Reflection

Hello,

I don't really have a single word to explain how I felt about this trip. There have been amazing moments, times where I felt uncomfortable and times where I didn't want the day to end. Each day and visit was different so at times it was difficult to prepare. On the other hand each day felt the same because we had normal early morning/late afternoon "shifts".  There were many positive but also some negative moments. Regardless I've learned from each moment.

I have come to appreciate many things that I took for granted in the States. We truly are the melting pot and thats something I did not see in Thailand. Walking down the streets or in the hotel lobby we definitely got some looks from locals or even visitors. I don't believe anyone meant any harm. I believe that people just weren't used to seeing someone that looked like or talked like me or some of my colleagues. Adjusting to this was a challenge but I think got through it just fine. :)

I remember one particular instance when we went to a traditional medicine hospital. A professor there was talking about certain size acupuncture needles and pointed out specific people that would need larger needles because of their physical size. I am not saying this wouldn't happen in the States but simply that I haven't witnessed it in the setting we were in. Most health care providers are aware about how weight conscious their patients or people in general can be. Again the intention was pure but there was a cultural difference. This was definitely one of the negative experiences but I still learned from it. I appreciate the diversity we have here. 

Moving on to the positives. 

Dr. Krebs said we were going to meet so many amazing people and he was not wrong. Noi, our coordinator, was incredible. We went to lunches/dinners with her and she would order everything. We'd have family style meals where we had the opportunity to try so many different dishes. She would explain each dish in detail and we learned a lot of Thai culture from her during these meals. She also traveled with us everywhere and guided us to the hotspots in the area. She was almost like a mom telling us what things to stay away from and what things were okay to do. I really hope to stay in touch with her. 

There were several people at the hospitals that were excited to have us. I remember our first visit and the hospitality was incredible. We had snacks and lunch through out the entire day. By the time we left, I decided I wasn't going to eat dinner! Every doctor, nurse and pharmacist that presented thanked us for being there several times. I was taken back because I felt as if I should be thanking them more for inviting us and taking time away from their patients. 

I think every trip has it's positives and negatives. This one by no means was a perfect trip but I've learned from every moment. There were times when I was home sick, missed pizza, was physically sick (will never eat oysters..ever again) or sleep deprived. There were also many moments where I was excited to be traveling, meeting new people, Thai food, hiking and so much more. I've learned from many different people about pharmacy and non-pharmacy topics. Every hospital, clinic or pharmacy we went to, we talked about more then just pharmacy. It gave us a chance to know each others culture and life style. It was amazing how different people see us based on the region we are from. It was an opportunity to teach each other! 

Truly an unforgettable trip!!!

Purvi :)

Reflection: Sara Stafford

Sawadee Ka for my last blog post!

I had an unbelievable time in Thailand that went by far too quickly. I had never been anywhere outside North America until this trip, so I came into the trip with no expectations. While most of the trip was amazing in so many ways, things were not perfect, and I think that is what makes these experiences so meaningful.

Some positive things that stand out to me culturally include the minimal expression of anger, the pride shown in their work, and the amazing sense of community that translates into great transitions of care. As you may have read, the driving in Bangkok is crazy. People cutting others off regularly and not using turn signals. You would think people would be outraged but there are no honks, yelling, or even rude gestures. The Thai people work very hard for very little. While going out to the markets, at first I did not realize the work it takes to put out and take down all the goods, box them up, go home late at night, then wake up and do it all again, every single day. Also, within each village, the residents take on different roles. These roles can include healers, cooks, tailors, and many others. The village residents take care of each other like family. When a patient is released from the hospital and goes back to their home, there is a trained healthcare worker for the village who will see them on a regular basis to discuss medications and symptom relief.

As much as there is to love about Thailand, there are also some negatives. For instance, individuality seems frowned upon and diversity is not commonly seen. There is a very strong promotion of a certain shape, size, and color that Thai people should be, women specifically. Comments were even made to our group pointing out "flaws" of some individuals during a lecture. We also saw ill-looking stray cats and dogs on the streets daily, along with rats and cockroaches. And some of the methods used in one the institutions was haunting, involving restraints and densely packed dormitories.

Every experience is not going to be perfect or better than what you are used to. I feel like it is important to look at another culture, hospital, or healthcare system and use it to determine what you can do better, what you are doing well, and what should not be taken for granted.

As I was going through my photos from this trip I saw temples, nature, food, museums, clinics, hospitals, more food, white coats, factories, waterfalls, beaches, elephants, and even more food. But what they all have in common is how much we all enjoyed each and every one of these things, as well as sharing the experiences with each other. Having the other students along with me throughout this journey, especially two of my best friends, helped me get so much more out of it. Not only did we have fun, but we were able to reflect on the experiences with each other and point out different viewpoints that we would have otherwise not seen.

Going back to the U.S., I will forever cherish our automated dispensing machines, our pharmacy-to-dose protocols, our clean streets, and healthy pets. And I will always remember the lengths they go to in Thailand to continue following the patient after they leave the hospital to ensure proper understanding, medication adherence, and symptom management. Although my aggression while driving may not change, I respect the ability of the Thai people to just let it go. Lastly, my new diet will consist of more limes and spices, and more Thai food in general, with the exception of cilantro, lime leaf, lemongrass, and coagulated pig blood.

Finally, our preceptors Dr. Krebs, Dr. Choi, and Dr. Warren were amazing. It was so good to have them there for their support and guidance. It was lovely getting to know each of them a little better. Our coordinator Noi and driver Nu answered all of our questions (no matter how absurd), ordered our food, led us through the streets of Bangkok and Chiang Mai, and were so much fun to hang out with for the past month.

I will never forget this experience!

Wat Prathat Doi Suthep, Chiang Mai

Khob Khun Ka [Thank you],

Sara Stafford

Final Reflection: Natalie Underdown

They drive on the opposite side of the road here. Their winter temperatures are still extremely hot. There are so many sharp contrasts between the United States and Thailand that it was initially very easy to place these countries into two separate buckets. As my time in Thailand has come to a close, I’d like to reflect on the stark differences but also the foundational similarities between the U.S. and Thailand that I have discovered over the past month.

One of the things that I noticed immediately when arriving in Thailand was how friendly everyone is. I’d like to think that as Maine native who grew up in a small town, I was surrounded by pretty friendly people, however, the treatment I received in Thailand topped most of my Maine experiences. Not only was I greeted by strangers on a regular basis, but people went out of their way to help us and always used respectful titles such as madam. One memory that will always stick with me happened on one of our first nights in Thailand. When we had left a clothing shop and were standing in the street, Casey got her ring caught on the zipper of her purse. A group of ladies who worked at the hair salon across the street saw us struggling to get her ring loose and ran over immediately to help. They brought with them a bottle of lotion to get her ring off and then dragged us into their salon to use pliers to remove the ring from her zipper.

They call this country the land of smiles and I now understand why; I had so many encounters with people that had the most infectious smiles and laughter. Their positive outlook on life was refreshing and brightened my days. I often noticed that instead of saying goodbye when you left a place, they would instead said "see you again soon" or "see you later." Ending your interaction in this way always seemed like the stranger in front of me was more like a friend, instead of someone I had just met moments before.

Another noticeable quality of my interactions with Thai people was that they intently listened to you. Here, they listen to understand, not listen and wait to say what they want to say. I’ve noticed that in the United States we all too often talk just to talk, not respond fully to what another person is saying. Escaping this back and forth way of communicating with people was refreshing and gave me the opportunity to have many meaningful conversations.

Although there are many differences between the practice of pharmacy in Thailand versus in the U.S., I have noticed that the same passion and desire to do good and protect the health of patients is rooted deeply in the pharmacy profession within both countries. Interestingly, in Thailand no prescription is needed for most prescriptions, even antibiotics. Other than certain drugs that we refer to as controlled drugs in the U.S. or are categorized as “dangerous drugs” in Thailand, such as opiates, pharmacists can freely distribute most medications to patients who come into a drug store. These medications include ones to treat high blood pressure, diabetes, high cholesterol, and infections. Even though these pharmacists are able to give these medications, they do not have the role that ambulatory care pharmacists in the U.S. have in managing chronic disease states in their collaboration of patient care with physicians.

Another contrast between the U.S. and Thailand is that in the States, a large majority of pharmacists work in the community setting, but in Thailand a majority work in hospitals. I’ve realized that this is the case because most people receive their healthcare through hospital services and is paid through their national healthcare plan available to all Thai residents, which is a lot different than in the United States where most patients see their primary care physicians for most of their health concerns.

A major similarity in both the United States and Thailand is the growing trend of herbal and natural medicine use and mistrust of modern medicine. A major difference in this issue is that Thai people have been using natural products and have been passing down their knowledge about plants for thousands of years, therefore, it is a part of their culture and history and they do not trust modern treatments. In the United States, the use of herbal medicine is more of a recent fad of people moving away from our country’s foundation of modern medicine and believing natural treatments are better, such as the growing number of people who are against receiving or giving their family members vaccines. This is an issue that we talked about on multiple occasions with pharmacists and pharmacy students in Thailand and it was neat to hear some of their patient stories, such as eating a gecko to cure COPD.

My experience in Thailand is one that I will never forget. My month in this country has opened my eyes to an incredibly rich culture with both many differences and similarities to the United States. After visiting so many healthcare related sites such as a HIV temple community, an orphanage, herbal medicine hospitals, a psychiatric hospital, a large public hospital, extremely fancy private hospitals, a children’s dengue ward, and spending time with students from Thailand, China, and Indonesia at a College of Pharmacy, I have learned to appreciate the diversity in healthcare and not continue to have a black and white, single format template of what healthcare should look like. Thank you to all of our coordinators and teachers who helped provide one of the most unique experiences I have ever had. I am eternally grateful to the University of New England for this opportunity and the growth that I have had because of it.

Warmly,

Natalie Underdown

Reflection: Desiree Barboza

Thailand was nothing like I expected it to be. In fact it was so much better than what I could have imagined! The decision to apply to Thailand was not decided easily. I constantly went back and forth with myself unsure if it would be the best fit. Worried because this would be my first trip out of the country. Despite all of this, I could not be anymore happy with my decision to go to Thailand! I fell in love with it so quickly and so easily, which made it so hard to leave.

This rotation has had such a positive impact on me. I was blown away with how happy and willing all the different hospitals and pharmacists were to teach us. It never felt like we burdened them. Not only this, but when I imagine being in their shoes... I imagine how difficult it must have been at times to communicate (knowing there could be a language barrier) but they persisted on! Which reminded me not to lose sight of these things. That showing care can go such a long way, as well as taking the time for others. But also how powerful persistence is. Especially when giving up can feel so safe and easy.

What I enjoyed the most was interacting with pharmacy students around our year, whether that was at the hospital or the school. It was interesting to hear from them about their culture and discuss similarities and differences.

What was very cool to see was how much herbs play a role in there medicine, but also how they they use it a lot of them time in combination with prescriptions. It was also cool to see that there use of herbs was not only based on experience, but at one hospital from research and clinical studies. All of there products are regulated. Being in Thailand has showed me how herbs can play a role in medicine. I know in the USA it is hard to regulate and know what is actually being put in herbal products, but Thailand was a great example on how these kinds of products can work. Especially for those who tend to lean to herbs before medicine.

Moments that impacted me most was visiting the Dengue hospital and the HIV community. The Dengue hospital consisted of children who were very sick. Yet you could see their strength and willingness to fight. Which was so beautiful to see! Visiting the HIV community reminded me that caring for everyone you come across makes an impact! Just by looking at someone you can't tell what their struggle or concerns are, and so you never know what kind of a difference showing compassion and care can make on a person. A lot of them deal with stigma or have been banned from their families, but what has kept them going is this community they have formed. Having people who support you is so essential and we can be an example of this to our patients everyday!

Just interacting with the people in Thailand has showed me more about what extending a hand to others looks like. They are so patient and willing to go out of their way to help. Some examples of this include; when a friend of mine got her ring stuck on her bag. Some ladies from a hair salon ran outside and dragged her in to help her get her ring out in one piece. Another example was at a sky top bar where they offered a friend a blanket to cover up her shorts instead of kicking her out, since shorts were not apart of the dress code.

I feel honored to have had this opportunity. I feel like it has changed me for the better! It was refreshing to absorb how people interact with each other. I have learned so much academically but I have also seen a lot of personal growth! Which I am blessed and thankful for!

Thank you for reading!
Desiree 

Reflection from Casey

Sawasdee ka for the last time from Thailand!

The past four weeks have completely flown by; each day has been packed with so many cultural and educational experiences that it's crazy to believe how many things we were able to fit in. I can say without a doubt in my mind that this rotation has taught me so many things that I will carry with my through my future career as a pharmacist.

I am not sure what exactly I was expecting when I came go Thailand but I can say this experience was more that I could have ever imagined. So much of what I learned and saw is difficult to put into words. One of the things I was most surprised about it how urbanized Thailand is. Bangkok has many modern skyscrapers with gorgeous hotels and name brand only shopping malls. Yes, on occassion there were a few less updated toilets that required squatting over a toilet bowl in the ground and flushings by pouring buckets of water into the toilet; but these experiences were fairly infrequent compared to what many of my colleagues have told me in the past. Thailand is very much in a transition period between a mostly rural to urbanized developing country.

One of the most heart warming things to witness throughout Thailand was though they are becoming more drastically modern (more similar to the United States) they have not left behind their culture and ever present hospitality. I will never forget the very first night that I arrived in Bangkok. Feeling exhausted from countless hours of traveling, fatigued from the heat and humidity, and overwhelmed by a drastically different country with a strange language, my colleagues and I were still determined to go and explore this new city. As we exited a small shop off of a narrow side street I managed to get my ring caught in the zipper of my bag (how this happened I will never undedstand)! As I struggled to free myself from my bag and my ring I was suddenly surrounded by 5 Thai women who dragged my into their hair salon to doors down. Grabbing lotion and a set of pliers the women worked together to finally extract my ring from the zipper and reattach the piece to my bag. These women did not speak English and never once asked me for money, but came to my rescue out of the kindness of their hearts. It was such a heart warming moment, and I would continue to receive these kind gestures throughout the duration of my stay in Thailand.

The second thing that truly surprised me was how much the healthcare workers in Thailand do for their patients each day with much more limited options. Thailand spends only 4% of their annual GDP on healthcare, significantly less than that spent in the United States. In the states we focus so much on safety, safe practices, safe drugs, etc. In Thailand, their number one focus is always on accessibility. Because there are many patients who struggle to receive the care they need so when a patient does get seen by a healthcare provider they focus on creating one stop services and stress the importance of patient education. It seems that the Thai pharmacists really engage with their patients and spend an equal amount of time during their conversation listening to the patient as well as educating them. I has the opportunity to witness interactions like this in various settings including in and outpatient hospital, community pharmacies, and home visits. It was amazing to watch because although I didnt understand the language on what was being said the patients body language and engagement in conversation really seemed to empower the patients and make them feel like a valuable part in their healthcare team.

One particular comment was stated my many of the healthcare providers we met and it always struck me as being so odd. Many times they would say, "we do the best with the resources that we have, but we are always striving to be more similar to healthcare in the United States." Sometimes it almost seemed as if they were apologizing for not being as advanced as they see the US being. Each time this statement was made I immediately felt that I had to remind the Thai of all the incredible work they are doing now. I personally was so impressed that they manage to do so much for their patients without spending a lot of money. There are many aspects of healthcare that I personally feel the Thai do better, specifically patient education. I think that it's important to not just strive to move forward but also recognize all of the accomplishments that have already been made. As the Thai move forward into a more advanced system of healthcare, implementing computerized patient records and other technology into their work flow I truly hope that they do not lose that incredible connection with their patients. Once that connection is lost or jeopardized such as it has been in the states it is much harder to regrow that bond.

I am still in awe that both patients and providers were so welcoming to us as foreign students to allow us to learn. I think in the states we are so focused on privacy surrounding patient healthcare and hold a culture of distrust in medical as students that we dont always have such a welcoming opportunity to engage in these learning experiences. But in Thailand we were welcomed into patient rooms, actively reading through their charts and able to talk to patients about their own experiences in the health are system. While it is important to notice these differences it is also vital to remember that neither our system nor theirs is better or worse than the other, rather just providing lessons on how we can improve our own healthcare system through mutual learning.

I would say my favorite activity of all the educational things we did was our class meeting with other international pharmacy as students from Thailand, China, and Indonesia. It was amazing to have the opportunity to learn from these other students. During our discussions we found that all 4 of our countries struggle with similar healthcare issues (for example antibiotic resistance and misuse, though the reasons for these issues were all different. It was so amazing to discuss with these other students ideas on how to address these health disparities, as well as have an open conversation on the benefits and challenges of these ideas. Having so many different students in one room really created such a diverse discussion that added a whole new dimension to conversations that are had regularly in our own countries. After that class not only did we gain significant insight in healthcare topics but we made some pretty cool friends.

Thailand is a country inhabited by welcoming people and a culture filled with incredible flavors, colorful temples, and kindness unlike any other. I learned so many more things than I every could have imagined, especially that mango and coconut do not belong together in desserts or smoothies. There are so many things that I will miss about Thailand upon returning to the states including the friendliness of the people, the street vendors lining the roads with food and souvenirs, the incredible flavors, and most importantly the thai tea and coconut ice cream! Though there are two things that I will not miss: 1. The heat and humidity, 2. The pungent smells especially in Bangkok that can be inhaled while walking through the streets. But nevertheless I would embrace these two downsides any day to come back to visit Thailand.

I can't thank everyone enough for the amazing opportunity to learn from our Thai friends. I know I can speak for all of the UNE students here when I say that we are incredibly grateful that everyone took time from their work schedules to meet with us. I know that it can be a major interruption to the daily work flow to not only meet with us but also show us around the facilities. We really appreciate the generosity of all the people who added to this incredible learning experience.

The most important thank you, though, belongs to Noi for guiding us throughout this journey. She dedicated so much time to helping us and giving us an incredible experience. Words can not thank her enough for everything that she did for us! Noi, we thank you and love you for all of your hard work and for putting up with us for 4 weeks! We will miss you.

Also thank you so much to Nu, our driver, as well as our three amazing UNE preceptors: Dr. Jim Krebs, Dr. Hailey Choi, and Dr. Ryan Warren. We could not have done it without you. Thank you all for dedicating your time to help us learn. You're hard work and kindness did not go unnoticed. Thank you for making this an incredible learning experience!

Lastly, I would like to thank UNE CoP for this incredible opportunity and everyone who took the time to read through this blog. We hope you enjoyed our posts and were able to follow us on our journey through Thailand. Please enjoy these last photos from our journey.

Best wishes to all,

Casey  

Reflections: A.J.

My favorite part of traveling is the tangible evidence that paradigms are just that. Doing something because it’s the way we’ve always done it doesn’t make it the only or the only right way. Food, healthcare, family structures, mores and aesthetics are social constructs and sometimes, you have to view them from a different perspective to realize it. 

Four weeks abroad seemed like a long time, but it went in a flash. I feel like I’ve only begun to scratch the surface of Thailand, but I have made many enduring memories from the experiences of the past month. Our hosts and guides have been gracious, warm and welcoming. They are the greater part of the highlights, above the places and activities. 

Our coordinator Noi always went the extra mile. She was our conduit into not just healthcare in Thailand, but many of its prominent cultural features as well. She wouldn’t just order new Thai dishes to try, she’d explain the culinary process, show us the component ingredients, and discuss when it was typically eaten and by whom. She patiently answered sensitive questions about Buddhism, politics, the monarchy, and the everyday life of Thai people. She and Nu, our driver, were the touchstones through the entire trip - consistent and dependable in each new situation we found ourselves in.

Every hospital, community pharmacy, and university we visited put visible effort into making us comfortable and providing a valuable learning opportunity - the Thai reputation for hospitality is well deserved. I am thankful for all the people we met along the way.

For a middle income country with limited resources, Thailand does an admirable job taking care of it’s people. By way of comparison, the United States spends ~17% of its considerably larger GDP on healthcare - Thailand spends 4%, but yet, it provides universal coverage to every one of its citizens. This care is not entirely free, and it comes with some drawbacks, but any Thai national can receive some basic level of services, affordably delivered. Many of the talking points used to rally against universal healthcare in the United States are found here; long waits and limited choice. Patients may spend a whole day in the process of seeing a doctor and picking up medications, and those UC medications come from a limited national formulary. Some of the preferred medications, like for HIV anti-retroviral therapy, are considered third-line choices in the US. This is not precision medicine. Still, I’ve seen American patients with wildly uncontrolled chronic diseases due to economic barriers, and I feel strongly that some care is better than none, no matter how “cookie cutter” it is. 

There is no prescription opioid crisis in Thailand. Acetaminophen is the king of analgesia here and non-pharmacological measures are routinely offered as first line treatments in chronic pain. There is a cultural difference in attitude toward pain here, too. Buddhism is the most common religion. I suspect its precepts and practices about the inevitability of suffering and the tools to rise above it, including meditation, encourage the acceptance of this treatment plan. Massage is also a large component of traditional Thai medicine, which is encouraged even in western medicine for the treatment of musculoskeletal pain. I hope that, armed with the knowledge we have now about opioids, America can shift to a similar culture in the area of medicine, and do a better job with integrative treatment. 

As you might expect, there were some experiences that were less than comfortable. There is a different emphasis on outward appearance here that feels more pressured than in the United States. All of our professional hosts were well made up and neatly attired, which felt impossible for me, in the heat and humidity. I felt sloppy, sweaty and awkward. Pointed comments about body image and weight were made toward our diverse-looking group, even by some health professionals. At the elephant hospital, we were mobbed by tourists, who all wanted to take pictures with us, and it felt like we were on constant display. 

We also saw many levels of care, from very posh private hospitals to rural health centers, The gap in resources between the highest and the lowest were very broad indeed. In a regional psychiatric facility, I was shaken by the difference in standards of treatment from what I’ve seen the U.S. When our pharmacist guide asked us whether the ward was like ours, I had no idea what to say. 

I think that with discomfort, comes growth. I used these experiences to re-examine what was at the base of the feeling, whether it was a personal insecurity or a closely held bias or belief. I appreciate when I am valued for the quality or effort of my work, more than the way I look, but I also know that appearance plays a significant role in human interaction. I believe in patient-centered care, that takes into account the autonomy of the patient, but I can also acknowledge the difficulty of this in low health-literacy populations.

For all the differences I observed, I also found that at the core of their work, Thai healthcare providers were in medicine for the same reasons I am; they are driven to help people achieve healthy, meaningful lives. Pharmacists in Thailand are fighting for a place at the table in hospitals, clinics and the community, in the same way American pharmacists did in the not so distant past. I don’t speak much Thai, but meeting with pharmacy students and residents, I realized we shared a universal language, connecting through our passion for the profession.

Thanks for reading,
A.J.

Chao Phraya Abhaibhubejhr Hospital

Chao Phraya Abhaibhubejhr Hospital is so much more than any other regional hospital. It is home to the Thai Traditional Medicine Museum in a beautiful building that is over 100 years old and was formerly a temple, pictured behind us below.

The museum consisted of a lot of old products used in Thai Traditional Medicine, including jars, bags, and bottles. There were also multiple cabinets containing all of the original manuscripts for Thai Traditional Medicine with recipes that have been transcribed to modern day textbooks.

In this same building was the Thai Traditional Medicine pharmacy. As we walked in there was a center shelf filled with jars containing dried fruits, plants, herbs, and insects.

When the pharmacist asked if any of us were sick, we responded that some of us had a cough. So he had them make a concoction, containing amla/indian gooseberry and some other dried components. They use the scale with weights on one side balanced with the ingredients on the other. Once weighed, the 3 or 4 ingredients used were placed in this satchel to be used for tea. The tea ended up being extremely bitter and sour, but actually seemed to work for a short period of time!

They also had their own manufacturing plant for Thai medicine and cosmetics. From which they distribute to hospitals and consumers around the country.

Thanks for reading!
Sara