Report 1

 Reporter: Patrick Elder (final year, Warwick University)

Contact at destination: Dr Erwan Oehler (head of department). The Bureau des affaires médicales (rh.med@cht.pf) can put you in touch with the head of the department where you’re interested in working.

Year of visit: 2017

Country: French Polynesia

Region: Pape’ete, Tahiti

Institution: Centre Hospitalier de Polynésie Française

Department: Médecine interne et polyvalente

Work/Study undertaken: I spent the vast majority of my time working on the Médecine interne ward. There is no medical school in French Polynesia, so the department only receives students from mainland France on an intermittent basis; however, they were very accommodating and integrated me into the team as an ‘externe’. After a morning shadowing one of the internes (specialist junior doctors), I was assigned a couple of patients of my own at a time. Each day, I would look at their investigation results, go and see them, take a brief history and examine them and then report my findings to the interne looking after them. If I was there when the patient arrived, I was able to do the initial clerking. We would then discuss further investigations and management, which the interne would then implement. I wrote their discharge summaries (though they often needed correcting for French and content!) and was also able to perform certain procedures including ECGs, skin biopsies, suturing and knee aspirations. I didn’t do any of the bloods or cannulas as these were performed by the nurses, usually very early in the morning before I arrived. The consultants discussed the patients each morning with the whole team and also ran a ward round once a week, both of which I was also able to join in with.

I spent the vast majority of my time with the internes, who were all very friendly. They were surprised that I had little experience of working on wards as part of the team; I got the impression that French students are usually much better integrated into departments than we are, and have their own duties and responsibilities. Nevertheless, the internes were happy to discuss the patients and any other problems with me at length, and my relative lack of experience did not prevent me from learning a great deal and enjoying the placement.

Description of destination: The hospital is located in the port city of Pape’ete, which is the capital of Tahiti and the whole of French Polynesia. This is a relatively small town by European standards, but it has all the amenities, and some of the hustle and bustle, that you would expect from a capital city.

Outside Pape’ete, Tahiti in many ways lives up to any expectations you may have of a Pacific island: the scenery is spectacular. Although there are not as many unspoilt white, sandy beaches as you might expect, they are there if you know where to look and there are a huge number of picture-postcard vistas. The island is very mountainous and the interior quite inaccessible, so the vast majority of towns, which are all fairly small compared to Pape’ete, and residential areas are located around the coast. It can be explored by the coast road that runs around almost the whole of the island; although Tahiti is the biggest island in French Polynesia, you can still see most of the coast in a day if you have access to a car. There are plenty of opportunities for swimming in the sea, diving, surfing and hiking, or you can just admire the views.

Mo’orea is the closest island to Tahiti and it is easily accessible by ferry, which takes around 40 minutes, from Pape’ete. It is even more spectacular than Tahiti and is well worth a visit.

 Description of the service and department: Before I arrived, I had not fully appreciated the nature of the speciality of Médecine interne, as it does not have a direct equivalent in the British healthcare system. As it turned out, the service manages patients with symptoms that do not fit into any other single medical speciality and those to which it is difficult to assign a diagnosis. This means that it manages patients with rare diseases and those which affect multiple organ systems, and as such it overlaps with rheumatology. For example, patients were regularly admitted with complications related to diabetes, such as infected leg ulcers and UTIs, gout, SLE and rheumatological conditions of uncertain diagnosis. In French Polynesia, the service also looked after patients with tropical diseases, such as dengue fever, leptospirosis and filariasis.

The department comprised a ward of 19 inpatient beds, all of which had their own room and en suite bathroom. There were also outpatient clinics every day, although I only managed to attend one; I think I probably could have gone to more if I’d asked. Patients were referred to the ward from clinics, the emergency department and other specialities, and they also referred patients on to other specialities. There were two consultants and three internes.

 Were locals friendly? On the whole, they were extremely friendly. One car even stopped by the side of the road to offer me a lift to the top of the hill I was climbing. Many of the staff and patients at the hospital were surprised that I had chosen to come to Tahiti and seemed intrigued by the presence of an English student! One of the western students at the university was heckled when she was seen out with a Tahitian man, but this seemed to be the exception rather than the rule.

Did you feel safe and if not, why not? I personally felt very safe and was more than happy to walk back to my accommodation alone in the dark. I didn’t encounter any problems at all throughout my stay.

 What did you do in your spare time? We spent a weekend driving round the island and also spent several of our days off at the beach: these can get crowded, but they’re still fairly nice. If you’re interested, there are also plenty of opportunities to go diving, although I believe they can be expensive. Apparently there are also very good beaches for surfing, although I did not try it out myself.

You can eat out very well, and relatively cheaply, at the numerous ‘roulottes’ around the island. These are small, mobile food outlets that often set up by the side of the road. You can take away or eat at the tables they set up. A large number congregate along the waterfront in Pape’ete in the evening and the atmosphere is very lively; it was well worth going along.

I also took two trips to Mo’orea, which is a short ferry ride from Pape’ete. It boasts more beautiful scenery than Tahiti, although it is a lot smaller, and more attractive beaches. There are plenty of activities to do there, including hiking, snorkelling, diving, surfing, horse riding and you can also hire quad bikes for tours of the island.

There are a huge number of other islands worth visiting in French Polynesia, of which Bora Bora is probably the most famous, but apart from Mo’orea, you will need to take the plane to reach them. The expense of the plane tickets and accommodation put us off exploring the other islands.

Is there anything that you would particularly recommend? Unfortunately, hiring a car, or at the very least a scooter, is a necessity in Tahiti. There are bus services that go around the island, but as far as I could gather there was no timetable and the locals said they were very unreliable; as soon as I mentioned to the hospital staff that I was planning to commute by bus, they advised me to go and hire a car. It cost £1,128 for the placement, but it was certainly worth it: it made travelling to and from the hospital far easier, and without it we would have struggled to explore the island at weekends. It was also incredibly useful for touring around Mo’orea, which has a similar type of bus service to Tahiti. It costs around £70 for a return ferry ticket for the car, and annoyingly you still have to buy your passenger ticket separately, but it was certainly worthwhile.

Many locals get around by scooter and it seemed fairly safe, but the commute was very hot and there were two of us, so it made a lot of sense to hire a car with air conditioning!

Time of year and climate: March-April. This was during the rainy season and it was very hot (over 30°C most days) and humid; however, although we experienced several heavy downpours, it did not rain that often and it was almost always sunny! It is cooler and less wet between May and August, which is therefore the main tourist season.

Accommodation: We stayed in the International Residence at the University of French Polynesia, which was a few miles outside Pape’ete, because it offered the best value we could find. It only took around 15 minutes to drive to the capital when there was no traffic, but it usually took us around 45 minutes to travel to and from the hospital during rush hour, which was a little frustrating. However, the accommodation was comfortable, clean and extremely cheap: it only cost around €400 for the entire six weeks of the elective, which I’m sure was much cheaper than renting an apartment would have been. We also had the opportunity to get to know other students staying at the residence, who were almost all from French-speaking countries. This allowed us to develop a good social network while we were there and also provided further opportunities to speak French. Although we were not technically studying at the university while we there, they were still more than happy for us to rent the student accommodation: all we had to do was email the accommodation coordinator at the university and arrange our stay with them. There were usually rooms unoccupied while we were there, so I do not imagine that availability should be a problem.

 How did I get there? There are no direct flights from the UK. Most trips seem to involve a stopover in Los Angeles, from where you can fly to Tahiti, whose airport is just outside Pape’ete. It takes around 24 hours to get there. On the way there we stopped over in New Zealand en route from LA because it was cheaper, but it increased our travel time significantly.

 Was it medically useful? If so, in what way? My placement was very medically useful. I had the opportunity to get used to looking after my own patients for the duration of their stay (albeit under very close supervision) and suggest management plans based on their evolving clinical features and investigation results. As I often drafted the discharge summaries for these patients, I was encouraged to think about what information would have been helpful for the GP. Both of these experiences have proved useful in preparing for Foundation training, especially considering you do not normally get such opportunities as a medical student in the UK. I was also able to practise a variety of clinical skills including history, examination, skin biopsies, suturing and knee aspiration.

 Has it improved your French? Although my first degree was in French, my language skills were a little rusty on arrival and my French improved a great deal; it was, however, very useful to have had fairly good knowledge of the language and I think that the placement would have been difficult without it. Most of the doctors spoke fairly good English, but they were all happy to converse with me in French and I was rarely asked to help people practise their English! The patients largely spoke French and Tahitian, so I was also able to communicate with them almost exclusively in French. The medical French, and the fact that all medications are referred to by their trade names, took some getting used to: I would strongly recommend going on the AFMS Medical French Weekend Course before going.

 Would you do anything differently? In hindsight, I wish that I’d asked to attend more clinics and spend some time in the emergency department to practise clerking patients. Although I was always able to take histories from patients on the ward, I was rarely the first to see them on their admission and I therefore gained less experience of clerking than I would have liked. It also would have been more useful, and more interesting, to have been able to create management plans for patients on their presentation, rather than after their admission to the ward.

 Approximate total cost? The flights were £1200 return (booked through an agency) and accommodation at the university cost €402 for six weeks, which was very good value. I’m not sure how much it would cost to rent a private apartment in Pape’ete, but I suspect it would be much more expensive. The hire car, which we rented from the airport also for the whole six weeks of the elective, cost £1,128 and was the cheapest deal that we could find; of course, we also had to pay for petrol, which was fortunately cheaper than in the UK. However, because virtually all goods are imported to Tahiti, food and drink is about one-and-a-half times the price compared to the UK, so the cost of living was fairly expensive. Overall, I estimated the total cost to be around £3500-4000, so it was certainly not a cheap elective!