Mariam Savabi
Reflection paper related to Thailand
When I decided to go to Thailand, I really had no idea what to expect as far as the structure of
the medical system. Being a Buddhist-based society, with strong national ties, and a very respectful and
kind society, I imagined that this would influence the way in which healthcare was delivered. I created
three learning objectives to assess during my time in Thailand, and with my time rotating at the Siriraj
Hospital, I was able to truly appreciate the uniqueness of healthcare delivery in the country.
My first learning objective related to my requested rotation in the country relates to my future
career as an OB/GYN. I wanted to observe patient care, and its relation to how it is performed in the US.
Having done extensive research related to women’s health, I have learned that medically, women’s
health can often be practiced without being evidence-based, and even with poor outcomes, but because
there is little to no discussion about what is appropriate obstetrical or gynecological care, patients are
unknowing about what to expect and are willing, and assuming, that the medical care received in the
hospital is the best. I have personally seen this in the United States where procedures are performed
that are completely inappropriate, namely episiotomies. For the first 2-weeks of my time at Siriraj I was
assigned to shadow c-sections, laprascopic surgeries, out-patient birth control clinic, and labor and
delivery. A majority of the care was very similar to the US with a few large differences. One of these
differences is that wasting medical equipment is not as common as in the US. Almost everything used is
something that can be re-used. For surgeries, the sterile draping, sterile gowns were all made of cloth
and were washed to be re-used. Culturally, outside shoes are not allowed into the ‘sterile’ zone of the
locker room, operating rooms, and L&D. Scrubs for women were often a dress, and no outside clothing
was allowed into the OR or L&D. The structure of the hierarchy of surgery was unique in the sense that
very few people were allowed perform surgeries unless they were the most senior person. The senior
resident, or attending was in charge of the entire surgery, and the only involvement that anyone else
could have in the surgery was very minor.
The second big difference was in the way in which patients were cared for and how they
interacted with staff. The L&D floor consisted of small alcoves that were covered with a curtain where
the patient was in. Each patient had their own small alcove. There was no privacy, there was no one in
the room with them, the woman sat by themselves while their partners and husbands sat outside the
ward on wooden pews. When the woman was finally ready to push the baby out, they had her
positioned lying down and EVERY SINGLE TIME they did an episiotomy. I was shocked. I ended up asking
the chief resident why episiotomies were being done for each patient. She informed that I was not the
first international medical student to ask this question, that she was aware of the detrimental outcomes
related to the procedure. She explained that the patients seen on this L&D floor were the poorer
patients and that because there were getting free care, that the students, and residents needed to learn
how to do certain procedures, and unfortunately that meant learning off of the patients. I was very
saddened for the patients that I saw having to endure this procedure – but I have often seen this
mentality also in the United States. We have our free clinic provided to the uninsured and students get
to practice their skills on patients, without any other training. While I don’t necessary think procedures
are don’t inappropriately, I have seen episiotomies performed for no medical reason. So while it was
shocking to see every patient receive an episiotomy, this was the previous standard of care for women
in the United States, and only with updated evidence-based medicine has this changed in the United
States, and I suspect will take time to move to Thailand. I hope this occurs sooner than later, in both
countries.
There were a few different issues that the hospital in Bangkok had to deal with versus what I
have seen in the US. There was an entire section that was dedicated to septic pregnant patients. This
was due to back-alley abortions, patients with TORCHS infections, and HIV. It was sad to see and hear
about patients that were having to access unsafe providers for abortion because it is illegal in Thailand.
It scared me greatly to see what it would look like in the United States should there be more and more
limitations and closures of abortions providers. This was the situation in the United States before Roe v
Wade, and now is becoming more and more of a reality. It is scary, unjust and very possible to happen in
our country. Additionally, patients have higher rates of thallasemia b and hemoglobin e, and so testing
was very important during the prenatal period in order to prevent adverse fetal outcomes due to these
genetic possibilities. Something that I will have to remember as a physician treating patients from
Southeast Asia.
The access to birth control methods seemed to be very easy, but possibly limited for patients
that lived far away from medical providers in Bangkok. The most frequently used birth control method
seemed to be the IUD. There were some different types of copper IUDs called multi-load, the mirena
IUD which is very expensive and rarely used, and the Jadelle – a different type of implant progesterone
based IUD. Birth control seemed to be a very accessible and easily discussed part of patient care.
Patients who had just given birth all were taken down to the birth control clinic in order to get
something for them before they left the hospital. This seemed very responsible and appropriate, and
something I wish was more stressed in our own country.
One major problem that was obvious, was the high number of cancers in the country. In
Thailand, breast cancer is the number one killer of women, while cervical cancer is third. Both of these
types of cancers have different screening measures, however both have challenges to be implemented.
For breast cancer there are only 400 mammogram machines in the entire country, and 60% are found in
Bangkok. Women do not get a mammogram unless it is for diagnosis, not for screening, and then it is
often very late in the disease process. It was very sad, and we saw entirely too many patients daily with
these findings. For cervical cancer, pap smears are becoming more prevalent, however in rural areas,
access to healthcare is limited, as is screening in general. Additionally, the HPV vaccine is very expensive
and so it is not accessible to many in the country. Since the vaccine is still on patent for probably
another 10-years, the ability to prevent cervical cancer is quite low. These health outcomes were very
sad, because many times they are preventable.
Cultural:
There were some cultural difference that influences the way in which people interacted with
their healthcare providers. Culturally, people are extremely respectful to each other, and particularly
patients to providers. ‘Sawadika,’ is the Thai greeting, where a bow and hands placed together are to
respectfully recognize another person. This was frequently done by the patient for the provider with
each interaction, and at the end of the interaction with a, ‘Kop kon ka,’ or thank you. I really appreciated
the respect that was visible amongst all people in the hospital and the dynamic of the patient – but I
suspect that this type of cultural respect also allows for the paternalistic behavior I witnessed with
healthcare provided to patients.
Another cultural difference that I really appreciated in Thailand was the acceptance and
normalization of children in life. When patients brought their newborns to a doctor appointment,
everyone helped with taking care of the child when necessary. A nurse would hold the child and care for
them while the mother was being seen. Children were often seen, and were part of daily life both in the
hospital, clinic, and life. I love it and it made me realize how much we try to sterilize and remove our
personal lives from our everyday lives.
Thai Traditional Medicine:
I requested to do a rotation in the Thai traditional medicine department. Not knowing that this
existed, or was an option, I requested the rotation when I arrived to Siriraj. The rotation was excellent! I
was able to learn about the tradition of medicine in Thailand, the history of Siriraj Hospital and Mahidol
University, and the importance of preserving this ancient art of herbal medicines, and Thai traditional
practices. I had a tour of the herbal garden where I learned to recognize flowers, plants, and roots and
the different medicines and foods they are used in. The department is working on making the herbal
medicines more standardized and isolating the therapeutic compounds that are found in each type of
herbal medication. There were a great many antipyretic options that completely blew my mind! I was
taught, and had performed on me, the different ways in which women are cared for in the post-partum
period. I really enjoyed learning this, and felt that the massages and hot herbal compresses would be
very nice for a woman to experience as part of her post-partum treatment. I had a new found
appreciation for traditional medicine, and hope to be able to respect and understand the needs of my
patients who use this type of medical care.
Conclusion:
I feel that a majority of my learning for this rotation came from the experiences with the country
itself. While the hospital was a great opportunity to see how a different healthcare system can work, my
classroom was the interactions I had with the people and country. When Thailand is described as the
land of smiles, it is not a lie. Being a Buddhist-based society, people are very welcoming. Transgender
and transsexual acceptance is prevalent in the society. I had never lived in or had experienced a society
that lives entirely minding it’s very own business, and it was refreshing and wonderful. I could even see
myself living in this country and being extremely happy. Overall, I think that the experience in Thailand
was wonderful, and I can’t wait to visit again!