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Medical Students' Column

"An American Affair"

The main building of the Children’s Hospital of Philadelphia (CHOP) is a dark brown steel and glass construct. It is an impassive looking structure, built alongside the red-bricked Hospital for the University of Pennsylvania (HUP). Both buildings face Philadelphia’s 34th Street, a busy thoroughfare cutting across the University City neighbourhood in the western part of downtown Philadelphia.

Walking towards CHOP on the first day of my elective posting in early May this year, I had a sense of the building’s sullen austerity, and felt a slight unease. The exterior might seem a tad threatening to children, I thought. This idea however, was swiftly vanquished when I walked past the swinging glass doors into a vast atrium lit by natural light which streamed in through glass panels built into the hospital roof.

Looking up, I saw a large mobile made up of coloured metal twisted into spirals and other shapes dangling from the glass roof, its crisp metallic sheen throwing light onto distant walls from which were hung framed National Geographic-type photos of children playing. I stood there, taking all this in, and breathed out a silent wow.

The sunlit atrium, the mobile and the framed photos of kids found their way into all the e-mails I sent that first day and more than a few on the following. Subsequent e-mails contained such shamelessly enamoured declarations as ‘the atmosphere here is great’, ‘got lost in the pediatric ICU today, it’s like being in the KK labour ward’, ‘the pediatric research building is three times the size of our CRC’.

In short, I was smitten. Like a country lad on his first trip to the big city, or an inexperienced teenage boy caught in the shoals of desire by an attractive older woman, my time at CHOP took on a highly romantic dimension. This was largely because I was (only) a visiting student, with no responsibilities except for self-fulfillment. But I have no regrets that I had such a good time, even if it might not be wholly reflective of what a genuine student there experiences. Who needs bad memories anyway? So indulge me and allow me to share from my 4-week ‘affair’:

The Place

CHOP is affiliated to the University of Pennsylvania Medical School. Established in 1855, it is the first children’s hospital in the USA. In rankings of American Medical Institutions, it jostles yearly with Boston’s Children’s Hospital for top honours. Penn Medical School itself was ranked 3rd in the country, after Harvard and Hopkins in a recent US World and News Report survey.

All these rankings meant that whenever I saw Penn medical students in CHOP, I could not help but think they were summa cum laudes graduates, PhD or MBA (yes, they have a joint MD-MBA course at Penn, in association with the Wharton School) candidates. I was not intimidated by them, though at times I had a strong urge to ask how much individual debt they were in; annual tuition fees (and that’s only for tuition) at Penn Med are more than US$20,000.

America is such a cosmopolitan country that a large proportion of those I met simply assumed I was the resident doctor on the team, one of those ABCs. The opposite scenario is less likely. A Caucasian student doing an elective in Singapore would not be able to join staff meetings or ward rounds as inconspicuously as I did.

Perhaps this is because U Penn itself is that perennial melting pot of cultures. There were so many Asians around, I started to wonder how the WASPs (white Anglo-Saxon Protestants) feel. Do they think I am a part of the Asian invasion? Indeed certain parts of the campus reminded me of our engineering faculty, with large numbers of those from the People’s Republic.

The Team

I was on the Pulmonology Team at CHOP for the duration of my elective. Doctorwise, there were 7 Attendings (Consultants) and 7 Fellows (R & SR) in the department. Nurse practitioners, dietitians, social workers and other administrative staff made up the rest of the team.

The mood was one of relaxed informality and lots of humour. It was tough initially to remember the names of more than 20 newly introduced people, and more than once, I called someone by the wrong name only to realise later. Everyone was too polite to correct me though. When asked about Singapore, I often said ‘its like Manhattan without chewing gum’.

As in Singapore, the pediatricians there seemed to know all their patients by name, a fine practice not as often seen in other specialties. Still, I was thoroughly impressed when an announcement of improved growth in a child with cystic fibrosis was met with cheers and claps from the staff.

Department activities start at 0800 hrs in the doctor’s workroom at the outpatient clinic. In the month I was at pulmonology, there was much discussion on clinical pathways for management of cystic fibrosis patients. There were also presentations on the use of artificial ventilators and tracheostomies. A journal club session revolved around a paper titled ‘Maturational Changes In Ovine Pulmonary Vascular Responses to Inhaled Nitric Oxide’. Much of the discourse went over my head, although I did remember one of the Attendings ask ‘why bother with the prose when there are so many interesting charts to look at?’.

Residents and medical students attend a daily noontime lecture. Most bring lunch along. Everyone eats while the lecture is taking place. This is one practice I can get used to. Topics ranged from the routine (glomerulonephritis) to the more esoteric (genetics of congenital heart disease). The latter were less well attended. Indeed students around the world are alike.

Hospital Grand Rounds are held every Thursday morning. Breakfast (doughnuts, bagels, coffee and tea) is complimentary. This is another practice I can get used to. The hospital auditorium is about twice the size of the NUH auditorium. Students and residents tend to sit near the back while more senior doctors filled the front rows. Indeed students around the world are alike.

A particularly memorable Grand Round was a lecture and demonstration on ‘What to do when things go wrong?’, which focused on how to deal with families when a mistake is made in the management of a child. This was the last session in a series termed ‘Anatomy of a Lawsuit’.

2 Attendings and a lawyer from the hospital’s legal department demonstrated through a short skit how to speak to a parent who had witnessed disagreements between hospital staff during the resuscitation of a child. It was heartening to note that the first point listed in the handout given at the end of the lecture was ‘Always tell the truth’. We should have similar workshops in Singapore, and consultants should be given the honour of demonstrating the relevant dos and don’ts.

The Patients

Perhaps it was because I kept away from unfriendly looking people. Perhaps it was my innocuous countenance. Perhaps it was the accidental bombing of the Chinese Embassy; I mention this last point because my classmate who did his elective at the Mayo Clinic had a patient come up to him who said ‘I am sorry we bombed your country’.

Whatever the reason, I kid not when I say that all the patients and families I had the fortune of speaking to were nice to a fault. In general, the patients at CHOP are more ill than those you’d find at the pediatric department of KK or NUH. This is because the community pediatrician deals with the more common ‘fitters, wheezers, fevers and shitters’ who tend to our wards.

I looked forward to ICU rounds even though at times it seemed like visiting one tragedy after another. I relished seeing heroism up close and enjoyed talking to the brave folk who stood guard next to the ventilators and knew all the medications their kids were on. They were a reminder ‘not to sweat the small stuff’.

4 weeks is a short time. But the density of experience makes up for the lack in duration. I am glad I left before seeing or realising the less positive aspects. So my recollections will always have that silver lining to it. And next year, after I graduate, if and when I get tired or disillusioned by aspects of medical practice here, I will be comforted by the idea that there are opportunities outside our little corner of the globe, in a place where walls are lined by National Geographic-type photos of children playing. Till then, I will just remember what Alfred Lord Tennyson said:

TERENCE LIM CHEE WEN
Final Year Medical Student, NUS
med50016@nus.edu.sg

The writer would like to express his sincerest thanks and appreciation to all the staff of the Division of Pulmonary Medicine, Children’s Hospital of Philadelphia.