber camp
(a fairly common occurrence), they
need to first transport the patient
with a jeep for hours to Kapit and
then three hours downstream by
ambulance boat to Sibu if the
hospital cant cope with the accident.

Child at a village clinic

The Sarawak General Hospital is the

biggest hospital of the state and
provides almost all necessary
services. You are not fixed to one
specialty, so you can explore several
if you wish. I mainly attached myself
to general medicine and neurology.
There are only two neurologists in
Sarawak (a state of 2.5 mill people!),
and these each only spend half a day
in the government hospital each (the

rest of the time they do private work

which they are also happy to have
students attend). The scarcity of
neurologists thus means that they
see only the most flowery and exotic
conditions which is great for medical
students.
Overall elective impression:
This part of the elective was certainly
a lot of fun and was exactly what I
had wanted to experience. Because
the staff there are really flexible and
helpful, you can tailor your elective
the way you wish.
How to organise the elective:
Dr Wong organises the electives. You
can contact him by email (contact
me to get his address). He will then
forward you the necessary forms and
can also advise on accommodation.
The elective application costs approx.
20 pounds. You can also join the
Facebook group Elective Students of
Sarawak General Hospital.
Any questions, please feel free to
contact me: juliusbruch at cantab.net

Orang-Utan one of 50.000 survivors