My elective in Ibadan, Nigeria, was worthwhile for many reasons. Firstly, I had the opportunity to better understand the importance of doctors' attitudes and patients' beliefs in a consultation. I also had the opportunity to learn about many conditions and a different kind of healthcare system. It was clear to me that common conditions in the UK were not necessarily common in Africa. I saw only one case of rheumatoid arthritis in my four weeks in Nigeria, and was told that it was very rare there. I did not see many osteoarthritis cases, but was told that it was common. It seemed like many elderly patients just learnt to live with the pain or self medicate due to poverty. Many of the joint replacements were for avascular necrosis of the hip joint, usually in young people who had sickle cell disease. Patients had different attitudes to health problems and the level of public awareness about health issues was much lower in Africa. Most of my time in orthopaedics was spent observing doctors in theatre, clinics and ward rounds. I also spent some time in accident and emergency. I practiced taking histories and doing examinations in the General Out Patients department towards the end of my stay. UCH is a large hospital with many specialists. My orthopaedics team included a consultant, a registrar, a house officer and nurses, who were all keen to teach.

Treatment in Nigerian hospitals is not free at the point of delivery, so doctors had to always consider the financial capability of patients before offering investigations and treatment options. Most conditions were diagnosed clinically or from x-ray films, because MRI and CT are expensive. Many of the orthopaedic patients would rather go to traditional 'bone-setters' for management of fractures because they could not afford hospital treatment. Sometimes, they would present very late with mal-union or infections, which could lead to amputation, sepsis or death. I also saw patients with chronic osteomyelitis and learnt about its management, including the use of antibiotic beads. It was sad to see that some of these patients were not being managed properly because they could not afford the best treatments.

Compared to my trauma and orthopaedics placement in the UK, this was more of a trauma placement in Nigeria. There were so many preventable fractures from terrible road traffic accidents. Motor bikes are a common means of public transport in Nigeria. Many of the riders do not wear protective gear and roads are bad. Fractures were managed with skeletal or skin traction, Plaster of Paris after manipulation, and open reduction and internal fixation (ORIF), which costs about the equivalent of £800. Many of the surgical techniques were the same as those used in the UK, but the orthopaedic theatres were quite inefficient in their use of time.

Although doctors in Nigeria work hard and are very knowledgeable, I noticed that there was still a paternalistic style of practice and ineffective communication skills. The patients were sometimes illiterate, but were respectful to the doctors, who sometimes spoke Yoruba to them. I was not comfortable with the little importance given to confidentiality and patient dignity, which, I believe, help to produce a more satisfactory patient-doctor relationship. This experience will help me to be a better doctor and apply the good I have picked up from both the UK and Ibadan when I start to practice as a doctor. I will take time to educate patients and try to understand their beliefs and circumstances, as these have implications for prevention and management of disease.