Country visited

Thailand

City or town

Bangkok

Hospital/unit/clinic

Faculty of Medicine, Chulalongkorn University / King Chulalongkorn Memorial Hospital

Dates visited

15^th April – 17^th May 2024

Contact details of your host:

chulamed.international@gmail.com

Please give an overview of what you saw / did

I undertook my elective in Bangkok, Thailand at the Faculty of Medicine of Chulalongkorn University, where I spent 5 weeks within Plastic and Reconstructive Surgery at King Chulalongkorn Memorial Hospital. During this elective, I gained a broad experience of the specialty and achieved a number of goals.

I attended theatre sessions, took part in outpatient specialist clinics, and joined MDT meetings. I spent time with a large plastic surgery team, with multiple consultants, and residents at different stages of their training.

Clinic Experience:

• I attended specialist outpatient clinics where I saw a wide range of patient presentations. I saw many hand related cases such as congenital malformations, various trauma related deformities, amputations, and post operative complications. As the hospital was a leading government hospital, I was fortunate to be able to see a wide variety of patient presentations, as most patients would not have been able to receive specialist care privately.
• Attending clinics also allowed me to understand the preoperative aspects of various surgeries. Particularly how social/economic/cultural issues were addressed during these consultations, especially in sensitive cases.

Surgical Theatre Experience:

• During the elective, I had many opportunities to join the plastic surgery team in theatre. I saw many hand-related operations such as skin grafts for burns, hand reconstruction after severe crush injuries, and congenital malformations such as polydactyly and syndactyly. I was also able to see many different operations including surgeries for gender affirmation, cancer related cases and many aesthetic related plastic surgery procedures. This exposure allowed me to appreciate the fine detail and precision that is required in plastic and reconstructive surgery.

Working with a Multi-Disciplinary Team and Alongside Multiple Specialties:

• During this elective, I witnessed the surgical team collaborating with other medical specialties, such as orthopaedics, neurosurgery, oncology, and dermatology on numerous occasions. I saw this particularly with cancer related cases, as an MDT approach is essential for comprehensive treatment planning. I saw a particularly interesting and complex case that involved reconstruction of the entire maxilla using bone grafts from the fibula. I was able to witness the collaboration between orthopaedics, ENT, plastic surgery, and oncologists for this case. Furthermore, I found it particularly interesting that in many of the cases I was able to observe, that there was significant consideration of biomechanics to allow for optimal outcomes.

The Chulalongkorn University Medical School made sure that all access related aspects were sorted on arrival for hospital placement. I had access to the medical school facilities, such as the library should and if I needed to use them. The international students team also held events so that we could meet other elective students in other departments and network.

What were the best things about the visit?

Being able to follow patients from preoperative clinic to the surgical theatre was very rewarding. Many patients presenting to the department needed complex surgical and medical care and being able to observe the surgical team navigate these cases was an incredibly valuable learning experience. The fact that patients could also see a specialist on the same day in a public secondary and tertiary hospital was also refreshing to see.

Outside of the hospital experience, I thoroughly enjoyed exploring Bangkok and other parts of Thailand in the evenings and on weekends. I was able to learn a lot about Thai culture, try amazing food, and appreciate the beautiful temples, markets, and natural beauty that Thailand has to offer.

What problems did you encounter?

Almost all patients communicated in Thai, however the doctors were accommodating and translated to English. The Thai medical students on placement with me also helped to translate.

What accommodation was provided?

The university provides dormitory accommodation; however I stayed elsewhere as it was quickly occupied.

Would you recommend this to someone else? 

Yes definitely!

Are you more likely to choose a career in hand surgery as a result of this experience?

Yes, this experience definitely gave me a greater insight into a career in hand surgery, and I am looking forward to exploring further into the specialty!

Country visited

Colombia

City or town

Bogotá

Hospital/unit/clinic

Clínica Universitaria Colombia

Dates visited

29/04/24 – 17/05/24

Contact details of your host:

educacionmedica@colsanitas.com

Please give an overview of what you saw / did

I completed an elective placement in plastic surgery at Clínica Universitaria Colombia. My time was divided between theatres, the emergency department, outpatient clinics as well as the wards. Most days would start with a quick ward round before then going on to either attend theatre for the day, or to the emergency department to review new patients.

I was exposed to many hand and wrist conditions including tendon injuries, fractures, hand infections as well as some congenital hand abnormalities. During this placement I had the opportunity to observe many hand surgeries and learn about different techniques such as wrist arthroscopy, tenolysis, bone grafting and flaps. I gained lots of hands-on experience, assisting with over 50 cases.

As well as observing hand surgery, I also had the opportunity to spend some time in other subspecialties of the plastic surgery. I was able to assist in many different surgeries including mammoplasty, abdominoplasty, skin cancer surgery as well as burns management.

Each week, multiple teaching sessions were provided covering various themes in plastic surgery. In my final week, I was asked to give a presentation covering the basics of flaps.

What were the best things about the visit?

The team! The consultants, residents and interns were all incredibly kind and supportive. They were very patient with my limited Spanish and took the time to translate things for me when I was unable to follow the conversation.

The doctors working in plastic surgery took very good care of me throughout my placement. They would invite me to lunch each day and ensured that I was made to feel like part of the team.

It was interesting to experience a healthcare system different to the NHS. I was able to gain an understanding of how different funding systems can impact the training that doctors receive as well as patient care.

What problems did you encounter?

The only problem that I faced was the language barrier. I took Spanish classes both in the UK as well as during my time in Colombia but still found the language challenging.

I was still able to get very involved and learn a lot during this placement however I would recommend learning as much medical Spanish as possible before attending.

What accommodation was provided?

No accommodation was provided.

I stayed in an Air BnB and took an Uber to placement each day.

Do you have an anecdote about your visit you can share?

My favourite day of the placement was where one of the consultants allowed me to attend his list at a different hospital in Bogotá. He had a full list of hand surgery cases where I was encouraged to scrub in and assist with each case.

He took the time to explain each surgery in detail, teaching me the anatomy and steps of the operations.

Would you recommend this to someone else?

Yes!

Country visited

India

City or town

Coimbatore

Hospital/unit/clinic

Ganga Hospital

Dates visited

30/07/24 – 10/08/24

Contact details of your host:

Dr S. Raja Sabapathy

Please give an overview of what you saw / did

At Ganga Hospital, I attended a mixture of surgeries and outpatient clinics, in addition to teachings, ward rounds and grand round. I wanted to fully engage with the typical life of a doctor at the hospitals to gain a better appreciation of the field and healthcare systems.

I was able to see a range of orthoplastic cases, including but not limited to post-trauma fixation and reconstruction, hand replantation, reconstruction of congenital hand differences and other anomalies and burns. Seeing the variety of tendon transfers, nerve grafts and skin flaps was fascinating. For example, following a road traffic accident (RTA) there was a global brachial plexus injury requiring a gracilis muscle transfer where the intercostal nerves 2-4 were joined to the obturator nerve. This meant that the patient would initially need to deeply inhale if they wanted to flex their elbow.

 Moreover, seeing the range of different techniques was also interesting, such as the   numerous groin flaps to cover skin defects of the hand, which is not a procedure I had seen   before.

Teaching at Ganga happened every morning at 7.30am with additional evening teaching a couple of days per week. These were very well presented, exploring topics from thumb reconstruction to syndactyly, in an accessible yet detailed manner. Combined with the 6-day working week and long working hours, it was clear that all the doctors there had a very strong work ethic involving both research and practice.

There was a high patient throughput, with the patients at Ganga able to be operated on very soon after their initial consultation, likely related to this being a private tertiary centre. This was largely helped by the large number of operating theatres dedicated to just orthoplastics procedures at Ganga. Additionally, the bulk of each operation was typically carried out by the consultants allowing for high quality procedures to be done quickly. During

Country visited

India

City or town

Kerala

Coimbatore

Hospital/unit/clinic

Plastic surgery, Amrita Institute of Medical Science

Plastic surgery, Ganga Hospital

Dates visited

24th June – 12th July - Amrita Hospital (3 weeks)

15th July – 9th August – Ganga Hospital (4 weeks)

Contact details of your host:

Ponekkara Rd, P. O, Edappally, Kochi, Ernakulam, Kerala 682041, India

313, Mettupalayam Rd, Saibaba Colony, Coimbatore, Tamil Nadu 641043, India

Please give an overview of what you saw / did

The first half of my elective was in Amrita Institute of Medical Science in Kochi, Kerala. I saw a diverse range of surgeries from reconstructive cases, including congenital hand differences and trauma cases, to cosmetic procedures such as hair transplant and gender affirmation surgery including facial feminisation surgery. The regular consultant-led teaching sessions provided useful insight into these fascinating cases.

Ganga Hospital is situated in the heart of Coimbatore, an industrial town thus prone to many trauma cases. It was incredible to see how the surgeons were able to dissect and reconstruct some of the major injuries, like a whole arm amputation, when it looked like there was no hope. Many of the cases were also joint with the orthopaedics team which gave a glimpse into this field as well as how well the teams worked together. The numerous operating rooms at Ganga enabled me to see a large variety of procedures, including a range of free flaps and local flaps. I was also able to see some surgeries that are not usually done in the UK such as abdominal and groin flaps.

Ganga Hospital also being a thriving academic centre conducted regular teaching sessions every morning and 2 evenings every week from Monday to Saturday. These were either led by consultants or senior registrars and were always in English.

What were the best things about the visit?

Seeing the range of cases that could be done in the field of plastic surgery was eye-opening in both hospitals. I saw many trauma and reconstructive cases each day due to the large number of cases operated on daily. Getting a glimpse of the cosmetic side of this field was also an entirely new experience. The consultants, juniors and staff were all extremely welcoming and keen to teach, which helped me have a very fulfilling experience.

Staying at the hospital guesthouse in Ganga also meant that I was able to meet doctors and students from all over the world who also stayed there whilst they came for their fellowships or electives at the hospital. It was great to hear about everyone’s experience in plastic surgery all over the world. Outside of work, we all travelled and explored the regions together during the evenings and weekends. There were many beautiful places to visit in South India and the cuisine was delicious!

What problems did you encounter?

I had a great experience during my elective and did not encounter many issues. Tamil was the language spoken in Coimbatore; this language barrier made it more difficult for me to form connections with the patients and some members of the team as well as understand consultations fully. However, since I speak fluent Malayalam (the language spoken in Kerala) and fortunately some of the words in Malayalam and Tamil are similar, I was able to slowly pick up the language and started understanding more of the conversations by the 4th week of my placement. The doctors also almost always conversed in English which meant that someone would explain what was happening or I could gather most information from their discussions. Since medicine is taught in English in India, the teaching sessions were always conducted in English so there were no difficulties encountered there. 

What accommodation was provided?

I arranged my own accommodation in Kochi.

Ganga Hospital provided accommodation at the Ganga guesthouse. The accommodation was very good and only a 10-minute walk from the hospital. All the other students and doctors visiting Ganga also stay in the guesthouse. It was a lovely experience spending time together with everyone in the evenings and weekends and walking to and from the hospital together. The guesthouse is a large house with a security guard outside 24/7 for safety. There are 2 floors and a kitchen on each floor. The rooms are all en-suite and air-conditioned. It costs $25 per night to stay at the accommodation. 

Do you have an anecdote about your visit you can share?

I found an emergency trauma case in Ganga particularly interesting. The patient presented with a machine injury of their hand where the entire forearm had been amputated in the accident. The forearm was left with the radius and ulna exposed and the amputated part of the hand was brought in a bag. Both plastics and orthopaedics were involved in this case; the orthopaedics team were involved in internal fixation. It was eye-opening to witness how the surgeons carefully dissected the arteries, veins, nerves and tendons and joined these together, often using the microscope to assist with the reconstruction and reattachment of the arm. The patience and care taken to do this surgery over hours was inspiring. Furthermore, seeing the regain of the function of the hands of patients who had similar injuries and reconstructive surgeries conducted was breath-taking. The Ganga upper limb replantation philosophy is “If the hand is structurally intact or can be made functional, however severe the proximal injury - attempt replantation if it would not put the patient to undue morbidity or risk of mortality”.

Would you recommend this to someone else? 

Yes, absolutely! I really recommend both hospitals to gain an enriching experience in plastic and hand surgery. I really enjoyed my elective and it has definitely exceeded all my expectations. This elective has been one of the most incredible experiences in medical school.

Are you more likely to choose a career in hand surgery as a result of this experience?

Definitely! I loved my elective experience and seeing the range of plastic and hand surgery cases at these hospitals has certainly consolidated my desire to pursue a career in this field.

Country visited

USA

City or town

Washington DC

Hospital/unit/clinic

Children’s National Hospital

Dates visited

01/05/23 – 26/05/23

Contact details of your host:

Specialcategory@childrensnational.org

Please give an overview of what you saw / did

I completed my elective at the Orthopaedics unit in Children’s National with a focus on paediatric hand and upper extremity surgery. My time there was divided between attending theatres and outpatient clinics, alongside attending weekly grand rounds.

I would start most days by joining the orthopaedics team for very brief and efficient morning ward rounds before going to theatre to observe the cases of the day. I was exposed to a wide range of orthopaedic procedures and hand and elbow conditions ranging from fractures to epiphysiodesis for macrodactyly. I also observed spine cases including a posterior spinal fusion for neuromuscular scoliosis as well as foot and ankle cases.

I also had the chance to see various conditions in general hand clinics where patients were commonly brought in with congenital abnormalities. Additionally, I attended a multidisciplinary team led brachial plexus clinic comprising of an attending hand surgeon, neurosurgeon, and physiotherapist.

What were the best things about the visit?

It was a unique opportunity for me to be able to rotate in paediatric hand surgery – a niche subspecialty that I had no prior experience of. The team at Children’s National were very welcoming and happy to teach me or answer my questions – especially one of the senior residents who took an interest in my learning and mentored me throughout this elective. It was also very interesting to watch how the healthcare professionals dealt with paediatric patients, having to navigate through the challenges of getting a physical exam from infants, for example. Additionally, this elective allowed me to compare the differences between a publicly and privately funded healthcare system and the impacts this had on the care patients received as well as the training that the doctors would get.

Apart from getting to see and learn a host of new things, I enjoyed networking with some leading surgeons in the field. I loved the atmosphere in theatres and was especially a fan of the banter among the different healthcare professionals in the team.

What problems did you encounter?

I did not encounter any significant problems.

What accommodation was provided?

No accommodation was provided – I had to book an AirBnB.

Would you recommend this to someone else? 

Yes, definitely! 

Are you more likely to choose a career in hand surgery as a result of this experience?

Yes, this elective has furthered my interest in orthopaedic and hand surgery. I will definetely consider pursuing a career in the field.

Country visited

United States

City or town

Boston

Hospital/unit/clinic

Massachusetts General Hospital, Hand and Upper Extremity Surgery Service

Dates visited

03/04/2023 – 28/03/2023

Contact details of your host:

RCROSS3@mgh.harvard.edu

Please give an overview of what you saw / did

I was an observer at the Upper Extremity and Hand Service at Massachusetts General Hospital. I spent most of time with Dr. Neal Chen. During my elective at MGH, I was afforded the opportunity to gain invaluable insights into the different aspects of orthopaedics, the vital aspects of shared decision-making and outstanding patient communication. I had the privilege of observing a diverse range of surgical procedures, including orthopaedic surgeries involving the shoulder, wrist, and elbow, as well as engaging discussions surrounding nerve-related issues and fracture management.

In this dynamic clinical setting, I witnessed first-hand how efficacious communication and collaboration significantly contributed to improved patient outcomes. By cultivating an environment that values shared decision-making, healthcare professionals were able to align their objectives with those of their patients, ensuring that the individual needs of each patient were met with utmost consideration.

Moreover, I recognised the importance of implementing personalised systems to reduce the chances of error. This approach, taking into account the unique circumstances of each patient, assists in optimising treatment plans and streamlining surgical procedures.

My experience at Massachusetts General Hospital underscored the importance of patient-centred care, shared decision-making, and effective communication in delivering top-quality healthcare.

What were the best things about the visit?

Having the opportunity to learn from Dr. Chen and his distinguished team was truly enlightening. It quickly became apparent that hand injuries and pathologies can have a profound impact on patients' lives, often hindering their ability to carry out daily activities or work. Observing the team engaging with these patients was truly inspiring; he approached each case with care and attentiveness, discussing the available treatment options while being transparent about potential limitations. In situations where a particular treatment would not be beneficial, Dr. Chen and his team would thoughtfully and gently explain the reasons behind this, as well as outline any alternative options for the future. His empathetic and honest communication style served as a testament to the importance of building trust and understanding between healthcare professionals and their patients.

What problems did you encounter?

None

What accommodation was provided?

No

Would you recommend this to someone else? 

Yes

Are you more likely to choose a career in hand surgery as a result of this experience?

I have become truly captivated by the field of hand surgery and the profound impact it has on patients' lives. Witnessing the intricacies of hand pathologies and the transformative outcomes achieved through expert surgical interventions has been both fascinating and inspiring.

This experience has solidified my determination to pursue a career in hand surgery. I am eager to continue developing my knowledge and skills in this specialty and to make a meaningful difference in the lives of patients suffering from hand injuries and pathologies. The values of empathy, effective communication, and patient-centered care that I observed during my elective will serve as guiding principles throughout my career in hand surgery.

Country visited

Cambodia + Australia

City or town

Phnom Penh + Melbourne

Hospital/unit/clinic

Children’s Surgical Centre (CSC) + Royal Melbourne Hospital (RMH)

Dates visited

11/02/2023 - 21/04/2023

Contact details of your host:

info@csc.org

rmh-electives@unimelb.edu.au

Please give an overview of what you saw / did

At CSC, I took part in morning meetings, consultations, ward rounds, theatre and a research project. I saw a lot of reconstructive operations for traumatic injuries such as flaps for open fractures and nerve surgery for brachial plexus injuries. I also saw a lot of procedures fixing childhood congenital conditions such as polydactyly and arthrogryposis. I gained a lot of experience in suturing and also learnt how surgery is carried out in low resource settings. My time in Cambodia definitely helped me better understand the problems which healthcare staff and patients face in LMICs. CSC also had other specialties including orthopaedics, ophthalmology and ENT so every day and every week was different. Specialist surgical teams from Hong Kong, USA, France, UK and Singapore came to CSC for surgical missions during my time so I received a great deal of high quality surgical teaching for which I’m incredibly grateful.

At RMH, I took part in ward rounds, clinics and theatre. I saw a wide range of different operations for traumatic hand injuries, open fractures and facial injuries. I was given the opportunity to help with a number of cases and also got to carry out short consultations with patients during clinics. It was incredibly interesting getting to compare my experience in Melbourne compared to Phnom Penh.

What were the best things about the visit?

he best part of my visit was learning about Cambodian culture and getting to know the local staff at CSC. They were extremely welcoming and I learnt a lot about their lives in Phnom Penh. My time there definitely made me appreciate how amazing it is to work in healthcare despite the difficulties that often arise. Seeing patients receive surgical care which they would not have been able to receive anywhere else and seeing them be able run or see again was very fulfilling. The six weeks I spent at CSC were the best six weeks of my time in medical school. I would highly recommend any budding surgeons to visit.

What problems did you encounter?

None

What accommodation was provided?

Self-organised AirBnBs

Would you recommend this to someone else? 

Yes, in particular my time at the Children’s Surgical Centre in Phnom Penh.

Are you more likely to choose a career in hand surgery as a result of this experience?

Yes, my experiences on my elective definitely showed me the variety that comes with being a plastic surgeon, as well as how important hand surgery is in improving the lives of patients.

Country visited

India

City or town

Coimbatore

Hospital/unit/clinic

Ganga Hospital

Dates visited

20/02/23 – 16/03/23

Contact details of your host:

313 Mettupalayam Road, Coimbatore, Tamil Nadu, India

Please give an overview of what you saw / did

Ganga hospital is a private tertiary centre renowned as a leading site for orthoplastic reconstructive surgery, particularly hand surgery.

During my time, I attended alternating clinics and theatres. The former gave insight into a plethora of pathology at different stages of intervention. The latter demonstrated a remarkable mixture of emergency and elective cases - predominantly for plastic, orthopaedic and maxillary-facial surgical teams.

I observed over 50 operations ranging in length from 20 minutes to 7 hours. Memorable surgeries included a second toe to thumb transfer, an opponensplasty for an exceedingly rare case of dorsal dimelia, and a radialisation for type IV radial longitudinal deficiency. There was also ample opportunity to be involved with plastic subspecialties other than hand surgery. These included cleft lip repairs, burns management, microsurgery, and more free flaps than I was even aware of.

Ganga evidently holds the education of its trainees as a core value. Every morning there was either a series of case discussions or a teaching presentation covering anything from eyebrow reconstruction to recreating a mandible from a fibula flap in a devastating case of oral cancer. As a result, the practical aspect of my elective was thoroughly backed by theory.

What were the best things about the visit?

The fact that patients travelled from all over India (and some even internationally) speaks volumes about how fantastic an opportunity this placement was to expose myself to a wide range of intriguing cases. Furthermore, the sustainable approach Ganga takes to reducing surgical waste and financial cost to the patient was thought-provoking.

Meeting the surgical team and fellows from all over the world, all with a wealth of specialised knowledge they were happy to share, was everything I hoped for from this elective.

Outside of surgery, there were plenty of places worth exploring, from local temples to verdant Kerala. South India is steeped in beautifully preserved culture and architecture; the cuisine was everything I hoped for too!

What problems did you encounter?

Language is often a barrier to medical electives abroad. I am grateful that, largely, this wasn’t the case. Impressively, all the surgeons spoke excellent English, as cases and teaching were always given in English.

Clinics were usually in Tamil or other Dravidian languages, which presented more of a challenge. However, it was certainly good for my observation skills, as much about the pathology and previous interventions could be gleaned by carefully assessing clinical signs, examination findings, and radiology.

Being supernumerary in theatre (usually alongside trainees at more advanced levels of surgical experience), there were no opportunities to scrub in and assist. With theatres so full, it could occasionally be difficult to see what was happening.

What accommodation was provided?

The usual accommodation was fully booked with fellowship surgeons, so I was placed in a nearby hotel, which was excellent and a 2-minute walk from the hospital.

Would you recommend this to someone else? 

Yes, it was an excellent opportunity to experience world-class reconstructive surgery, as well as a rich and interesting culture. I would recommend learning a little Tamil for students or doctors considering going, as even a small amount is appreciated.

Are you more likely to choose a career in hand surgery as a result of this experience?

Absolutely.

Country visited

United States of America

City or town

Boston

Hospital/unit/clinic

Mass General Hospital

Dates visited

15/08/2022 – 15/09/2022

Contact details of your host:

MGHplasticsurgery@partners.org

Please give an overview of what you saw / did

I observed theatre/clinic, engaged with grand rounds, and attended online conferences by renowned surgeons in both the plastics and orthopaedic field. I had the opportunity to contribute to research and I worked closely with the global surgery team based in Harvard.

What were the best things about the visit?

I can honestly say that the entire experience was constantly mentally stimulating and highly motivational! The staff were extremely kind and welcoming, and I will never forget this experience. I was privileged to have the chance to shadow Dr Neal Chen, a world-renowned specialist hand surgeon, and the current chief of the hand and arm centre.

What problems did you encounter?

None encountered.

What accommodation was provided?

I organised my own accommodation through AIRBNB.

Would you recommend this to someone else? 

Yes!

Are you more likely to choose a career in hand surgery as a result of this experience?

Before attending the elective I was interested in a few career options which included hand surgery. However, the clinical experiences I gained over the last 4 weeks have given me a realistic insight into my passion for hand surgery and only further cemented my desire to commit to this unique career path.

Country visited

United Kingdom

City or town

Liverpool

Hospital/unit/clinic

Alder Hey Children’s Hospital

Please give an overview of what you saw / did

Alder Hey Children’s Hospital-

In this elective, I had the opportunity to observe a variety of surgeries and attend clinics as well as the burns/critical care ward. I shadowed the plastics surgeons as well as the orthopaedic surgeons with specialist interest in hand surgery. There were a variety of clinics that I had the opportunity to attend including laser clinic, congenital hand clinic, general plastics surgery clinic as well as nerve clinic. It was also fruitful to shadow the physiotherapists and specialist plastics nurses highlighting the importance of the role of the multidisciplinary team. It was inspiring to see the way the plastic surgery team cohesively worked together to improve the functional recovery of patients with hand pathology. Having the opportunity to assist and scrub into theatre cases was also very enjoyable and gave me a glimpse of plastic surgery as a speciality.

Johns Hopkins Nerve laboratory meetings-

Prior to the Alder Hey elective, I was fortunate to attend weekly virtual meetings over six month period where I was able to understand the importance of new therapies e.g. IGF1 to complement the surgical management of nerve injuries of the hand.  It was interesting to see that these therapies may help the outcome of the surgery by not only improving the function but also addressing the pain.  These novel therapies aid functional recovery from nerve injuries.   These laboratory meetings helped me to understand the anatomy of the nerves and hand function but also gave me insight into how research can be translated into clinical care.

What were the best things about the visit?

  The highlight of the Alder Hey Children’s hospital elective was the specialist hand clinics.  These clinics were fascinating, and I was able to appreciate a lot of medical conditions.

  I observed a patient who had brachial plexus reconstruction surgery. Seeing the recovery of the young patient at that time was truly remarkable. Here, I learnt that in early reconstruction surgery, primary nerve surgery is favoured (nerve transfer).   In the hand clinic, I was in awe to see how grateful the families were following the functional recovery and the impact on their quality of life.  My supervisor, Ms Sian Falder, was a plastic surgeon with burns interest. During this month, I also had the opportunity to shadow her and see the journey of a patient who had 32% burns injury. This included the scalp, face, as well as both arms and hands.  I saw that this young person required multiple grafting procedures. 

 I saw a variety of cases in the specialist hand clinic, varying from mild congenital abnormalities to severe deformities. The most common abnormality was the extra digit.  Polydactyly, syndactyly, symbrachydactyly and thumb duplication were other presentations.   I also learnt that certain genetic conditions also involve hand abnormalities. This included Apert syndrome as well as Holt Oram syndrome.

 The variety of cases that I observed in the clinic made the experience particularly enjoyable and interesting.  I noted that some of the hand abnormalities appear to be minor at birth but become more challenging to the child as they got older.  Early intervention was considered key for improved outcomes.

  The occurrence of malformation in the hand can have a significant psychological effect on the children as well as their families.  I learnt that achieving early and improved hand function helps the child participate in school and sports activities.  Surgery not only improved the cosmetic appearance but also the functionality.

Working in a specialist paediatric multidisciplinary team included creating treatment and rehabilitation plans for individual children. It was impressive to see the close work between different specialisms such as orthopaedics, anaesthetics, radiology, neurophysiology and psychology. These clinics offered a holistic multidisciplinary approach to patient care

 I also had the opportunity to shadow junior plastic surgeons and core surgical trainees giving an insight into the training pathway of plastic surgery and hand surgery. My supervisor specifically allocated me a hand fellow to oversee my progress.  We identified key topics in this field and I was able to complete a literature review on “Hair tourniquet syndrome”.  I intend to submit this review to a medical journal for publishing.

What problems did you encounter?

This elective ran smoothly during my time spent in Alder Hey, therefore, no problems were encountered.

What accommodation was provided?

No- I had to arrange my own accommodation for the elective.

Would you recommend this to someone else? 

I would thoroughly recommend this elective to someone else due to Alder Hey’s state of the art facilities. The variety of clinics on offer from congenital hand clinics to nerve clinics gave me a glimpse of the importance of hand surgery and its positive impact to patients.

Are you more likely to choose a career in hand surgery as a result of this experience?

This elective experience surpassed my expectations.  I had great exposure to a variety of clinics, theatre as well a burns/critical wards. I certainly am more likely to choose a career in hand surgery as a result of this experience. The congenital hand clinic was interesting and having the opportunity to spend time in a tertiary centre and in one of the biggest paediatric  hospital in Europe is an experience that I will cherish.

Country visited

UK

City or town

Wrightington

Hospital/unit/clinic

Wrightington Upper Limb Unit

Dates visited

23/05/2022 – 29/07/2022

Contact details of your host:

upperlimb@wrightington.org.uk

Please give an overview of what you saw / did

I attended upper limb theatre lists 3 days per week, 1 to 2 clinics per week, and the remainder of my time was spent undertaking research. Theatre lists varied between shoulder, elbow, and hand/wrist lists.

What were the best things about the visit?

The networking. I was able to meet incredible mentors who were interested in my development. I will be keeping in touch with these fellows and consultants as I progress throughout my career.
I also was able to see operations that are performed in much lower volumes in other centres. Operations like the triple tendon transfer for spinal accessory nerve palsy, four corner fusion of the wrist, and many anatomical and custom shoulder arthroplasties.

What problems did you encounter?

Getting set up on the IT systems was complicated and tedious. It took almost 4 weeks for me to get set up with an email address and access to the clinical software.

What accommodation was provided?

No

Would you recommend this to someone else? 

Yes

Are you more likely to choose a career in hand surgery as a result of this experience?

Yes. I have met inspirational hand surgeons like Mr CY Ng and Mr Mike Hayton here at Wrightington. I am fortunate to have assisted Mr Hayton in theatre and received a great learning experience as a result. I will definitely be considering hand surgery as a career.

Country visited

UK/USA

City or town

Oxford/Boston

Hospital/unit/clinic

John Radcliffe, Plastic Surgery Department/Brigham and Women’s Hospital, Orthopaedic Department

Dates visited

18/04/2022 to 17/05/2022 and 31/05/2022 to 23/06/2022

Contact details of your host:

Miss Sara Atkins. Please email secretariat@bssh.ac.uk for contact details

Michael J Weaver, MD. Please email secretariat@bssh.ac.uk for contact details

Please give an overview of what you saw / did

At the JR, I was able to attend specialty clinics and scrub into hand surgery cases with Miss Sara Atkins, Prof Henk Giele, and Prof Dominic Furniss. I also received teaching in plastic surgery, including hand surgery.

At BWH, I saw ward rounds for orthopaedic trauma patients, including hand trauma, and participated in daily handovers of orthopaedic patients from admissions and referrals. I observed multiple orthoplastics surgical cases. I attended a full day research conference for Orthopaedic Trauma, which included presentations on hand trauma. I actively participated in research, including consenting patients to clinical trials and working with orthopaedic and plastic surgeons to design new research projects.

What were the best things about the visit?

The best part of this visit was the opportunity to observe a wide variety of orthopaedic and plastic surgery specialties, not limited to hand surgery, as this allowed me to put the differences between them into perspective and really highlighted my fascination with improving form and function as part of hand surgery! I also really enjoyed being able to contrast care in the NHS with care at a private American hospital, including the differences in approaches used and the focus on financial burden in many studies based in the USA.

What problems did you encounter?

I was unable to scrub into cases at BWH due to temporary COVID restrictions in place, but the surgical teams were still great in incorporating me into clinical care and education.

What accommodation was provided?

None, I had to find my own accommodations.

Would you recommend this to someone else? 

Yes, it was incredibly interesting and rewarding to observe practice in a different country that was both similar and so different to the one I had been training in! The teams at BWH and MGH also are incredibly supportive and welcoming which made it very enjoyable while the teams at the JR are very engaging and empowering.

Are you more likely to choose a career in hand surgery as a result of this experience?

Yes! I was very inspired watching the orthopaedic and plastic surgeons work together to tackle complex patients. I really appreciated the meticulous approach and fine motor skills taken by the hand surgeons in particular. I also had the opportunity to observe other subspecialties of plastics and orthopaedic surgery, which further solidified by interest in hand surgery as a specialty by comparison.

Country visited

UK

City or town

London

Hospital/unit/clinic

Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital

UCL Centre for Nerve Engineering

Dates visited

28/03/2022 – 28/05/2022

Contact details of your host:

Mr. Tom Quick, Consultant Peripheral Nerve Surgeon 

Please email secretariat@bssh.ac.uk for contact details

Please give an overview of what you saw / did

I attended and engaged with ward rounds, outpatient clinics, theatre and grand rounds with a focus on reconstructive nerve surgery. I also had the opportunity to work within the UCL Centre for Nerve Engineering on a variety of translational research projects which hope to benefit nerve injury patients.

What were the best things about the visit?

1. Support to develop my own research ideas.
2. Being able to extend my professional network will also benefit my future career ambitions to become a hand surgeon-scientist.
3. Working within a team with a diverse skill set to tackle clinical and research problems.

What problems did you encounter?

Trying to juggle clinical work with research was a challenge. The clinical arena is often fast paced demanding fast decision making whilst research environments tend to be slower paced requiring careful planning and thought. Switching between these two different mindsets can be difficult. Balancing research and clinical medicine also required effective time management skills; something I have worked and improved on during this placement. I am excited to continue my journey towards a hand surgeon-scientist and thank BSSH as well as my supervisor for supporting my involvement in this elective.

What accommodation was provided?

Privately sourced.

Would you recommend this to someone else? 

Yes.

Are you more likely to choose a career in hand surgery as a result of this experience?

Yes.

Country visited

United Kingdom

City or town

London

Hospital/unit/clinic

Plastic Surgery Department, Royal Free Hospital

Dates visited

1705/2021 – 18/06/2021 (5 weeks)

Contact details of your host:

UCL Medical School electives: medsch.visitingelectives@ucl.ac.uk

Royal Free Hospital telephone: 02037582000

Please give an overview of what you saw / did

I spent most of my time in theatres. There were lists daily: consultant-led lists in which there was a huge variety of presentations, and junior-led trauma lists which involved a lot of hand trauma.

The junior-led trauma lists offered the best opportunities for me to get involved, something for which I was really grateful as a student amongst a bunch of trainees who were chomping at the bit to maximise their case numbers. There was lots of hand trauma including tissue exploration and debridement, tendon and nerve repair, and abscess incision and drainage. A couple of stand-out moments from these lists were the amusement of seeing some cutely named [bone] nibblers being used and watching an FY2 do her first microscopic digital nerve repair.

Equally, there were a couple of stand-out moments in the consultant-led hand lists. I got to see one surgeon separate syndactyly in a young child, and another apply a Giddins frame in a middle phalanx fracture.

As well as seeing the weird and wonderful in theatre, I was fortunate to be able to attend trauma clinic whenever I liked and assist the registrar in minor surgeries of the skin (typically of the hand or face).

There’s plenty of research and teaching in plastic surgery that goes on at the hospital, and I was able to have a look round the wet labs and surgical skills labs, including having a brief go at cell culture. My supervisor allowing me to wash, transfer, and feed his stem cells was like a parent hiring a babysitter for their first time. In hindsight he was very trusting to let me do that, but I am proud to say that his hardy stem cells fared really well following their encounter with me.

What were the best things about the visit?

The breadth of operations occurring daily, even within hand surgery alone, meant that every day was different. I think this is a huge selling point for a specialty.

Aside from the surgery, the people made it a great experience. Everyone was really friendly, enthusiastic and motivated and it was clear that they were all delighted to be there doing work they were passionate about. It’s very easy to enjoy, and be inspired by, an environment like that.

What problems did you encounter?

None really day to day. Everyone I met was friendly, helpful, and made an effort to get me involved. I couldn’t have asked for more.

However, I must say that doing an elective in London was expensive. I am hugely grateful to BSSH for their kind award of this bursary. It allowed me to just enjoy myself and not worry about the cost. 

What accommodation was provided?

None – I didn’t request any. I think the trust does provide accommodation, but I stayed in an AirBnB with friends also doing their electives in London.

Would you recommend this to someone else? 

Absolutely. Those five weeks were the best I had during my entire time at med school.

Are you more likely to choose a career in hand surgery as a result of this experience?

Yes.

I was already very keen on the idea, but now that I have real experience to support the notion I have no doubt that I want to pursue this career.

Country visited

United Kingdom

City or town

Oswestry

Hospital/unit/clinic

The Robert Jones and Agnes Hunt Orthopaedic Hospital

Dates visited

1705/2021- 11/06/2021

Contact details of your host:

Mr Simon Pickard.

Please email secretariat@bssh.ac.uk for contact details

Please give an overview of what you saw / did

My time on my elective was mostly spent either in clinics or in theatre. Most clinics were hand surgery clinics for either new or follow up patients. At first, I would shadow the consultant watching him carry out the history and examination and subsequently coming up with a management plan. After a few clinics I was able to start seeing patients in the clinic before they were seen by the consultant. I found this an excellent opportunity to practice my examination skills which was something I was not confident on previously, having done few orthopaedic examinations during my time in medical school. By the end of my elective I was confident that I could carry out an adequate history and examination of the hand and wrist, as well as get the correct diagnosis for common conditions. I was surprised to find that in the field of hand surgery patients could be of any age from children to the elderly. I suppose this is due to the mix of both trauma and elective surgery as well as the speciality covering a much broader range of conditions than I had assumed. Some of the most interesting clinics I attended whilst on my elective were the specialist clinics. These only run once a month or so, but I was lucky to be able to attend both a spinal injuries clinic as well as a spasticity clinic whilst on my elective. My supervisor also encouraged me to spend time with other healthcare professionals. In particular I spent time with the physiotherapists, occupational therapists and nurses who were also involved in the care of the patients. This gave me a much greater appreciation for their role, particularly in the rehabilitation aspect after surgery.

When I wasn’t in clinic, I spent most of my time in the operating theatres. I was able to see and assist in a wide range of surgeries including neurectomy’s and tendon lengthening, tendon repairs, tendon transfers, carpal tunnel decompressions, fixation of upper limb fractures and trigger finger releases. This made me realise there’s a lot more to hand surgery than just carpal tunnel releases. One of the most interesting surgeries I was able to observe was an exploration and reconstruction of the brachial plexus in a young man that had been stabbed and subsequently was experiencing weakness of his shoulder. During the surgery it was interesting to see the use of instruments such as an electrical nerve stimulator as well as a microscope. In addition is was a great opportunity to put my anatomy I had learnt in medical school into practice. I was fortunate enough to be able to assist and suture during this surgery. Other procedures I was able to assist in included carpal tunnel releases and trigger finger releases. I have sutured a few times previously, but it was great to put this skill into practice once again and gain further confidence. I also became more familiar with different suturing techniques as well as the different types of sutures. I really enjoyed my time in the operating theatres as I was able to assist and feel a part of the team.

Despite thoroughly enjoying the clinics and theatres I attended, I was also able to get involved in other educational activities. During my elective I had the opportunity to carry out a research project looking at the biomechanical testing of distal radius osteotomy for malunion’s. We have been comparing patient specific plates to standard distal radius plates. Not only was this research project a great academic opportunity, but also an opportunity to get hands on with surgical instruments such as drills and sagittal saws whilst preparing the samples. On Friday afternoons I was able to attend the Registrar’s teaching sessions. They were aimed at preparing the Registrars for the exit exams; however, it was useful to see the kind of knowledge they were expected to have at that level. In addition, some interesting topics were covered during these sessions, one of my favourites being the session on amputations. One thing that stood out to me during my elective was that all the staff were keen to teach, which I am very grateful for.

What were the best things about the visit?

Overall, I have thoroughly enjoyed my time on my elective in hand surgery. It has been an excellent opportunity to put my knowledge I had learned at medical school into practice as well as gain a greater understanding of the speciality. It was extremely valuable to meet people at different stages of their career, from Juniors to Registrars to Consultants: giving me a greater appreciation for the speciality during different stages of the career.

Would you recommend this to someone else? 

It was a privilege to undertake my elective at The Robert Jones and Agnes Hunt Orthopaedic Hospital and I would highly recommend it to others with an interest in hand surgery.

Are you more likely to choose a career in hand surgery as a result of this experience?

These 4 weeks have reiterated to me that hand surgery is definitely a career path I am interested in and would love to pursue in the future.

Country visited

Brazil

City or town

Rio de Janeiro

Hospital/unit/clinic

Hospital Federal dos Servidoers do Estado do Rio de Janeiro

Dates visited

06/05/19 – 31/05/19

Contact details of your host:

Dr Chang Yung Chia

Please email secretariat@bssh.ac.uk for contact details

Please give an overview of what you saw / did

My elective rotation took place at the department for reconstructive microsurgery in one of the main government surgical hospitals in Rio. The days usually started around 8.00am. My days usually consisted of attending theatre, sitting in clinics and attending surgical ward rounds. I also managed to take several histories from patients (with the help of a nurse to translate) from which I am considering writing a case report up.

As I had expressed my interest in upper limb surgery to my supervisor, he made sure that I was able to attend the relevant surgeries that were planned during the week. I was fortunate enough to witness several different types of upper limb surgeries, including surgeries for pathologies such as cubital tunnel syndrome, carpal tunnel syndrome, tendon repair from knife cuts and skin flaps due to burns. I also was able to see other types of surgeries to other regions of the body (as my supervisor was a general plastic surgeon). Unfortunately, because of the language barrier, I was only able to observe the surgeries and was unable to scrub in. Although, when in theatre with my supervisor, he would try as much as he could to explain and show what was going on. After each theatre, I would join the surgeon in his office and would have a chance to ask any questions from the surgery (with the help of google translate).

Clinics were run by general plastic and reconstructive surgeons. There was no dedicated hand surgeon, however hand cases were prominent during clinic time. I was able to see many common hand pathologies, but also some rarer pathologies not usually seen in the UK. I was unable to take histories during clinic time or ask any questions due to the language barrier. However, when I sat in with my supervisor, I was able to ask him questions after the consultation. What made clinics even more interesting, was that I was able to follow some patients from their clinic attendance to eventually their operation.

Ward rounds gave me the opportunity to see different hand cases. Although they were done in complete Portuguese, any interesting patient, I would come back and try to take history from them – either by using google translate or by asking a nurse to assist with translation.

What were the best things about the visit?

The best things about my time spent in Rio can be split into elective positives and city positives. Starting with my elective, one of the best positives was that I was able to supplement my academic learning with clinical experience. I was able to witness the majority of the pathologies that I had been learning about over the last year, in both clinic and theatre. This is what I set out to achieve by organising a plastic/ hand elective and so I was pleased that this came through.

I was able to witness several hand trauma cases, you wouldn’t normally see in a UK hospital, such as those involving knife wounds, animal bites and burn injuries. I knew that in Rio, these injuries are more prevalent than in the UK. The fact that I was able to be in the operating theatre for these cases was very satisfying. In fact, one of the most memorable cases for me was a seeing a patient present with flexor tenosynovitis from a dog bite, which needed urgent drainage.

Lastly, it was an amazing experience to see how hospital care is delivered in a popular government hospital in the centre of Rio, and compare my experience and patient experience with that of a hospital in the UK.

In terms of city positives, Rio was a fantastic city to complete an elective with. It was vibrant and there were always things to do. From beaches, to treks, to sightseeing, it had everything.

What problems did you encounter? (120 words max)

The biggest problem I encountered was definitely the language barrier. Although my corresponding surgeon, Dr Chang, spoke reasonable English, I was not with him for the majority of operations, which meant I was observing other surgeons whose English was extremely limited. Thus, for many of the operations, I was unable to interact with the surgeon and his team and was reduced to a very much observer role Clinics were also proven difficult due to the fact that I was relying on the language ability of the clinician as translators were not available. When on the wards, my ability to speak to patients was limited understandably and therefore I had to have nurses attempt to translate for me when taking histories.

What accommodation was provided?

Unfortunately, the hospital I was attached to was unable to provide accommodation. Therefore, I had to arrange my own accommodation using the AirBnB website. My accommodation was situated approximately 30 minutes from the hospital.

Would you recommend this to someone else?

Yes and no. Yes, because I was able to see many of the common hand and elbow pathologies, which I had been learning about during my academic year. Furthermore, I was also able to see knife and burn injuries to the hands (which are prevalent in Rio) which is what I set out to do initially. No, because the language barrier meant that it was difficult to engage with the patients and the surgical team alike (meaning that I was unable to scrub in and could only observe), whether that was in the operating theatres or in clinics.

Are you more likely to choose a career in hand surgery as a result of this experience?

I already had developed a keen interest in hand surgery over the previous academic years. This elective then gave me further confidence to pursue a career in hand surgery. The variety of pathologies that I was able to see (which supplemented my learning) as well as the theatre and clinic experience has given me a very good insight as to the day-to -day life of a hand surgeon. This is something, which I will strive to achieve now.

Country visited

Australia

City or town

Perth

Hospital/unit/clinic

Royal Perth Hospital

Department of Plastic, Reconstructive, Maxillofacial and Hand Surgery

Dates visited

14/07/2019 to 26/08/2019

Contact details of your host:

University of Western Australia Elective Coordinator: Kathryn Edhouse

Please email secretariat@bssh.ac.uk for contact details

Please give an overview of what you saw / did

During my elective I attended the plastics clinic on Mondays and plastics theatre from Tuesdays to Fridays.

In plastics clinic I shadowed Mr Rawlins and many other members of the plastics team as they took histories from newly presenting patients, as well as those who had been referred or were attending for a review following past treatment. I also took the opportunity to get involved and took many histories from newly presenting patients, which was a great opportunity to gain some independent clinical experience. The patients attending the clinics provided me with experience of a great array of plastics related presentations, including skin cancers, traumatic injuries often involving the hand, and there were many review appointments for patients who had undergone complex procedures such as free flaps and tissue transfers.

In theatres I was fortunate to observe and assist in a great variety of procedures, including debridement and washout of wounds, reduction and fixation of fractures of the hand, excision of skin lesions, tendon repairs and transfers, skin grafts, and also a range of flaps. My experience in theatres was great and I feel it has given me a thorough introduction to basic surgical skills and the functioning of a surgical team.

What were the best things about the visit?

I’m not sugar-coating this report when I say that every member of the plastics team was very welcoming and were keen to get me involved in every aspect of patient care, with Mr Rawlins in particular showing an infectious enthusiasm for the specialty.

I gained plenty of surgical experience with the time I had, being able to scrub in for practically every case in theatre. I was also able to practice multiple surgical skills frequently such as suturing, harvesting of split-thickness skin grafts with a dermatome, and also applying dressings and assisting in applying plaster of Paris. 

I also particularly enjoyed the friendliness of the entire team, especially in theatres where they had great humour and an excellent team culture! 

What problems did you encounter?

I didn’t actually encounter any particular issues during my elective.

I was possibly a tad hesitant in getting involved during the first day or two of the elective, which is to be expected when joining a new team of strangers! I did however soon find myself getting stuck into all the work that was available for me to do.

My advice to other students going on their elective would be to not fear showing your enthusiasm for the specialty as this will spur the team to involve you, and always ask questions, as there is never a stupid question.

What accommodation was provided?

I organised my own accommodation through AirBnB. I stayed in the suburb of Carlisle which was only a 20-minute bus journey to the hospital. Perth generally has good public transport and so you should find no difficulty in getting around by bus or train.

Would you recommend this to someone else? 

I would highly recommend Perth as an elective destination for any student. I thoroughly enjoyed my time there and have come away with a fantastic experience of what a career in plastic surgery has to offer.

Also, I organised my elective through the University of Western Australia, who were very happy to refer me onto their welcoming rugby team which really put the icing on the cake. And so, if you’re keen on any sports just ask and you’ll be put in touch with the right people! There are also a range of other things for you to do during the downtime, such as a visit by ferry to the quokka infested Rottnest island, trips to the beach, and plenty of excellent hikes nearby to the city.

Are you more likely to choose a career in hand surgery as a result of this experience?

For me, this elective was a golden opportunity see if a career in plastic surgery really is for me, and having thrown myself into the placement and seen what amazing outcomes patients can have from the plastics armamentarium, I’ve come away with the determination to pursue this specialty. In particular I’ve found hand surgery to be incredibly interesting as a subspecialty, with its complex nature and the great rewards of returning form and function to one of the most important parts of the body!