When I write a blog entry, I try hard to capture the essence of the emotion of the experiences of what we’re going through at the time. That isn’t easy, and it’s all the more difficult when writing about events that happened weeks, or even months, earlier. After my last blog entry, several people emailed and called to effectively share their condolences at the difficult time we were going through. Grateful as we are for the concern, perhaps my blog painted a harsher picture than reality. The human psyche is afflicted with what they call ‘loss aversion’, whereby our instinct is to recall the negative aspects of life, and ignore the good stuff. The perfect example is when stuck in traffic on a motorway; you always notice when the lane next to you is advancing while yours is static, but it’s only when you realise the same car has overtaken you three times, that actually your lane is moving just as quickly, just at different moments.
So, I think that the negativity of the blog was for two reasons – one was loss aversion – the sudden awareness of what we are missing. But the second – simply that I didn’t want to ruin the build up to the progress in our lives... In honesty, while I was writing about the difficulty finding work and our financial situation, I had already started work; while talking about the two weeks of cleaning our new home before we left it again, we were already back, settled and living.
Shortly after our return from the UK, Deborah and I both passed the so-called ‘entrance exam’ to medical ulpan – a special course for new immigrants to learn the specific parts of the language required for working in our field. The general rules for attending are:
1. Must have moved to Israel in the last ten years
2. Must be a doctor or similar medical professional
3. Must have a good knowledge of Hebrew prior to starting the course
4. Must commit to 5 hours of lessons every morning, 5 days a week, for 3 months.
One would imagine a group of medics from all over the world, keen to learn the necessary vocab in order to start work here and manage to not kill people due to confusion between anatomical and medical terms. All sounds pretty straightforward, no? No.
In order to run the course, the government require a minimum of ten people. Due to the fabulous organisational skills and publicity of governmental bodies here, no one seemed to know of the course's existence, except those who really shouldn’t have been there.
At the entrance exam, for example, we met a RETIRED pharmacist and his daughter, about to undertake a computer management course at the age of 19, neither of whom could count to ten in Hebrew. Although they were accepted on to the course, they had the good sense to turn it down and await something which might actually benefit them in some way. Knowing the phrases ‘gastric banding surgery’, ‘duodenum’, ‘anal fissure’, ‘Fragile X Syndrome’, ‘Oedipus complex’ and ‘porcupine’ (no idea why that last one features in our vocabulary list. But it does), is generally-speaking less important for the average Israeli immigrant layperson than ‘house’, ‘food’, or ‘Do you speak English?’. I remember being given a book of alternative useful phrases for the world traveller, many years ago, which included in six languages the phrase, ‘Excuse me, I am bleeding profusely. May I please use your belt as a tourniquet?’. Again, not one of the most commonly used phrases, but important in certain circumstances nonetheless.
So, as the lesson stands now, we consist of:
- A general physician (which is the non-demeaning way to say unspecialised good-for-nothing; me)
- An unlicensed pharmacist (Debs)
- An unlicensed gastroenterologist approaching retirement
- An unlicensed cardiologist approaching retirement
- A psychologist
- 2 dentists
- A retired French fireman
- A sports management consultant
- A Maldovan health care assistant, who frankly, produces enough hilarious moments in our lives that she deserves her own blog
- A physiotherapist
Making a total number of 11 – just enough to run a course; which is why they lowered the ability level to... well, nothing. So instead of a dynamic group of medics learning about trauma terms and drug names, we whittle away many an hour with our psychology-obsessed teacher talking about the origins of the Oedipus complex (I know I’ve mentioned it twice – it comes up at least 3 times each week in class and therefore deserves several mentions), why men never ever ever become anorexic (apparently), why gay men look after themselves better (apparently), why fibromyalgia really exists (apparently) and how glucosamine can help, and finally, what the origins of the Oedipus complex are.
The rate of learning is rapid – we cover hundreds of words every week, and the vast majority are very useful, either in medicine or in the general world; if not learning the phrase for ‘central crushing chest pain with radiation to the left arm’, then at least ‘drain blockage’ will come in useful for plumbing calls, if not for angina pectoris. Failing that, did I mention that we learned about the Oedipus complex? We follow a loose agenda, and learn whatever words come up in conversation, and as a result, my vocab list can cover everything from ‘immunosuppression’ to ‘chamelion’, on one page.
Given the informality of the Israeli educational system, we are all free to interject and add in our own experiences and beliefs, for the benefit of the others in the class. It’s just as well, because it means that when our teacher tells us that the urethras connect the kidneys to the bladder, and a single ureter takes the urine out to the fresh air, we can point out that she is in fact spouting crap. On occasion though, our class democracy backfires. We had a heated debate recently (sparked by our Maldovan comrade) over the dangers of various colourful fruit and vegetables, namely pomegranates and carrots. Yes, carrots. Our inferior British medical system neglected to tell us that pomegranates are potentially lethal, as they can ‘thicken the blood’. But that isn’t nearly so scary as carrots, which are notorious for ‘altering the chromosomes in one’s blood’. Appalled at these glaring omissions in the Western medical syllabus, I asked what the mechanism of injury to the DNA was. “I don’t know, but in my opinion, carrots are really bad for the chromosomes.”. End of debate.
But in the same time period, much more has been happening than just ulpan. At the end of July, I finally started work, just 2 weeks after getting my license.
I’m working for a chain of private clinics that do something really unique in Israel, but which has revolutionised the health care system here. Filling a gap between primary care and emergency medicine, we are a walk-in centre, but with our own instant laboratory, radiology department, orthopaedics, gynae, and minor procedures. Patients don’t need to wait eternity in an emergency department, and the health insurance companies don’t need to pay a fortune for an unnecessary hospital attendance. Seeing up to 500 patients a day at a high turnover, and with the option to refer the few really ill ones directly to hospital, we have become an intrinsic part of the medical system. So much so, that we keep having NHS managers popping in to pry and work out how they can set something similar up in London.
Starting work in Israel was never going to be straightforward, but moving from the freedom and incredible support of the NHS to a private clinic with such a massive turnover was in itself a massive challenge. For the first time, I wasn’t at the bottom of a ladder of people, working in a team who could always advise me on what to do next; instead, each patient was my own, I can order whatever tests I want when I want, and from start to finish, no one else will interfere... unless I get really stuck and call the boss at home. In fairness, there’s always support when it’s needed, but at the same time, in a private clinic, time is money, and so finding a balance where you stay in control and don’t ever put anyone at risk, while still meeting your quota of patients per hour, is not easy when you need to pop out and call someone for advice. Now, try getting used to that system, while working entirely in a foreign language. Finally, and most importantly, don’t forget that you’re dealing with the largest Jewish population in the world.
Chest pain: A case study
A UK patient
Doc: How are you?
Patient: My chest hurts.
Doc: Where?
Patient: In my right armpit
Doc: When did it start?
Patient: Yesterday, when I was drunk and fell onto a railing outside the pub
Doc: Any shortness of breath?
Patient: No, just pain where this big bruise is.
An Israel patient
Doc: How are you?
Patient: Doctor, I’m in the worst pain of my life. I have this central crushing chest pain in my right armpit, which came on during exertion, shortly after I fell from a height onto a sharp metal railing. Please could you do an ECG, Troponin, and a full blood count? Also, I’d like a chest X ray, because I had a cold last week and want to make sure it hasn’t gone to my chest. Oh, and while I’m here, please could you check my thyroid function? I put on 6 ounces last month. Do you think I need to go to hospital for a CT scan? Or can you do that here?
The sad thing is, in private medicine, where patients can be stubborn, often the patient will get what they want, within reason, even if it isn’t medically justified, or in their best interest. Why? Because, as I learned the hard way, trying to reason with them just wastes valuable time while more patients build up. And the more a patient waits in line, the more they feel they’ve ‘earned’ a longer consultation, and the more justified they feel in asking for even more obscure, pointless, and dangerous investigation. All of a sudden, the whole modus operandi of a doctor has been turned on its head. No longer do we ‘treat the patient, not the illness’ – that is what family medicine is for. In an urgent care clinic, we very much focus our efforts on the matter in hand. ‘If it’ll kill her tonight, treat it, if she’ll still be alive next month, send her to her GP’.
At the end of the day, it makes perfect sense. Allowing ourselves to be slowed down by timewasters not only puts other patients at risk, but also effects business. But it’s hard to get used to saying ‘What’s brought you here today’ instead of ‘How are you?’, which invites the patient to list non-urgent problems too. It’s even harder to refrain from saying at the end ‘Is there anything else I can help you with?’.
So while I’ve been having fun in my clinic, Deborah has also been sent to the grindstone, after finding work in a local pharmacy as an assistant, while awaiting her impending licensing exams. On paper, the job is perfect. Five minutes walk from home, dispensing meds, learning the system, the practicalities of pharmacy here, and the necessary lingo. So what’s the problem? In reality, she has become a shopkeeper’s slave, organising handbag displays, aligning bottles of shampoo, unpacking deliveries. Like me, she gets to enjoy the front line of patient exposure here; for example, the woman who arrived after closing, covered in hair-dye with a towel round her shoulders, begging to be let in for an emergency; upon entering, she handed three pages of repeat prescriptions, all due to run out that evening. And all for 30p over minimum wage... which means that she can afford to buy a cup of coffee each half hour. But, it’s work, and the money adds up (extra large double latte with cream and chocolate sprinkles please!), and in reality, until she gets her license, it won’t be easy to find anything that pays better with any relevance to her training. Almost all of our friends from the first six months have landed comparable jobs, or jobs that pay equally appallingly but with greater risk, like building work, cleaning, or telesales. Many remain unemployed, and make do on the £200 monthly unemployment benefit, with top-ups from mummy and daddy. Some have gone off to the army, where they will not need to spend a penny for the next however-many-months, while earning... well, pennies. And one or two have already packed up and moved back to wherever they came from.
To supplement the hours, she’s also started some online work ‘categorising clinical trials of oncology drugs for their unlicensed uses’. ROCK AND ROLLLLL!
In terms of daily routine, things have really settled down for us now. Were it not for the fact that we are juggling three jobs between us, mine being based on a 4pm to midnight shift most weekdays, and are both spending 25 hours a week in education, with 3 hours of commuting each day, life would feel quite normal. But as things are right now, I get home for 5 hours a day, of which I try to spend every moment sleeping. When I see my wife, we’re either in class, or she’s fast asleep. Until ulpan finishes in 2 weeks, we won’t be exactly living a normal married life. But on the plus side, it’s very difficult to argue with each other, when the only conversations we can have are about carrot-induced chromosomal defects, and we both share exactly the same views on that.
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