Student Reflection by Soita Wycliffe Chitiavi

Elective Placement at The University Of Toronto (14th April To 19th May 2009)

Soita Wycliffe Chitiavi at Genesis Research Foundation 18th Breakfast

Soita Wycliffe Chitiavi at Genesis Research Foundation 18th Breakfast.

Preparation For Electives
The six-week-long elective placement in Moi University School of Medicine can be undertaken in a health institution within or outside of Kenya. I was privileged to have been selected to do mine overseas. On 14th January, we balloted for the various centers available in North America. I chose the University of Toronto (UofT). Being a relatively new elective center, I knew little about it and about Canada as a country. Over the following two months however, we had a lot of interaction with UofT, with Mr. Aaron Yarmoshuk and Dr. Dave Caloia, both of whom we met in Eldoret, as well as constant communication with Dr. Rachel Spitzer via e-mail. They patiently answered our many questions on various topics about the electives. Timely responses from UofT facilitated the processing of our passports and visas. Two students, Anne and Damaris, who had done their electives at UofT last year, were also invaluable in orienting us beforehand on what to expect and how to prepare for Toronto.
Travel

It was very exciting travelling by plane as it was very fast for most of us. We left on 13th April at 11.10PM from Nairobi and arrived in London at 7:00AM. Six hours later we were airborne en route to Toronto via a British Airways flight. On landing at the Pearson Airport, and after clearing customs, we collected our bags and proceeded to the waiting bay where Dr. Spitzer and Mr. Yarmoshuk were waiting to receive us. As we got out of the Airport, the reality of the cold weather hit us. It was extremely cold – probably about 2-5°C – and despite having my jacket on, I still shivered in discomfort. We were taken to the 89 Chestnut Residence on Chestnut Street where we checked into room 538, which would be our residence for the elective period.

Accommodation
89 Chestnut residence is a UofT residence, formerly called Colony Oak Hotel. On check-in, we were given electronic ‘welcome’ cards which we used to access our room, the gymnasium, elevators, washing areas and other facilities at the residence. We also had an electronic meal card which would be swiped through a scanner every meal time in order to access the cafeteria. We had two meals per day – breakfast and dinner – at the residence, which were of amazingly diverse variety. I tasted almost every variety of food available and by the second week, I had settled on the menu most agreeable to my palate, the names notwithstanding. Ugali (a Kenyan staple food) was of course conspicuously missing! But not to mind, there were more than enough cuisines done by top-notch chefs to fill the gap. Our room – 538 – was generous, had ample reading space, neat lavatory facilities, and a breathtaking view of thecity. A telephone and modem for internet connection were also available. The hotel was about a 10-minute walking distance from the placement hospitals: St. Michael’s, Mt. Sinai, and Women’s College Hospital. We felt honored to have been accommodated at 89 Chestnut.

Clinical Rotation – St. Michael’s Hospital (SMH)
I started my clinical rotations at SMH where I spent the first 3 weeks, from 15th April to the 1st of May 2009. Registration and orientation went smoothly with the assistance of Angela Lacroix (Secretary to Dr. G. Lefebvre, Dept. of Ob/Gyn) and Sonya Surbek (Education coordinator, Med. Educ., FitzGerald Academy). Most of the time I shadowed Dr. Stephen Im. Occasionally, I worked with other doctors such as Dr. Eva Morcaski, Dr. Freire-Lizama, Dr. Mark Yudin, and Dr. R. Shah, among others. They were great teachers, always patient in guiding me through the various procedures to ensure my comfort with the new environment and gadgets. The resident doctors and nursing and support staff were also very handy in facilitating my learning at SMH. Areas in which I rotated included:

  • Labor and Delivery floor
  • Prenatal clinic
  • Operating Room for Gynecology surgeries
  • Women’s Health Care Center – Colposcopy clinic

On the labor floor, many aspects of labor management were intriguing, for instance: the use of OBTV and Powerchart computer programmes in managing patients’ data, continuous electronic monitoring of fetal heart rate and uterine contractions with built-in alarm systems in case of deviations from normal parameters, routine use of epidural and Patient Controlled Analgesia, External Cephalic Version and amniocentesis under ultrasound guidance, and for every delivery the resident and attending doctors were always present. I was surprised too that the husband/partner always accompanied the woman throughout the process of labor and delivery. I was given the opportunity to participate in many deliveries, repair of episiotomies, caesarian sections, and triaging of patients, among other learning activities. The 24-hour calls provided a great chance to master various skills on the labor floor.

In the prenatal clinics, I learned to use the tocodynamometer and interpreted various tests for fetal well-being, especially genetic screening. For the first time, I witnessed laparoscopic surgery in the OR. I was subsequently allowed to assist in several other endoscopic surgical procedures such Laparoscopic oophorectomy, hysteroscopic polypectomy and endometrial ablation. This was quite an exciting experience for me. In the colposcopy clinic, I participated for the first time in colposcopy, LEEP, and ECC procedures. I was given the chance to do speculum exam, apply vinegar and TCA, and to collect pap smears, endocervical Chlamydial, and vaginal swabs.

I attended several teaching rounds, which I found very enriching and educative. Overall, SMH was a great learning opportunity. The relationship of the health care team to the patients, their relatives, and to one another was very warm, cordial, and impressively professional.

Clinical Rotation – Mt. Sinai Hospital (MSH)
For the last 3 weeks of the electives, I rotated in MSH from 4th to 19th May 2009. On the first day at the hospital, I found the ever-orderly Jane Gracey ready with a folder bearing my name. The folder contained a schedule of the activities I was to undertake for the entire period of placement at MSH. Orientation to relevant units, training in use of Powerchart/OBTV, and registration to get MSH identity cards was ably coordinated by Jane.

My supervisor was Dr. Elyse Levinsky. Her energy, sense of humor, enthusiasm, and patience as a teacher enhanced my learning experience at MSH greatly. Other Doctors I had the privilege of working with included: Dr. Allen, Dr. Shapiro, Dr. J. Thomas, Dr. J. Kingdom, Dr. M. Sved, Dr. F. Engle, Dr. M. Barkin and Dr. Greenblat. The team of resident doctors, nursing, and auxillary staff at MSH also enriched my overall experience at the hospital. Activities of interest were in:

  • Labor and Delivery
  • Prenatal and Postnatal clinic
  • Operating Room
  • NICU
  • EOPS
  • CEOU
  • IVF clinic
  • Seminars and Grand rounds

Experience on Labor floor, prenatal clinics, and operating room was similar to that of SMH. I however witnessed for the first time a laparoscopic hysterectomy and the use of ‘Sidney’ computer programme to control insufflation, white balance, etc. during laparoscopic operations. The state of the art facilities and multidisciplinary team of specialists providing care in the NICU was quite impressive. In the EOPS, I assisted in various operations done by Dr. Allen, for example: hysteroscopic polypectomy, endometrial ablation and endometrial curettage. In the CEOU, I observed ultrasound scanning at various gestational ages. Dr. Gare explained the interpretation of the fetal scans, especially how to diagnose abnormalities such as hydrocephalus, intestinal atresia etc. In the IVF clinic, I witnessed the embryo transfer done by Dr. Greenblat assisted by a team of Embryologists. Grand rounds and seminars for 3rd year medical students were equally informative.

Research Meetings
We had the privilege of attending three research meetings relating to Ob/Gyn which proved very informative. These were:

  1. The 18th Genesis Awareness Breakfast
    Held on 23rd April ’09 at Mars Discovery District, 101 College Street. It was an educational session focusing on Breast and Ovarian cancer. We are highly indebted to the Genesis team under the chairmanship of Dr. Alan Bocking, for the invitation and role in funding many programmes in MTRH/Moi Sch. of Medicine including our electives.
  2. The 7th Annual Global Health Research Conference
    It was held from 27th to 28th April ’09 in Macleod Auditorium, 1 Kings College Circle, Faculty of Medicine, UofT. The theme was “Convergence of Maternal & Child Healt – global perspectives”. It was organized by the Centre for International Health, Dalla Lana School of Public Health and University of Toronto Department of Obstetrics and Gynecology.
  3. Obstetrics & Gynecology University of Toronto 26th Annual Research Day
    Held on 8th May ’09 in Emmanuel College, 1st Floor Victoria University, 75 Queen’s Park, UofT. This is a yearly event in which students of UofT at various levels – undergraduate, residence, fellowship, etc. – make a presentation on research they have carried out to a panel of Judges (Lectures). Posters are also put up, presented, and then assessed for awards. The organization of the conference, quality of research, posters, and presentations were top notch. The Henderson lecture by Dr. David L. Keefe, titled “Burning the Candle at Both Ends – A Telomere Theory of Reproductive Aging,” was quite sobering.

Extracurricular Activities
Despite the busy academic schedule, we sought to learn other aspects of the Toronto city and the Greater Toronto area.

Visits within Toronto city
We made daily walks about the city every evening to savor the rich architectural designs of buildings, the road network (it was surprising that motorists generally adhered to traffic regulations!), the parks and the populace with its rich diversity in terms of racial descent and, not in the least, the fashion sense! Specific places of interest we visited included:

  • The Toronto Islands
  • CN Tower
  • Royal Ontario Museum
  • Ontario Art Gallery
  • AMC Yonge-Dundas movie theatre
  • Various Ethnic Restaurants

Dr. David Zakus and Mr. Yarmoshuk took us to a baseball game at the Rogers Centre when The Blue Jays were playing The New York Yankees. Unfortunately “we” lost. The next day, we were back at the Rogers Center with a group of medical students from UofT. This time round, we won against the Chicago White Sox.

We did enjoy the lunches & dinners we had with friends, the most memorable being:

  • The invitation to Dr. Spitzer’s. We had a wonderful fellowship with her family. Seth was just around the corner but hadn’t come along yet. We were to meet him a few weeks later.
  • Lunch with Abu Sriharan, Blair, and Leena, who work at the Peter A. Silverman Centre for Global Health, MSH.

We sampled transport options in Toronto by using at various times: the streetcars, the subway train and the Greyhound buses.

We shopped in various malls including Eaton Centre and Future Shop. Chinatown and Dollarama were handy places for relatively cheap items.

Visits outside Toronto
Aaron took us down to Niagara Falls. Along the way, we enjoyed the sight of the green fields, vast farms of grapes, and vineyards. We had to make a detour to one of the wineries to test the age-old homegrown wines. Niagara Falls was breathtaking. The height of the waterfall, the mist created by the falls, the “Maid of the Mist” visible near its base, the fact that the second fall was entirely in the US and Buffalo University was just across the channel, were all incredulous.

From Niagara Falls, we went to Niagara-on-the-Lake. It’s such a scenic town with tulips in bloom in a variety of colors. After lunch, we visited Aaron’s parents at St. Catherine’s before hitting home –Toronto.

We visited several Kenyan families, first in Kitchener-Waterloo, and were shown around Waterloo University where the couple is doing their PhDs. Then in the Vaughan area of the York region was the 2nd family, with whom we attended a Sunday church service at New Life Christian Church. Lastly, we visited a young Kenyan couple who were being discharged from Rouge Valley Hospital in Scarborough upon delivery of their first born son.

Challenges At the Hospitals

  • New technology was somewhat disorienting for the first few days. At SMH there was no formal training on the use of OBTV and Powerchart and therefore even with the requisite password it was difficult to operate effectively on the labor floor.
  • A few of the patients or their relatives would refuse my presence in the room during certain procedures.
  • The elective period was too short. The differences in medical practice between SMH/MSH and MTRH were significant and it we would require more time to be able to grasp the new practices in order to function effectively.

General Challenges

  • In the first weeks, the weather was hostile and uncomfortably cold for us.
  • The food tasted strange in the first few days and needed getting used to. Making an order for food at a cafeteria or restaurant was a challenge since specific descriptive lingo was required; being in the company of a native friend was strategic.
  • Communication with family and friends back in Kenya needed some adjustment due to the time differences between the two countries and relatively punitive mobile phone tariffs in Canada. Skype mitigated the problem somewhat.

Recommendations
To benefit optimally from the OBTV & Powerchart training given at MSH, either both students on electives should do their first 3 weeks at MSH; OR

Both students should have a 2-day induction to the programmes after which one of them moves to a different hospital.

Accommodation for next year electives students be maintained at 89-Chestnut Street. The allowance for next year elective students be maintained at CAD 750.

Conclusion
Doing my electives at the University of Toronto was a huge milestone in my life and will forever be etched into my memory. It was a great learning opportunity, an eye-opener to advances in obstetric care I hither-to had not witnessed, a chance to interact and make friends with people of all walks of life, and an epic adventure, too. It was worth every dollar spent and an evidence of the generous spirit of the people of Canada.

Acknowledgements
Every single person I interacted with in Canada, and they were many, left an indelible mark and facilitated my academic and social development one way or the other. Of special mention however were: Dr. Alan Bocking, Dr. David Zakus, Dr. Rachel Spitzer and Mr. Aaron Yarmoshuk, who ensured that we had the best that UofT and hospitals of placement had to offer. My primary supervisors: Dr. Stephen Im of SMH and Dr. Elyse Levinsky at MSH made learning so much more interesting. Thanks for being great teachers. Unraveling the complex set-up of the hospitals would have been impossible without the facility of Angela Lacroix at SMH and Jane Gracey at MSH – you made me achieve so much in such a limited period of time. I wish to acknowledge other doctors, residents, and nursing staff at the two hospitals for aiding my learning at various levels of supervision. Medical students at UofT made great friends. Mr. Sospeter Kaai & family, Mr. Maina & family made us feel Kenyan away from Kenya. We appreciate their hospitality.