MY TORONTO ELECTIVE EXPERIENCE

                                                MY TORONTO EXPERIENCE 2019

                                                      DR. KHADIJA MBENEKA ALI

The preparation for electives started way back in January 2019 when we applied; I’m grateful to my referees Dr. Odongo and Dr. Kosgei who wrote my recommendation letters way ahead of the deadlines. I knew that Toronto was my elective choice right from 1st year hence the tag ‘Team-Toronto’ by a section of my classmates; I always took it as a nice little prayer. The group that did the electives in 2017 were full of praises of the program and interacting with Dr. Julie Thorne made me more enthusiastic about an experience in Toronto; she encouraged us all to apply when we sought her opinion and she was ever present to answer any questions regarding expectations in Canada and about the program. 

Many people back home are hesitant to apply to International Electives due to the fear of being just observers, but I was ready to take it all in and learn the most no matter the nature of the elective. It was very exciting when we knew that CPSO certification was an imminent possibility. It was also great meeting Joseph George (Joe) and Salvo Candela in Kenya and this made the many application emails and communications later on bearable. The whole process can be very overwhelming and CPSO is very thorough to fine details but looking back in retrospect, it was definitely worth it. I feel more internationally acceptable as a medic based on the gruelling CPSO process - it’s a major boost for my C.V. 

My visa work was a nightmare but honestly, visa process could probably be compared to having a child; very painful in the process but you easily forget the pain once everything goes through.

 I missed 2 weeks after my colleague had started but thankfully, I was able to recover the lost time through an extension at the end. Without the help from Dr. Spitzer and Joe, I probably would never have made it to Canada.  Joe became more of a brother, it was not uncommon to do correspondence deep in the night; Toronto time, just to keep ahead with the different time zone in Nairobi. He went far out of his way to make sure I made it for my electives and for that, I will always be grateful. I think the first words that come out of my mouth each time I speak to him are ‘Thank you for everything, as always.’  My Heads of Department back home under Dr. Omenge and later Dr. Itsura were also very supportive and prompt to correspondence, readily sorted the many forms to be filled and they agreed to my two weeks extension at the end. I remember Dr. Itsura readily making quick arrangements for my urgent CPSO-Extension paperwork when he was away on other duties; I don’t take all that for granted.

The pre-elective period in Toronto was quick and fast paced. I remember being whisked from the airport by Joe directly to the university to finish up with administrative work so as to avoid getting CPSO work jammed on a weekend, then going to the bank the same afternoon and getting a whole orientation of the transport / subway train system.

I was tired, confused with timings, dirty, sleepy but timelines had to be met to enable me start as soon as humanly possible. It was a good adrenaline start and I endeavoured to keep that pace throughout. I never got jet-lagged because I was home towards 9pm that evening - I quickly adjusted to the time zone. I spent my first weekend in Toronto going through my POWER-charts, preparing for its test, generally exploring Toronto when I could and spent a lovely Sunday with Dr. Spitzer and family. 

WEEK 1

I started my 1^stweek on a Tuesday because the 14^thOctober was a public holiday; it was a short, fully packed period. This week was a bit of everything including the Tuesday academic afternoon and this enabled me to have a quick look of all the units I was going to rotate in. This helped me to familiarise myself with the different locations of all clinics, systems, individual spectrum of conditions per unit and the colleagues who worked there. Looking back in retrospect, I’m grateful with this calculated allocation that was done because it helped me settle in faster and know what was expected of me all-round. I was also very lucky to have had 2 clinics and an O.R day at Paediatric Gynaecology unit; though as an observer in the first week. The main Fellow in the unit is very lovely, she was understanding from day 1 and understood my role as an observer while making me feel useful and as a team player. (I was initially an observer in Paeds-gynae because there wouldn’t have been any time for my training on the EPIC system). Later-on, I was lucky to get an extension and spend a considerable amount of hands-on time at the unit. The main challenge in this particular week was getting lost in the Sick-Kids O. R – I had wrongly presumed that I would find my way easily and that the Mt. Sinai scrubs access would work in the scrub-machines at Sick-kids. Luckily, I had arrived in the unit much earlier and was able to find my way and sort the scrubs issue before the first case started. Lesson learned was to always get familiar with new places a day prior or to ask a colleague before to clear any wrong assumptions.

WEEK 2-3

My 2^ndand 3^rdweeks were mostly in the Mt. Sinai Fertility Clinic (MSF). I was inducted into seeing patients on my own right on the Monday afternoon after attending to a few cases with the consultant (staff) who was covering the day; this was lovely and exciting for me. The most positive thing about the Fertility Rotation is that we had been given notes to read on a wide spectrum of conditions and procedures in the unit. I got my notes while in Kenya as I waited to pick my visa, and this helped me adjust very fast when I arrived; I went through them back at home and mid-air on my way to Toronto. This week was study-intensive for me and it was thrilling getting to participate in the management of real-time cases than can be investigated fully and managed comprehensively due to a more availability of Fertility-Related resources compared to back in Kenya. The consultants were friendly, ever willing to teach and their different patient-pools and approaches complemented each other enabling me as a student to learn and understand conditions from all different angles. One consultant went out of her way to organize for me to have an IVF Procedure Day and this to me was a very kind gesture. Seeing the different procedures was an unforgettable experience. The staff who took me through that day was very lovely and was very eager to teach me and answer my questions. I got fond of all colleagues in the unit and leaving was difficult. I didn’t have any major challenge in MSF. The eIVF patient system was very easy to learn and straightforward. The fact that my days were build up as a block instead of being distributed between other units helped to build my experience continuously and in a more consistent manner. My colleague Elizabeth had rotated there before I arrived from Kenya and this could have easily contributed to me having a softer landing. Reproductive Endocrinology and Infertility (REI) is top on my list of sub-specialisation choice.

I first got a little glimpse of Fetal Medicine Unit on the Friday of my 2nd week. 

I was pretty lost on the first day because I didn’t know what was expected of me; so, I tagged along Fellows, Nursing Practitioners and Consultants alike; whoever was available and seeing a patient. There are no residents attached to the unit, so I had to figure my way around. FMU is more radiology-intense so with or without CPSO, residency there is mostly observership by default. I was lucky to find my way quick by the subsequent allocation to the unit. I mainly shadowed one particular Clinical Fellow. I went from being a lost resident to an enthusiastic one about Fetal Medicine thanks to him. I would also join in staff as they analysed interesting cases we had seen or as they cleared out suspicious findings. It was a good learning point seeing normal anomaly scans then occasionally seeing what different conditions and congenital anomalies would appear on sonography and the delineation from normal. Helping and observing procedures such as Amniocentesis and Chorionic Villous Sampling was also very memorable, and it was very nice to see the nurses and Fellows willing to have me assist. I found the nurse practitioners there to be very skilled in sonography, ever willing to teach and answer questions and are the first and by far the most crucial link to FMU. The association of the unit with Genetics and Genetic Counsellors was also very interesting and conditions that would only be suspected in most low-resource settings would be diagnosed through microarrays etc. In the end FMU helped me with my MFM and YPP rotations because I would make orders knowing in my mind the procedures, protocols of the FMU and the reports to expect. 

WEEK 4-5

MFM was mostly on my 4th and 5th weeks.  It was a wonderful experience as expected especially because I had interacted with a few staff from the unit through the new Fellowship programme in Kenya. It was also very hands-on, and I was allowed to see patients on my own right from day one. As I had earlier written, the brief orientation window in my first week helped me step in into the unit smoothly. The clinics and management of medical disorders were very organized. Different days had been allocated different spectrums of conditions and there was collaboration from Obstetric Medicine Physicians specialized in the different conditions on most clinic days. Haematology day on Fridays was very unique to me. I didn’t imagine that I would learn Sickle Cell Anaemia More Comprehensively in a North American setting instead of Africa as would be expected. You see, Toronto is very multinational, and I always joked that comprehensive textbooks were written with this city in mind. I saw things that I only memorized in exams for the sake of passing. There were separate days for Bariatric/Obesity in pregnancy, Mental Health/Infectious Diseases, Hypertension and Endocrine diseases, Cardiac Disease and Neurological/Rheumatological conditions and Friday was Haematology Conditions in Pregnancy. Pregnancy Induced Hypertension remains one of the key antenatal conditions back home; I learned it more comprehensively during my stay here. Prof. Nan Okun’s clinics were always very engaging and she gave me the push to write/dictate comprehensive notes for new patients right from day 1. This was a confident booster by all means and her positive feedback always meant so much to me.  The many round teachings in MFM were always very captivating. Everybody walks and eats lunch fast in the unit - walking to different buildings over lunch for sessions while eating at the same time and quickly getting back to the clinics briskly to continue with work. The Clinical Fellows and Nurse Practitioners in this unit also treated me as one of them and were always available to help when needed.

Pre-conception care, early neonatal diagnosis and Mental Health Care of mothers is huge in Ontario and at an advanced work in progress. If we could go in that direction as Kenya even just a quarter-way, I believe that the impact would be very significant. This stood out for me very much. 

WEEK 5-6

My mid-5th to 6th weeks were mostly spent in Adolescent Gynae. I was to miss these two weeks due to time lost during visa applications but luckily got an extension. I was happy to be back to Sick-Kids this time as any other resident and not as an observer. I was a free bird because all systems were now very familiar, and this felt very good. The consultants there were also very lovely and were happy with our grasp of paeds gynae concepts. It was easy applying the same to patients. There were lots of learning points and positive corrections as always. Paediatrics Gynae is also very organized and if not careful, one can easily be left behind. There were so many early morning revisions, lunch-time Resident Teachings, journal clubs etc. I decided to be arriving an hour earlier always to avoid missing out on anything and to always have lunch in the office just in case a teaching happens as people munch away their lunch. I learned communication skills for the paediatric population and I’m looking forward to being part of the start of a separate Gynae clinic for the paediatric population back home. This is definitely a Unique age group with a different Gynae approach. The Young Pregnant Parents Program was also very mind-opening. The social and mental needs of pregnant adolescents would be addressed in a more tailored environment. It was also fantastic working with our direct supervisor Dr. Spitzer and being a familiar face, made me even more comfortable. 

No elective experience is complete without mentioning the patients. I always feared standing out as a black-person or patients not understanding my accent but those were just fears after-all. All my patients were extremely lovely, they didn’t even notice that I was a visiting resident and when told, they didn’t mind it, I faced no racism at all and everybody seemed to understand my English perfectly. Whenever I couldn’t answer a patient’s question, I would be honest enough to admit that I would run it through my seniors then we discuss together, and they didn’t mind this; if anything, they were happy.  I felt so much at home, I never felt any different and I saw people from many origins and backgrounds, some who needed interpreters. Eliud Kipchoge and the long-distance athletes somewhat helped to be conversation starters in my elective as this would be a common exciting question from patients when they learned that I was from Kenya. Getting the temporary CPSO License was the best part of this journey; if this is not a career highlight, I don’t know what is!

The mode of teaching in Toronto is impressive. Residents are strictly under a consultant(staff); after a resident sees a patient, the staff discusses it with the resident on the side to see what the resident’s plan is and see the patient later as one team. That was very impactful on my learning. I never faced harshness or correction in front of patients. Every case was a learning point at different angles. Students and Consultants also interact in a more friendly but professional manner; no intimidation or threats. Everyone strives to improve knowledge and patient care. It’s not uncommon to see consultants and residents having a group teaching at a coffee place or in between lunch. Students here are also guided step by step especially in surgical skills; they learn the right methodologies no matter the length of time taken.  Academic times for students are also taken very seriously and residents have to leave clinical duties during the specified academic sessions. I also greatly enjoyed the simulation classes at St. Michael’s Li Ka Shing Centre for different obstetric emergencies; I got to learn step by step on how to do different procedures like B-Lynch, Bakri balloon etc all in the correct manner under direct supervision. I participated in different simulations, sometimes as a team-leader and this made me feel so much at home at UoT. I kept wondering if had truly been doing the right things all along for some sessions we had; especially on a teaching we had on 2nd Stage C-Sections. Nobody treated me like I was from a very poor resource setting and everyone seemed to know a lot about Kenya based on the different exchange programs; I was treated as an equal. Theatre (O.R) sessions were also wonderful ; 90% of Gynecological surgeries are laparoscopic .

P.S : I found it very unique that most Clinical Fellows I worked with were younger than me , you see Med school is a continuous process in Canada ; with no breaks between Med-School and Residency and with a direct transition to Fellowship after Residency . I found the finalist class in residency making decisions on Fellowship positions a few months before their final exams. 

Away from academics, Toronto was lovely. I enjoyed fall and winter. The fall colours would be a wonder for me; I would sit in parks after work and just take it all in and take lots of pictures of nature. I became healthier in Toronto due to the daily walks to and from work; a trend I intend to continue in Kenya. I strived to always take a different route home each day if not dark just to see different things and to relax my mind after work. I enjoyed the multicultural nature of the city; I would be amused by all the different accents and languages at the subways or streets. 

I enjoyed P.A.T.H and understood it very well and this was a blessing to me in wet sliding winter. Winter experience was also a first one for me; when everybody was gloomy about it, I was enjoying the serenity. There were lots of fantastic food restaurants and I made many friends at work. We worked so hard over the week and explored harder over the weekends; I’m good with directions so we went to Niagara Falls on our own with just google-Maps on our side and we had a fantastic time. 

We explored several areas in the city like CN Towers, The Ripley’s Aquarium, Wonderland, many exciting random walks in downtown Toronto and the shopping district at Dundas-Yonge-Queens area. We were lucky to experience different special occasions like the Halloween and the annual Christmas Parade which were totally new and exciting .

Our friends and faculty invited us for dinners and interactions with their families and this was very lovely. I was never alone in Toronto; I found Elizabeth and left Chege behind; I never had dinner on my own and having company from home was great. 

We were accommodated comfortably and had a decent stipend; these are things that made our stay so easy. 

We never lacked, and we had decent warm houses in a safe area to go home to. Our health, travel and professional indemnity insurance covers were also well taken care of. Everything was sorted!

Was Toronto experience worth it? More than worth it!! I would come back a million times. Each night before going to bed I would write down new academic concepts and life skills learned in the day and each day was always very fulfilling. 

ADIOS TORONTO. I still look forward to more learning opportunities in the future. Seeing other Kenyans from Eldoret doing Fellowship Programs in Toronto gave us hope towards getting into similar programs back home or in Canada in the near future.

Asante sana! Mungu bariki UoT !