“My clinical rotation in Norway was one of the most rewarding experiences I’ve ever had,” says Adil Manzoor, OMS IV, who spent a month in Oslo.
World View

All students should serve international clinical rotations, fourth-year says

Adil Manzoor, OMS IV, spent a month in Norway learning about national health care, radiology and more.

This isn’t the Norway I remember, I thought to myself as my plane readied to land in Oslo and descended below the clouds. Out my window, I saw nothing but ice sheets, mountains and frozen rivers, a vista incongruous with the lush forests and shimmering lakes I recalled from my summer visit a few years back.

I had forgotten that Norway is one of the world’s most northerly countries. During my March trip, I would face short days and frigid nights. But they didn’t faze me because I spent most of my time in the hospital.

I was completing a radiology rotation at Oslo’s Ulleval Hospital, a branch of Olso University Hospital, which is one of the largest hospital systems in Scandinavia. Ulleval is Norway’s largest health care facility and a Level 1 trauma center. In addition to learning radiology, I hoped to further understand the Norwegian health care system, which differs greatly from the U.S. health system.

Norway’s health care system is primarily funded by the government, and all citizens receive free health care. The Norwegian government strives to provide all citizens with the same access to health services regardless of social or economic status or geographic location. The majority of health care clinics and hospitals are publicly owned. So health care personnel are mainly salaried government employees, with the exception of general practitioners, who sometimes choose to have their own cash-based practices.

Patients in Norway have generous rights. For instance, patients have the right to access all of their medical records free of charge. Norwegian citizens have a legal right to receive health care, and those who feel that their rights as patients have been denied can have their cases reviewed by the authorities. Usually, county medical officers handle these cases. Patients also have the right to receive care within a specific time frame—and to get treated in a private or foreign hospital if they don’t receive care within that window.

Patients in Norway have a lot of autonomy, but the type of care they get is not always under their control. For instance, patients have the right to choose their hospital, but they cannot choose their treatment. In public facilities, patients can only get procedures such as MRIs and CT scans if a physician authorizes them.

Patient care

After learning the basics of the Norwegian health care system, I was curious to see what the daily practice environment was like for Norwegian physicians.

On my radiology rotation, I would start encounters by discussing a patient’s history with the attending. We would speak English—my Norwegian is minimal, but almost all of the hospital staff and patients I encountered spoke English well. Then, I would help the radiologist make a diagnosis. I was impressed by how meticulously the radiologists would work to confirm or contradict the suspicions of the internists, taking into account patient presentation along with the X-rays. I was as astounded by the radiologists’ depth of knowledge as I was by their eagerness to teach me and answer any of my questions.

Adil Manzoor, OMS IV, enjoyed observing Norwegian physicians such as Hans-Jorgen Smith, Doctor Medicinae (Norway’s physician designation), the head of the radiology and nuclear medicine department at Oslo University Hospital. (Photo provided by Manzoor)

After working with the radiologists, I would follow up with patients and talk to the internists to see how they planned their care. My impression was that, as most osteopathic physicians do, Norwegian physicians take the whole patient into account when it comes to prescribing treatments and planning care, discharge and outpatient follow-up. They were very empathetic and took time and care to explain diagnoses and treatments and to address patient concerns.

One important lesson I learned from my interactions with Norwegian physicians is that in hospital care, we shouldn’t treat patients only for the problems they present. Instead, we should seek to counsel them on all of their conditions with the goal of helping them improve their quality of life and avoid readmission to the hospital.

For instance, one of our patients was diagnosed with a pancreatic abscess. When he was discharged, his physician advised him not only on healing his abscess but also on controlling his hypertension, and he shared resources that could help the patient give up alcohol. This is how medicine should be practiced. We must strive to treat the whole patient, not just his or her acute problems.

OMM in Norway

Before leaving Norway, I wanted to demonstrate osteopathic manipulative medicine to the physicians I worked with. I talked with several physicians about the philosophy behind OMM and many were open to it, though some were hesitant. It was difficult to perform any manipulation for radiological interventional procedures. So on night calls, when there wasn’t much going on in the radiology department, I would take a Razor scooter—the hospital is massive, so staff use them to move about—to an intensive care unit or patient floor. I would introduce myself to the nurses and physician on call, and on multiple occasions, I had the opportunity to perform OMM on patients.

One time, I worked with a patient who had urinary retention following surgery. I talked to him and his nurse and doctor and told them that OMM could help normalize his parasympathetic and sympathetic nervous systems, which could make it easier for him to urinate.

When I assessed the supine patient, instantly I noticed muscle hypertonicity in the lower aspects of the latissimus dorsi and quadratus lumborum as well as in the erector spinae muscles. I explained that doing balanced ligamentous tension and even myofascial release would relieve this tension on the patient and normalize the sympathetics to the bladder. I also found sacral restrictions and explained that I would do sacral rocking last, which would address the sacral dysfunction by relieving the possible compression on the sacral pelvic splanchnics and normalizing the parasympathetics to the bladder.

“One important lesson I learned from my interactions with Norwegian physicians is that in hospital care, we shouldn’t treat patients only for the problems they present.”
Manzoor

I wanted the treatment to be perfect, so I spent more than half an hour with the patient. As expected nothing happened right away, and I moved on. The next day, I was approached by the nurses, who said the patient was able to urinate after I left. Of course, I’m not sure whether the OMM was responsible for his improvement, but I’d be interested in conducting a study in the future investigating OMM’s effect on patients with urinary retention following surgery.

Pros of international clinical rotations

My clinical rotation in Norway was one of the most rewarding experiences I’ve ever had. I will carry the experience and the skills I gained with me for the rest of my life, and I recommend an international rotation to all medical students. It’s a great way to broaden your perspective on health care and learn how another country approaches care delivery. I secured my rotation by looking up Ulleval Hospital’s head of radiology and nuclear medicine and sending emails to him and his secretary. I suggest that other students who pursue international rotations plan well in advance and be sure to consider how you’ll finance the trip. I personally funded my rotation, though I didn’t have to pay the hospital and I was able to stay with my aunt who lives nearby.

On my rotation, I learned a ton of radiology. Now when I am presented with a chest X-ray or abdominal CT scan, I can confidently point out a lesion and talk about the pathophysiology.

My mentor, Magnus Mejlaender-Larsen, Doctor Medicinae (Norway’s physician designation), taught me that you should not limit your medical knowledge to just the field you may go into. Indeed, because radiologists knew the pathophysiology of diseases and their treatments, they were able to make more accurate interpretations of X-rays.

I also saw the similarities between U.S. and Norwegian physicians. Despite our very different health care systems and training, physicians in both countries have a similar goal: We want to help our patients have a better quality of life.

As I took my last tour of the vast hospital, I realized that my month in Oslo had gone by too fast. I wanted to learn and do so much more, but I knew my limited time had been well spent. When my plane took off, I felt relieved. My excitement at being in another country had deprived me of sleep, and I was finally going to get some rest. Outside my plane window, the airport, the buildings and the vehicles quickly disappeared. When the sheets of ice and the Scandinavian Mountains came into view, I caught a last glimpse before I nodded off to sleep.

Adil Manzoor, OMS IV, attends the Rowan University School of Osteopathic Medicine in Stratford, New Jersey.

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