Student Reflection by George Gatebu Ngare

The Journey Of My Life

George Gatebu Ngare at the Toronto Islands

George Gatebu Ngare at the Toronto Islands.

My name is George Gatebu Ngare, 25 yrs old, Kenyan by birth, and a fifth year medical student at Moi University (MU) in a 6 year medical undergraduate programme. I came to Toronto for an elective in ObGyn courtesy of the exchange between MU and the University of Toronto. This opportunity was availed to me on merit but it is by chance that I picked this destination from a jar. Twenty-four others (students) in my class got to go to other places like Indiana, Portland, Sweden and Brown University. The bulk of my class (85) are in various places within the country and a few are in neighbouring countries doing an elective programme of their choice. This is my first international experience save for Uganda and Tanzania. My school is located in Rift Valley province, 700 kms from home. I stay with my parents in Nairobi over holidays (roughly 5weeks in December) but home is somewhere in the Mt. Kenya region. I don’t have a family of my own yet; that is in the future, as well as clearing 6th year, an internship for 1 year at a public hospital, and a residency in Obstetrics and Gynaecology. Before I came to Toronto I loved jogging, movies, and playing soccer; my self-identified strength was endurance and no one had a problem with my Kenyan brand of English. My biggest fears were benign prostatic hyperplasia and spiders.

I come from Murang’a which is in Central Kenya and which is home to the famous Mt. Kenya. Mt. Kenya is the highest (4,572m) mountain in Africa after Kilimanjaro. My home was a focal point during the Mau Mau disturbances (struggle for independence) in 1952-56. The Kikuyu (my tribe), Meru, and Embu people cultivate Mt. Kenya’s fertile lower slopes. From 1,524 – 4,572 m altitude are dense woodlands inhabited by elephants, buffalo, and leopards (note: “NGARE”, my family name, means leopard in kikuyu).

Preparations
I had three months to prepare for this journey. Mrs. Sarah Ellen Mamlin (of Indiana University and who is based in Eldoret, Kenya) took the task at heart to make arrangements for our passports, VISAs and flight bookings. She told us what to expect at our places of electives. We were immunized, took a short course on fancy dinners, and she introduced us to a Canadian $2 coin and instructed us to try everything (food and drink). Dr. Rachel Spitzer was in touch with us on the other end. She sent us all the official documents and welcomed us beforehand. She made all the arrangements for our stay here and formally introduced us to students and staff at UofT, Mt. Sinai, St. Michael’s, and Women’s College Hospitals. She also had the help of Mr. Aaron Yarmoshuk of CIH (Centre for International Health) who we met while still in Kenya.

I traveled home on April 9th to spend the Easter holiday with my parents as well as to say good bye. The mood at home was vibrant. I must say I regret stealing the holiday from them because my journey occupied their minds greatly. My mum was so happy she kept praying and thanking God for the miracle. She was at the time nursing my Grandmother at home who has advanced breast cancer and even she was filled with joy. I spent the nights with my older brother who rammed in me some wisdom about this opportunity. He told me in my mother tongue “not to pee on good fortune and told me to feel free to become a Canadian Obama!”

I did not get much sleep as we had been told to get into the plane tired to so that we could sleep through most of the journey in order to arrive fresh and shorten our jetlag.

I arrived at the airport accompanied by family (7) and friends (9), thereby getting a small village send-off. When I had said goodbye to all, I pulled my dad aside and told him that I would make him proud. Funny thing no one was crying; it seemed like they were pushing me onto the plane.

I did not get much sleep on the first flight. I was fascinated by the technology on board and I kept checking under my seat for the safety jacket. I think I was the only person paying attention to the safety measures being explained. I was anxious about the stay away from familiar territory (because I love control!) and all the responsibility on my shoulder. I was to uphold the university’s name and have fun, learn without tiring my teachers, talk English all the time but not come home with an accent, buy gifts for friends with an unknown price tag, etc. During the flight there were two humming noises: my stomach and the engines. My GI tract rejected the foreign plane food violently. I chose what to eat carefully on the second flight. We sat near the emergency exit and I remember telling Wycliffe during some turbulence that we would jump out before there was a cause to. I finally got sleep thanks to a Mr. Jack Daniels.

We arrived in Toronto on 14th April 2009 at exactly 13:30 pm to be welcomed by Dr. Rachael Spitzer and Mr. Aaron Yarmoshuk. It must have been 5°C outside; though I had been forewarned, having 15°C as my lifetime record lowest temperature, any preparation would have been futile. My ‘warm’ attire turned out to be summer wear and nothing worked. I knew it was spring so I couldn’t help but wonder what winter was like. Mr. Aaron kindly offered to adjust my wardrobe with a jacket and so did Elaine of Mt. Sinai later on. The drive to the residence was exhilarating; seeing all the smooth roads, beautiful buildings, and a complex transport network had me stunned. Rachel and Aaron gave us an introductory tour but all I remember was the CN Tower, College St, University Ave and Mt. Sinai. The huge city before my eyes was awesome; I made a mental note to commit to memory a few phone numbers in case I got lost and to always walk in one general direction.

We arrived at the residence; still a hotel to me. Our hosts were keen to know whether the hotel was to our liking and I thought it was fantastic. We were to have breakfast and dinner from the residence. The residence had a pool, gym, foosball table, piano, study place, a view of the city, and it was located next to a fancy star hotel called the Metropolitan. From the window we could see City Hall, the Hilton Hotel (which looks beaten down), and for three weeks we could see the Tamil protest on University Ave When our hosts had left we appreciated the room further and were taken for a brief tour by a friendly staff. He further gave us a number to a doctor from Kenya who had spent time some time at the residence and who now works at Sunnybrook. I slept that night soundly amid my confusion, disorientation, and anxiety. I prayed there were only a few things that I didn’t know I needed to know.

The broad objective of the elective programme in MU is to provide the student with an opportunity to acquire knowledge, skills, and experience in a different learning environment in areas of their interest.

Specific objectives include:

  • To widen the students’ experiences in undergraduate education and strengthen their areas of weakness
  • To develop the ability to participate in the planning and the implementation of their learning activities and in making rational decisions
  • To increase the students’ responsibility for self determination in their education

I also wanted to see, feel, experience, participate, hear, and understand as much as I could take in of all aspects of human life in a G8 country over 6 weeks.

MSH Journal
Wednesday, April 15
Registration at the Medical School Building
Signing malpractice insurance forms
Brief tour of the library
Computer training in power chart
Obtaining passes to call rooms and access codes to scrub dispensers

Thursday, April 16
Dr. Windrim’s High risk clinic

Friday, April 17
Round on hyperthyroidism in pregnancy
Dr. Windrim’s High risk clinic
Computer training in OBTV

Monday, April 20
OR with Dr. Wendy Wolfman – laparascopic procedures

Tuesday, April 21
Dr. Paul Bernstein prenatal clinic
Overnight call in Labour and delivery

Thursday, April 23
Dr. Windrim’s High risk clinic

Friday, April 24
Day call in labour and delivery

Sunday, April 26
Day and overnight call in labour and Delivery

Monday, April 27
Evening launch of the Maternal Child health conference

Tuesday, April 28
Maternal Child health conference

Wednesday, April 29
OR with Dr. Michael Sved

Thursday, April 30
Dr. Windrim’s High risk clinic

Friday, May 1
Round on developments in surgical wound care
Day call in Labour and delivery

While at Mt. Sinai I was mostly under Dr. Windrim. In his clinic there was a team of sonographers. I spent most of my time with them. While there, I picked up some lessons on twin- twin transfusion, renal anomalies, gastroschisis, IUGR, fetal demise, reduction surgery, estimation of weight, and anatomy scans. I also attended Dr. Paul Bernstein’s antenatal clinic. This is a man with famous patients who were all distinguished and had cool histories. I saw a patient who was 36 but looked 20 years old.

While in Labour and delivery calls, I worked with team B taking patients’ histories and doing physical exams at triage. I used the computer based programme for monitoring labour, as taught. I participated in SVD’s and scrubbed for a number of CS’s while observing an even larger number. By my third call I was very comfortable with what went on there. Every labouring mother had the comfort of a single room, one full time nurse, the company of a midwife and spouse, and few family/ friends. All the patients I met were accompanied by their spouses; something we observed with Wycliffe was that the family units were tight knit. The patients had a team taking care of them composed of staff (Consultant), fellow (visiting consultants/residents with further training), Resident (Registrar), and student. The level of comfort afforded to the patient was fantastic. I saw my first birth plan, which guided the care providers on how mothers wished to be helped. On my first day on call my supervisor delivered a son in the same facility. I wondered how many of our staff back at home would do that, again reiterating on the level of confidence the staff has in its own care here at Mt. Sinai.

Operating room: I watched 5 laparascopic surgeries for hysterectomy and endometriosis. I was shocked to observe prophylactic oophorectomies based on high risk and BRCA gene tests. I found the Drs. (esp. Wendy Wolfman and M. Sved) in the OR particularly cheerful and helpful. They explained, asked, answered etc. I wish I had spent more time there but honestly I don’t know what would have been cut out to avail this opportunity!

Rounds: I attended rounds on various topics held at lunch times and Friday mornings. These were very detailed and covered various topics. I feel that my divergence with pizza began there. The last piece I had was in one of those; I don’t like pizza any more.

I attended a conference on the 27th – 28th of April. I met Prof. Heather Morris and some of the students who had come to visit Kenya.

I attended a teleconference conducted by Lindsay and Dr. Kelly Murphie about HIV/ AIDS and was amazed to learn that the prevalence of the disease in Canada is 50,000 in a country with 30 million people. The level of care for these patients was also evidenced-based and very humane. Dr. Kelly Murphy is a brilliant teacher and a cheerful person; she was the happiest person I met.

I ventured into the NICU and I was amazed at the number of incubators and the variety of procedures done for those born premature. The youngest at the time was 23wks and the lightest was 650g.

I attended the Genesis Research Foundation annual breakfast meeting. A group that had a hand in the presence of the Riley Mother and Child Wing of MTRH back at home.

Above all I will not forget the lessons I carried out of the whole experience. I learnt so many things but the following were burnt in my heart. I was really moved.

I spent close to 2 weeks at Women’s College Hospital. This hospital was where I did the most in gynaecology.

Monday, May 4
Registration
Tour of the hospital
Labour and Delivery in the morning
Afternoon clinic- gynaecology with Dr. Jamie Croft

Tuesday, May 5
Dr. Zalts gyne and prenatal clinic

Wednesday, May 6
Day and night call in Labour and Delivery

Friday, May 8
Research day

Monday, May 11
Day and night call Labour and delivery

Wednesday, May 13
Dr. Akoury’s high Risk clinic
Dr. Jenifer Blake’s Gynaecology clinic

Thursday, May 14
Prenatal clinic with Dr. Ori Nevo
Lunch with the Silverman foundation staff

Friday, May 15
Infertility clinic at Create fertility centre with Dr. Ari Baratz

Tuesday, May 19
Clinic with Dr. Akoury

There were many things unique to my experience at Women’s College. It was the first time I met other students. Since it was a smaller hospital, I had the advantage of knowing most people by their first names. I felt particularly at home during labour and delivery calls because of the nurses and the very able residents. This was an obviously shorter stay, worsened by a research day and a national holiday on 18th May. It was the only facility in which I got to see gynaecology patients and thus was very beneficial. I saw patients pre-op and those with problems not warranting admission; this is deficient at home where the bulk of patients in gynaecology are managed in the doctors’ private clinics.

I enjoyed research day. I met most of the students who had come to Kenya for their electives. I listened to all their presentations and couldn’t help but notice that they had very controversial topics which sparked the interest of the judges. I will never forget the presentation by Elissa on CARE, a unit that takes care of patients who are victims of sexual assault. The appalling findings greatly disturbed Dr. Heather Shappiro and Dr. Nevo greatly.

Dr. Zalts, Pittini, Akoury and Nevo allowed me to do as much as possible while on the labour floor. Patients of this hospital seemed to stop coming in from around 2AM In the clinics I was able to help around as I learnt.

The infertility clinic blew my mind. I saw what many of my classmates will only get to read about. Dr Ari Baratz was energetic and got me inside the rooms with patients 100% of the time. I saw three IUI’s, a retrieval of ova, diagnostic hysteron-sonography, and I sat through the whole process in various pieces. At the end I had a clear conception of what was done at the clinic, including the social and legal issues surrounding interventions. Dr. Ari counseled patients with failed interventions and one without hope of success. It was hard for these patients and the way in which this counseling was done moved me. I learnt that it costs about $11,000 to try to get pregnant 1-4 times, and that the government did not cover in-vitro fertilization for women with intact fallopian tubes. I also met a Dr. Glass who attends to cancer patients before they go through therapy to secure future reproductive options. She explained the various services they offer to these patients. I finished the day with a tour of the very secure rooms where embryos, ova and sperm were stored. Sadly, I did not see retrieval of spermatozoa by a urologist or the rooms where the samples are collected. I can only imagine.

In summary for the two facilities:

  1. I saw a staff so kind to the patients and their families, and concerned about their comfort, well-being and happiness.
  2. I had the opportunity to talk to the most polite, patient, and receptive clients and patients. I experienced a sense of order in paper records and protocol and saw how adherence makes a difference.
  3. I met the most hilarious doctors, and their cheerful demeanour reflected strongly in their good work.
  4. I saw a style of teaching which encouraged understanding.
  5. I met, shook hands with, and talked to the people who write policy-changing papers, and who contribute greatly to the textbooks we commit to memory back at home. I shook hands with Dr. Greg Ryan and shared a table with him.
  6. I met the most generous crowd: people who give you coats when you are cold, people who call you up because they heard you were from Kenya, and people who offer you a pen because yours is not as nice.
  7. I saw a level of training above reproach. Systems workers and staff were on time and kind to students and patients.
  8. I listened to very informed patients. I liked it and I think it increases the demand for proper care all the time.
  9. The health care in Toronto has a huge preventive element. What can be picked out in-utero is obviously greater.

There was nothing that annoyed me about my visit to Canada. The visit gave me an opportunity to meet other sets of cultural values. I found Canadians very accepting and accommodating. I had dreaded standing out as the only dark skinned person initially, because this would have drawn attention to me and hindered my appreciation of the place. I was wrong. What shocks me is due to 25 years of a life seeing things done differently in Kenya. With this being said I need to state that Canadians drink a lot of coffee. Dundas street smells of burnt coffee, people pay to receive calls, people are crazy about pets, and patients have unreasonably high expectations about the quality of the product of conception.

The Exchange Programme: I got to know more about the partnership between Moi University and the University of Toronto. I appreciated that most of it is based on the generosity and good will of individuals and organisations within Canada. I listened to students present research they had done in my back yard; I was impressed and motivated to participate. I became surer that I want to specialize in obstetrics. I did achieve my academic and non-academic elective objectives working here.

There was also time for play after work. I got to do the following:

  • Niagara falls
  • Ontario on the Lake
  • St. Catherines
  • Waterloo
  • Toronto Islands
  • Rode a street car, a Greyhound and a subway train
  • CN tower
  • Many dinners with families in Toronto
  • Made friends with random Canadians
  • China town
  • Eaton Mall, Canadian Tire, Future shop, Best Buy
  • Visited 4 Kenyan families
  • Spent time with medical students and residents
  • Youthful entertainments spots
  • Tried Thai-food, Somali cuisine, Indian, and accepted uncooked veggies finally
  • Fell out with pizza, pickles and hotdogs
  • Put money in a viewing machine at Niagara and got ripped off
  • Stopped converting every expense into Kenya shillings
  • Took photos of a 1⁄4 of the journey and engraved the whole thing in my heart