Ahmad Khalifa

Introduction

My medical elective experience in Syria revealed the profound impact of the ongoing conflict and resource limitations on healthcare delivery, underscoring the need for a comprehensive understanding of non-clinical aspects of medicine, including ethics, patient culture, and resource allocation.

Analysis of Elective Plan

I chose to undertake my elective in the Syrian Arab Republic for multiple reasons. Firstly, because I am from Syria and my family resides there. Additionally, I wanted to explore clinical practice in a war-torn country with limited resources, where the healthcare system must make do with what is available to provide sufficient care for the population.

Arranging my elective posed several challenges due to Syria being on the red list in terms of safety. As a result, I could not follow the usual process for arranging my elective and had to meet with the Health and Safety team lead at Aston University. During the meeting, I explained and justified the measures I implemented to overcome these challenges. One such challenge was travelling to Aleppo for the shadowing, as the city’s airport has limited commercial flights. Consequently, I had to arrange my flight from Lebanon, a neighbouring country, and then organise private transportation to the Syrian border where I met my family and travelled home.

Ensuring safety at the placement location was another critical aspect to consider, as there was a risk of physical assault. To address this, I organised a briefing session with my placement supervisor to understand the safety practices in place at the hospital. My supervisor provided me with relevant contact details and explained the processes for summoning help.

Discussion of Elective Experience

My experience during my elective placement was highly fruitful in many aspects, including some interesting dilemmas in ethics, patient culture, and education that are particularly specific to the region.

In this discussion, I will break down the experience from induction onwards, culminating in my involvement in a small teaching and development course for incoming residents who were due to start working in the department. This was intended to ensure a good standard of care for patients in the department.

The experience began with a meeting with my placement supervisor, who also serves as the hospital’s medical director. During this meeting, we outlined the outcomes from the attachment as mentioned in earlier paragraphs. I was then attached to the team of residents responsible for ward care, overseeing postoperative patients, admitting new cases, and reviewing admissions presenting to the emergency department. To make the most of the opportunities available, I was given a tailored schedule to follow, which included an Ophthalmology Day once a week, involving clinics in the morning and theatre sessions in the afternoon.

I found the tailored plan and schedule extremely helpful as it allowed me to remain proactive throughout my placement. Achieving my clinical objectives, developing my clinical skills, and bridging the gap between being a medical student and becoming a doctor with supervised responsibilities were my main goals for this attachment. I feel I successfully achieved these goals while gaining insights into the Syrian healthcare system, which is heavily influenced by the country’s war-torn state.

I was particularly shocked by the extent to which the lowest standards of care have been forced on a community of experienced clinicians due to resource shortages and outdated protocols. The patient journey in Syria is almost entirely self-directed, with patients deciding when to present to the emergency department, often after seeing physicians of their choice. This lack of a standardised system for information sharing often results in neglected conditions and late-stage complications that are challenging and expensive to manage.

This starkly contrasts with the UK, where general practitioners (GPs) provide continuous oversight of a patient’s care from the very beginning. Early detection and timely referrals often prevent illnesses from progressing to severe complications.

Another cultural difference I observed was the practice of withholding information about illnesses from patients, often at the request of their families. Families, aiming to protect their loved ones from the psychological impact of a diagnosis, frequently pressured doctors not to disclose the full extent of a condition. This practice contradicts the principles of transparency and patient-centred care upheld by the General Medical Council and other ethical guidelines in the UK. Doctors practising in Syria sometimes face threats from family members, which, given the current security situation, forces them to comply with these requests.

Additionally, resource shortages mean that even the simplest procedures require patients to turn to the private sector, which is prohibitively expensive for most. With the majority of the population living below the poverty line, many patients neglect chronic illnesses, only presenting with severe complications that require extensive and costly interventions.

A case that stayed with me involved a 75-year-old woman presenting with acute shortness of breath, complicated by poorly managed diabetes and multiple undiagnosed infections. While her condition warranted immediate transfer to intensive care, her family hesitated due to the high costs involved. The resulting delay led to rapid deterioration, sepsis, and disseminated intravascular coagulation, ultimately highlighting the dire consequences of resource limitations on patient outcomes.

Reflections on Emotional and Psychological Impact

One potential drawback of my elective experience was the emotional and psychological toll it had on me. Working in a war-torn country with limited resources and witnessing the struggles of both patients and healthcare providers was distressing and overwhelming. Constant exposure to severe cases, inadequate facilities, and difficult decisions caused significant emotional strain and risk of burnout.

It was emotionally challenging to witness patients facing life-threatening complications that could have been prevented with better resources. The ethical dilemmas and cultural practices I encountered added further complexity. Confronting the stark inequalities in healthcare left me feeling frustrated and helpless at times. Acknowledging and addressing these emotional challenges was essential, and I sought appropriate support and implemented self-care strategies to cope with them.

Conclusion

The ethical dilemmas I encountered during my placement highlighted the challenges healthcare professionals face in balancing patient autonomy with cultural practices and safety concerns. The scarcity of resources and lack of funding significantly hindered the healthcare system’s ability to provide adequate care. Patients often delay treatment or neglect chronic conditions due to financial constraints, resulting in severe complications.

Despite these challenges, the resilience and dedication of healthcare professionals in Syria were inspiring. Their commitment to delivering the best possible care, even under extremely difficult circumstances, served as a powerful reminder of the impact compassionate providers can have.

My medical elective experience in Syria provided valuable insights into the complexities of healthcare delivery in a resource-limited, conflict-affected setting. It emphasised the need for a holistic approach to medicine, encompassing not only clinical skills but also ethics, cultural considerations, and resource management. This experience will undoubtedly shape my future practice as I strive to contribute to more equitable healthcare systems.