October 2003

My eight week elective in Boston at the Massachusetts General Hospital (MGH) doing Paediatrics, Genetics and Teratology turned out to be one of the "highlights" of my medical training so far. Not only was my visit there highly educational and increased my medical knowledge to a great extent but it also offered me the chance to experience a completely different healthcare system than the NHS and work with some outstanding people in the field of paediatrics and genetics. Furthermore, it gave me the opportunity to experience life in America and visit many exciting places I always wanted to go to and never had the chance before.

Planning for my elective started about ten months before I commenced my attachment at Boston, in October 2002. Choosing the destination was not difficult since I had never been to America before and was very keen to exploit the opportunity and cross the Atlantic for the first time. The reasons behind my selection of Paediatrics, Genetics and Teratology as the subject of my elective were rooted to my Medical Genetics BSc, my previous work experience at a Fetal Medicine Unit and some lengthy research into what Departments were available for me to apply to. I was particularly eager to spend my elective on something I had previous experience at in order to be able to make the most of it and be as involved as possible.

After long searches over the Internet, reading reports from previous GKT students’ electives and talking to some Professors I had known to be relevant to my choice of elective, I created a shortlist of Genetic Departments at American universities, updated my CV and started sending emails. To my good fortune, my first choice of all, Dr Lewis B. Holmes, Professor of Paediatrics at Harvard University was kind enough to accept me to spend my entire eight-weeks at his Unit at Massachusetts General Hospital (MGH) in Boston, something that fitted perfectly with my plans. Topping that, I was awarded the John MacMillan Memorial Trust Prize for my Elective Summary in March and thanks to my parents’ support had no problems arranging my flights and accommodation in Boston.

Before setting off for the start of my attachment, and in order to be able to reflect on my elective once I returned to the UK, I set a number of aims and objectives I had to fulfil during my time in America. In brief, these were:

1. To expand my knowledge of medical genetics at the MGH.
2. To focus on a number of medical issues I have encountered during the past years (e.g. management of congenital diaphragmatic hernias, teratogenicity of chorionic villus sampling) and identify any differences in approach between the MGH and King’s College Hospital.
3. To compare and contrast medical practice between the UK and USA (both generally and in the field of medical genetics specifically).
4. To enjoy my first visit in the United States and appreciate the quality of life in New England.

Although I had never travelled outside Europe before, Boston had always been my favourite of American cities. A small, compact city, it offers a wealth of attractions to visitors mostly due its historical past and prominent image as a centre of learning and scientific progress. Being one of the few American cities preserving human-scale living areas, famous for being the "Athens of America" and home to my favourite basketball team, the Celtics, Boston always seemed especially appealing to me (Fig.1).

Massachusetts General Hospital (Fig.2) is located in downtown Boston on the bank of Charles River. It is the third oldest hospital in the United States founded in 1811. During the past it has been the site of many important milestones of medical advancement. The first use of ether as an anaesthetic (1846), the recognition of the true nature of appendicitis (1886) and the first X-ray image in the United States (1896) all took place at the MGH.

At present, the Massachusetts General Hospital consistently ranks as one of the best American hospitals according to the U.S. News and World Report. For the year 2001 it ranked 3^rd best hospital in the United States It conducts the largest hospital-based research program in the United States with an annual budget of 300 million dollars (approximately 190 million pounds sterling). In addition, it is the largest and oldest teaching hospital of Harvard Medical School with nearly its entire staff belonging to the Medical School’s faculty.

he MGH is the largest non-government employer in the city of Boston with 16,000 employees of who 2,900 are nursing staff and 3,700 medical staff. The hospital has 868 beds in total (average occupancy rate 79.88%) and offers sophisticated diagnostic and therapeutic care in practically every speciality and subspecialty of medicine and surgery. Each year, it admits 42,000 inpatients and 1,200,000 outpatients both at its main campus and its four associated health centres. The MGH emergency services handle 75,000 visits annually and the surgical staff performs 32,000 operations per year. Finally, the MGH Vincent Obstetrics Centre (where I spent a large amount of time during my attachment) delivers approximately 3,400 babies per year (Fig.3).

During my time at the Genetics and Teratology Unit of MGH’s Paediatric Service I had a fixed weekly timetable in addition to unplanned in-patient visits and conference attendances. My average week included: a General Paediatric Clinic, three Genetics Outpatients Clinics, two Perinatal Diagnostic Clinics, one Dysmorphology Clinic, one Metabolic Disorder Clinic, one session with the Genetics Counsellors, a Pre-clinic Conference, a Weekly Case Review Meeting, a Perinatal Conference and occasional Antenatal, Neurofibromatosis and Huntington’s Disease outpatients clinics with the obstetricians and neurologists respectively. In addition, I attended the Paediatric Grand rounds and Noon Paediatric Conferences at the hospital and every other week had to give a talk and prepare a hand-out for the Teratology Conference which happened at the Brigham & Women’s Hospital (another Harvard hospital). The latter was initially rather daunting (being a mere medical student I was quite nervous lecturing Professors from Harvard and Yale about topics in their field of expertise) but after the first talk I started enjoying the experience which added to my confidence and helped me learn subjects in greater depth (Fig.4).

The rest of my time was spent shadowing the Genetics Fellow and seeing in-patients with him or following my Professor to conferences. During my elective I attended more than 40 conferences, symposia & seminars the most important of which were a lecture on Prenatal Diagnosis at the Massachusetts Institute of Technology, the 1st Annual Commercial Human Genetics Research Retreat at Charlestown, the Epigenetic Mechanisms & the Stem Cell Paradigm Conference at the Museum of Science and the Clinical Obstetrics Conference at Boston’s luxurious Four Seasons Hotel.

My responsibilities during my work at MGH included taking histories of patients and adding to their notes as well as carrying out morphological examinations on children and babies. A large amount of my time was devoted to researching certain syndromes and conditions before clerking a patient and finding out what testing was available for them and how to order it. At the beginning of every week, I was assigned with "my own patients" for the dysmorphology and genetics clinics (Fig.5) for whom I was responsible in doing the necessary preparations before they were seen. In addition, I had a few administration responsibilities and apart from updating the Department’s student elective timetable I also had the task of "showing the ropes" to new elective students arriving at the Unit after myself. Finally, I was involved in conducting some research about the VACTERL association, which is a non-random tendency for a group of birth defects to associate together.

While taking part in all of the activities listed above I was fortunate to come across a variety of rare and interesting clinical cases that broadened and enhanced my acquaintance with genetic and other disease. MGH is a tertiary centre and we had patients transferred from many other areas whose rare conditions required the expertise of the physicians working at our Unit. In fact, the first patient I clerked in Boston was a baby from Osaka, Japan suffering from a rare genetic condition of metabolism. During my attachment I kept a log of all the cases I encountered and by the end of my elective I was surprised to realise that I had witnessed 56 distinct conditions ranging from Argininosuccinate Lyase Deficiency to Williams Syndrome. The range of disorders was quite large spanning from relatively common conditions like Autism, Amyotrophic Lateral Sclerosis and Talipes Equinovarus to extremely rare diseases like Geleophysic Syndrome, Sulfite Oxidase Deficiency and Proteus Syndrome. Overall, I came across a "treasure-trove" of clinical experience during my MGH elective.

The Museum of Fine Arts, the JFK Museum, Harvard Yard, the Freedom Trail, Paul Revere House, the Boston Public Library, Boston Common, Trinity Church, USS Constitution, the Christian Science Centre, Massachusetts State House (Fig.6), the Custom House, Quincy Market, Faneuil Hall, the New England Aquarium, the Museum of Science, the Old State House, the Basketball Hall of Fame at Springfield, the town of Salem (famous for its …witches) and the Universities of Tufts and M.I.T. were only some of the most notable venues I went to see during my eight-week stay.

At some point in my elective I also managed to spend a weekend in New York (Fig.7) and marvelled at that great city that although so close to is so different from Boston. I also travelled through the States of Rhode Island and Connecticut and had the chance to admire the vast forests of New England during the autumn.

In addition to having so many noteworthy attractions, museums, galleries and monuments, Boston is a very student-friendly city with lots of magnificent restaurants and bars. It is also a great place for those who love shopping as many things tend to be cheaper than in London. To summarise, Boston is a wonderful tourist destination with many things to offer to visitors and I definitely look forward to my next visit there.

Overall, my elective in the USA was a great experience. Not only did I have the opportunity to learn a lot but also sampled the American way of life. Things could not have turned out better and even if I had the ability to turn back time I would not change a single thing. I would highly recommend Boston and the MGH as an elective destination to all students who want to use their electives as a learning opportunity and do not mind hard work.

Finally, I would like to add that nothing of the above would have been possible without the support I received from my parents and brother before and during my elective experience. I would also like to thank my supervisor, Professor Lewis B. Holmes and colleagues Dr Joan Stoler, Professor Vivian Shih, Dr Wen-Hann Tan, Dr Angela Lin, MS Rosanna Greco, Ms Phyllis Dennehy, Laura Segura and Andrew Dauber at MGH for being so hospitable, welcoming, friendly and keen to help me during those eight weeks. Special thanks should also go to Professor Chris Bartsocas, to my clinical advisor Dr Paul Booton who supported me throughout Year 4 and to the John MacMillan Memorial Trust for their generosity towards our College and for providing me with the Trust’s award.