Friday, January 23, 2015

ปราโมทย์ [joy]

After coming down from the mountain trip last weekend, our week has been filled with lots of generous learning opportunities, hospitality, laughs, and helpings of delicious Thai foods!

Monday morning we met at another location of the University Pharmacy, which is the community pharmacy run by the Faculty of Pharmacy at Mahasarkham University. All of the 16 Faculties of Pharmacy in Thailand have their own community pharmacy practice sites. This location in Maha Sarakham has a small classroom, so we met Arjun Phayom (arjun is the Thai word for teacher) and a few other Thai students for a presentation on the Faculty of Pharmacy, University Pharmacy, and community pharmacy practice in Thailand. There is a big focus in Thailand currently to advance the health system through community leaders, and to have pharmacists engage in customer protection (monitoring medication and food usage throughout the communities). The district hospitals are too large for one pharmacist to manage, so they utilize health volunteers, which are everyday citizens that volunteer to promote community health for a small reimbursement of 600 Baht per month. These citizens check formaldehyde use in local markets, examine cooking pots for lead, monitor illegal drug sales, etc. More on this in a little bit!

We found it very interesting that there are 12,000 community pharmacies in Thailand, but not all pharmacies will have a full time pharmacist on hand. This means a patient could go into a community pharmacy and have their glipizide prescription for diabetes refilled or be given a product from a common illness without a pharmacist being involved. This is an area of pharmacy practice that is undergoing great change though, since a Good Pharmacy Practice (GPP) Law has been established to set standards for quality and patient care and will be implemented over 8 years beginning from June 2014. Currently only 1,000 pharmacies have received the accreditation that they are following all requirements of GPP Law. When they receive this accreditation, they display a hand symbol proudly on the pharmacy sign. University Pharmacy is of course one of the GPP accredited pharmacies and serves a practice site for many student pharmacists during their rotations and offers many advanced care services for the community.  3rd year student pharmacists engage in blood pressure and blood glucose monitoring, 4th years advance to more in-depth disease counseling, and 5th and 6th years participate in home visits. All 3rd-6th year students engage in smoking cessation counseling.

Another exciting change as community pharmacy practice is evolving in Thailand is that the Faculty of Pharmacy at MSU is moving from a curriculum that focuses on preparing students for roles in a hospital to incorporating education that also focuses on community pharmacy roles. As previously mentioned, they are also trying to incorporate community pharmacy services into the National Health Care reimbursement model so that patients can come to the community pharmacy for primary care, instead of a primary care unit or community hospital. Under National Health Care, patients only pay 30 Baht for any health service at a PCU or hospital. However, they get no coverage, or must pay out-of-pocket completely for counseling and medication obtained at a pharmacy. Maha Sarakham University community pharmacies are the first in Thailand to attempt to join the 30 Baht reimbursement system! It is neat to see the worldwide endeavors that pharmacists are making to advance the profession of pharmacy.

We also spent some time in the morning discussing a few patient cases of patients with uncontrolled diabetes who had been seen by the Thai pharmacy students during their multidisciplinary home-visits. We really enjoyed collaborating to develop a plan for these patients and compare and contrast the diabetes care and education that is done in Thailand, Japan, and the United States. We learned that Thailand also follows the American Diabetes Association Guidelines for their treatment methods, however they do not utilize medications beyond metformin, sulfonylureas, and insulin, since most other diabetic agents are very expensive. In Japan, they utilize all other agents that we have available in the United States, such as the newest agents, the SGLT-2 inhibitors. We gathered from our discussion that barriers to achieving blood glucose control in diabetic patients are universal, with patients having a poor adherence to healthy lifestyle choices and medication and lack of understanding of diabetes and its effects on the body. We discussed the similar methods we use to educate patients with diabetes, such as visual aids showing the patient a bag of sugar demonstrating how much sugar is in a coke in the United States or a piece of Jackfruit in Thailand!

Takhonyang Primary Care Health Unit

In the afternoon we visited the Takhonyang Primary Care Health Unit. This is a traditional primary care unit also called a health promotion hospital located in Maha Sarakham. This is considered a one-stop-service location and is run by 2 nurses, public health workers, and healthcare volunteers. Thirty to forty patients are seen each day by the nurses for common illnesses like a cold, sutures for minor accidents, childhood vaccinations (in Thailand these are the tuberculosis vaccine known as BCT, Hepatitis B, Tetanus, MMR, and Japanese Encephalitis vaccine), and family planning, which includes contraceptives and check-ups during pregnancy. On Fridays the nurses run a dental clinic and the doctor and a pharmacist come once a month to see patients and dispense 3-months supply of refills for chronic disease medications. This primary care unit had a very welcoming, community feel with gorgeous flowering bushes out front, smiling faces on every worker, and it even had a sauna and massage room used to provide pain relief to patients. We like the idea of the easy access to a healthcare provider that this setting provides and the opportunity to establish relationships with families of patients, and provide health promotion and community activities like classes for the elderly.   

Monday night we took it easy and just biked over the Talla Noi (small market) for take-away dinner and worked on finishing our Journal Club Presentation and Role Play Scenario due later in the week. We were of course so thrilled with ourselves that we ordered the Pad Thai Guy (gui is chicken…the chicken guy!), pineapple slices for morning breakfast, and jasmine and coconut bubble tea on our own. Now that we’ve got our Thai numbers down and a few phrases, we feel like we’re ready to take on Night Market in Chiang Mai this weekend!

On Tuesday morning we took a trip in the Faculty of Pharmacy van to the neighboring Roi-Et province where we visited Selaphum Hospital. This is a community or district hospital, meaning it is a smaller 60 bed-hospital providing more basic primary and secondary care to the 120,000 citizens within the Selphum district of the Roi-et Province. If a patient needed more advanced care, they would be referred from Selaphum to a Regional Hospital, such as Khon Kaen Hospital, which we visited last week. There are 13 regions, 77 provinces, and then countless districts, sub-districts, and villages in Thailand. Interesting to note that in a district of Selaphum, there are 235 villages, 34,000 households, 100 primary schools, and 177 temples. The hospital is currently expanding to 120 beds, as they are over capacity, often treating 70-80 patients a day. We were again humbled by the generous reception we received, with the Hospital Director as well as the Directors of Pharmacy, Medicine, and Nursing greeting us and attending the presentations by the pharmacy department. The first presentation described the services of the hospital and pharmacy department, which were very impressive. The 12 pharmacists at this hospital provide unit dose distribution, medication reconciliation, discharge counseling, high alert drug monitoring, and round with physicians daily on the 2 inpatient medicine wards and also dispense medications at the outpatient pharmacy and participate in the ambulatory care clinics held at the hospital.

The second presentation at Selaphum Hospital was on the role of pharmacist in Consumer Protection. Unlike any pharmacist’s role in the United States or Japan, pharmacists in Thailand are responsible for ensuring the safety of medications, foods, and cosmetics. Pharmacists along with health volunteers and community leaders go out into the community and inspect businesses and even food vendor stalls at markets to look for potentially harmful and unsafe practices and products. The particular pharmacist giving the presentation became very passionate about Consumer Protection after seeing several patients at the hospital with serious health complications such as gastrointestinal bleeding, Cushing Syndrome, anaphylaxis, and even death after taking YACHUD. YACHUD is the term for a packet of 5 to 6 tablets of medication a patient can purchase inexpensively in the community from various vendors who claim the medication will heal them.  The danger is that the patient is unaware of what medications are in the YACHUD and they often contain steroids, which have many severe adverse effects and typically should not be taken chronically. For example, 5 medications identified in one YACHUD packet were indomethacin, phenybutazone, piroxicam, chlorpheneramine, and betamethasone. If a business or vendor is found selling YACHUD or any other unsafe practices such as reusing cooking oil, which is carcinogenic, or selling cosmetics containing mercury, the products are taken and the owner is simply educated and will then have follow-up inspections every 3 months. Most of the owners are unaware that their practice is unsafe or illegal.  

In the inpatient pharmacy


After our presentations we took a tour of the Selaphum Hospital, where we saw the only two wards, one for males and one for females, the medication storage room, and the inpatient pharmacy. We learned that the hospital only orders medication once every 2 months and that it takes 2 weeks for the order to be delivered. We also learned that the hospital makes its own herbal pill for hemorrhoids and is actually sponsored by the Ministry of Public Health to produce safe herbal treatments.  A unique piece of culture we noted during our tour is that there were Christmas decorations everywhere. When we asked about the celebration of this holiday, we were informed that while it is not recognized as a holiday, Thai people love Christmas decorations and use them in conjunction with their many, many New Years celebrations.

One of two wards

Nurses station between wards

After our tour, we were generously treated to a delicious lunch at a local restaurant and then rode in the van out to a rural area, where we visited the Ban Nongpha Tambon health promotion hospital (HPH). This HPH is a nurse operated, one-stop-service responsible for patients within 9 of the villages of the Selaphum district (population ~ 5,500). We were again humbled by the generous reception we received, this time there was even a specialized banner hanging to welcome us, plus an abundance of fruit, drinks, and snacks waiting for us. They even had a translator present so that they could be sure to speak with us and answer our questions. The effort put into the English language here is admirable and while we are always so impressed with their English, the Thai people are always trying to improve. We made an important discovery that R’s, L’s and G’s are very hard for them to pronounce, as well as to discern when we say words. For example, the difference in “grass” and “glass” is quite difficult. This is very good to know so that we can tailor our speech and help our friends learn!

They gave us a tour of their facility and a presentation on their drug and medical supply management, which includes great practices like temperature and humidity controlled storage and system to keep up with medication expiration dates. They also talked extensively about the consumer protection efforts in the community, their capacity development system in which they hold seminars in order to build their network, and how they utilize “local wisdom and village leaders for healthier villagers.” They gave several examples of how this program has made a difference in the community, including establishing local wisdom centers for herbal therapy and Thai massages, community-wide smoking cessation, and seizing crocodile blood capsules that were being marketed and sold in the community under the claim that they heal diabetes, treat hypertension, and cure cancer!! The message we took away from this presentation was that overall, Thai healthcare is very holistically focused: they treat the physical, mental and social aspect of the patient. The passion for their people and community is obvious in everything that they do, and we are so glad we get to learn from them.

Ban Nongpha Tambon health promotion hospital 

Tuesday night we met even more generous people! The four 6th year pharmacy students, who were a part of the exchange program last year picked us up from the dorm and treated us to a great family style dinner at a restaurant in downtown Maha Sarakham. We got to try some new and interesting Thai dishes such a chicken with a lemon sauce and fried octopus, revisit some old favorites like fried morning glory, and of course plenty of sticky rice! Then they took us to the mall and treated us to ice cream at Swensen’s for dessert (we need to find a way to get their macadamia nut ice cream when we return home. The Turkish coffee was also incredible). One of many town night markets is located right outside the mall, so we walked around and were able to pick up more of our new favorite fruit Jackfruit! We even got to see the Jackfruit before it was cut! It’s a huge fruit with large yellow pods, which are the part you eat!

Night market fun!

Next came the most exciting treat of the night. The 6th years had purchased fire lanterns for us to light together. We had loved seeing these magically floating amongst the fireworks on New Years Eve at Ao Nang Beach, and were so excited for the opportunity to light our own. Our Japanese friends also appreciated the reference to Rapunzel, or Tangled! In Thailand, it is a tradition at a celebration to light the lantern and make a wish as you release them to the sky. You can even write your wish on them if you like. Each set of exchange students and the 6th year students had a lantern to wish upon and light. We opted to write parts of the beloved Auburn Creed on our lantern because to us, there is no better way to wish for a happy and healthy 2015! We also added a War Eagle, of course. It was fun to light the lanterns together and watch as each lantern floated up and away. Some came precariously close to some power lines, which is perhaps why this practice isn’t 100% legal within the Mahasarakham University city limits. But, they all made it and we can’t wait to see our wishes come true! Sometimes you just have to live life a little on the edge to experience true magic.

On Wednesday we walked to school in perfect weather: sunshine and breezy with not a cloud in the sky! We met in one of the laboratory classrooms at the Faculty of Pharmacy for our very own Thai Traditional Medicine class, where we learned to make an herbal compress. The herbal compress is often used in Traditional Thai Medicine for pain relief after a massage, for massages can be painful when they are done as medical treatment to truly unknot muscles! The professor had an instruction sheet for each of us and explained what each of the locally grown herbs was used for and then demonstrated how to measure each component using the scale, and form in the compress ball with cloth and rope. Then we each got to make our own! The herbal compress we made contained aromatic herbs with properties for muscle relaxing, skin cleansing, skin nourishing, and stimulation of blood circulation. After we finished making our compresses, the professor showed us how to use the herbal compress. You place the compress in a steamer for about 10 minutes and allow it to become warm and damp, then you press the compress against the patients skin in the area where they are experiencing pain. This is very soothing for the patient!  It was fun to use our compounding skills again and we are looking forward to using these awesome remedies! However, we don’t envy the Thai students who have to learn both Western and Traditional medicines! We thought learning drug structures was tough and can’t imagine having to know the herbal medications appearance, names, and indications, but think this is incredibly beneficial to their role as pharmacists in Thailand!

The professor also generously took us just across the street to visit the facility where students and professors from the Faculty of Pharmacy manufacture the natural products they have developed right on the MSU campus. We really enjoyed seeing this facility and learning about the PharmacareNeutracuetical products. They are currently making 12 products, all of which have come from the required project of 3rd year pharmacy students or the thesis project of a 5th year student.  These products, ranging from capsules to drinks and soaps, have been licensed by the Ministry of Public Health and are currently being sold in community pharmacies across the Northeast Region of Thailand as well as Bangkok and within several hospitals. There are 20 more products currently in development and it typically takes about 4 months to a year to obtain a license. The cost of the license application is about 2,000 baht, while average development cost is about 500,000 baht. MSU is only one of 3 schools in the nation to have a pharmaceutical manufacturing facility. Whenever the facility completes a batch of product, they keep samples in a large stability cabinet until the projected expiration date to ensure safety.

When our tour concluded, we walked over to a food court near the Faculty of Politics and Governance for a quick lunch with Mint and Boss. It was fun feeling like college students again, and eating amidst the hustle and bustle of a class change. Erin also enjoyed her new obsession, jasmine greentea with bubbles. After lunch we walked back to our dorm and relished the weather for as long as possible before crawling into bed for some quick naps. We have officially heard back from all the residency programs we applied to and were able to finally set our schedules for when we return to the States. This is such a relief and we both feel extremely fortunate for our residency opportunities…and can finally rest easy!

The late afternoon and night brought more special bonding with our new friends. Airi and Risa have been patiently waiting for Japanese food, and tonight was their time to shine! In the car on the way to Japanese dinner, they taught us the country of Japan’s cheer “Nippon!” (similar to our USA! USA! USA!). We have so much fun with them! The six of us exchange students joined Best, Tony, Boss, Fern, Prim, Honey, and Beauty for dinner and even had a quick visit from Tina! At dinner Hannah, Camellia, Risa, and Airi gave each of us a souvenir of a cute Cambodian dancer figurine from their trip to Cambodia last weekend. Dinner at Shabushi  was a cool experience, the restaurant is set up with barstools and in front of each seat is a pot with boiling broth and a conveyor belt that winds through the restaurant, bringing different meats, vegetables, and noodles right to you. You can simply pull whichever item you would like to “cook” in your pot from the conveyor belt or order special items like sushi or chicken straight from the menu. We really enjoyed flavoring our pots with garlic and herbs and eating the warm chicken, Udon noodles, fresh carrots, morning glory, and a few unique varieties of mushrooms!

The restaurant also had our favorite dessert, ice cream, but quickly ran out of vanilla, so Erin hunted through the unopened tubs in the freezer for more vanilla. Our friend Tony was there to help us and quickly told us that the unopened tubs were chocolate ice cream to which Erin exclaimed in shock “You can read that?!” This led to a few moments of hysterical laughter, because of course Tony could read it since it had ‘chocolate’ written in Thai on the top of the tub!

Thursday morning we walked in the warm sunshine to the Faculty of Pharmacy to give our Journal Club presentations to a small group of Thai 5th year pharmacy students and professors. We had been asked to present in a PowerPoint format on a journal article that was relevant to the main medical conditions in Thailand, such as cardiovascular diseases, diabetes, or smoking cessation. We presented on the most recent study exploring the association of mortality and digoxin use in patients newly diagnosed with atrial fibrillation. Hannah and Camellia, the students from Tennessee then presented a study evaluating the efficacy of varenicline vs. vareniciline in combination with nicotine replacement therapy for smoking cessation. Both presentations lead to interesting discussions of how we utilize guidelines for our therapy choice in atrial fibrillation and the pharmacists roles in smoking cessation in Thailand, Japan, and the United States. We were excited to share about the efforts of the Pack It Up Club at Auburn.

After the presentations Arjun Thananan, one of the professors, treated us to a lunch of delicious ham and pineapple pizza from The Pizza Company and also chicken from KFC. We decided in terms of Thai pizza, The Pizza Company > Pizza Hut. It was nice to have some time to speak with the professors and the pizza was the closest to American pizza that we have had in Thailand! During our lunch break, we learned quite a bit. Prim, Fern, and Tony taught us how to write our names and a few other beautiful phrases in Thai. This was a highlight for sure because since we came to Thailand we have been admiring how gorgeous the Thai written language is with its 44 intricate and elegant characters.  Also, Toy and Champ, two of our Thai host students, showed us the laboratory where they are working on their extensive research project. This project involves identifying a compound from an herb that will inhibit the enzyme alpha-glucosidase (just like the prescription drug acarbose used for diabetes), which can be used by diabetic patients as a natural way to lower blood sugar. In this lab we also met other 5th year pharmacy students who explained that they were working to extract compounds from specific plant leaves and testing their ability to kill several types of bacteria and fungus. They are hoping to utilize the effective extracts to they identify to create a face wash, but struggling with the unappealing brown color that their extract had formed. We were so impressed by these research endeavors and hope to hear that they are manufacturing these students’ natural products at the University’s Pharmaceutical Manufacturing facility in the future.

We wrapped up the afternoon with a group discussion of the experience at Mahasarakham University. This was a chance to share with the students and Arjun Pattarin what we learned and liked, and to give feedback on how to improve the rotation. It was actually quite hard and at points emotional to put into words the immensity of what we have learned and what were the best things! Both of us feel incredibly fortunate for the opportunity to study for a few weeks here at Mahasarakham and truly could not have asked for a better group of exchange students, Thai students, and professors to experience this with. We will forever hold this experience dear in our hearts.

Since we were all feeling rather sentimental after this discussion and realization that our time together is coming to an end, the six of us exchange students decided to spend our free time in the afternoon biking over to the Talla Noi (small market) for one last fruit smoothie from our smoothie lady. This was an extra special trip because this time she had fresh mango making Megan’s pineapple and mango smoothie the best smoothie of the Thailand trip thus far! The rest of the afternoon we spent working on our blog and other projects outside in the perfect weather. We will continue to soak up as much sunshine and experiences as we can during our last few weeks in Chiang Mai, Maha Sarakham, and Bangkok!   

For dinner our professors treated our group of 6 exchange students and 10 Thai hosts to a farewell dinner at a restaurant in downtown Maha Sarakham. This wasn’t your typical dinner in Thailand though…we had our own large room that was equipped for karaoke! We all had a blast eating traditional Thai dishes family style while singing and dancing to songs in Thai, English, and languages/countries we are not quite sure about. Some highlights were doing The Wobble all together again (we were excited that most of the students remembered this dance we had taught them), and belting out Shake It Off (by Taylor Swift who is considered to be Megan’s doppleganger by the people of Thailand) and Let it Go from Frozen! This was such a memorable way to end all of the wonderful meals we’ve shared and discover some of our friends hidden talents in singing and dancing! We haven’t laughed that hard in a long time!

All 16 of us!!!

After dinner we headed to a festival in downtown Maha Sarakham held in the province once a year. It is sponsored by the Ministry of Health and benefits the RedCross. The festival lasts 10 days and was like a huge market with vendors selling food, jewelry, toys, furniture, etc. The festival also has small amusements rides like a carousel and ferris wheel.   It reminded us both of a state or county fair in the United States. Even after our big dinner, we enjoyed sampling some of the foods at the festival. First, we tried the Thai version of a coke slushy, which is made by placing a glass bottle of Coca-Cola into a barrel of ice water and then the barrel is slowly swished back and forth. Next, we tried the most unique ice cream we’ve had in Thailand yet. It was delicious soft serve ice cream in a curved cone made of a corn puff. It was like eating ice cream in a cheese puff, minus the cheese taste. Then we picked up Kao Tan and Kao Mao, the Thai snacks we were nicknamed after, as snacks for our trip to Chiang Mai.

With our respective Thai nickname snacks

One of the best parts of the night and maybe the most hilarious/memorable 5 minutes of our trip so far was leaving the festival. Our friends Tony, Best, and Tina had invited us to go see the movie American Sniper with them and the only time we could go was the 11:20pm showing, so we had to quickly leave the festival to make it to the movie in time. This resulted in the 4 of us (Tony, Best, Erin, and Megan) literally running through the festival and rows and rows of parked motorcycles back to Best’s car. We jumped in the car to head to the movie and Best realized suddenly we were not in his car! Somehow his key had unlocked the door of another car that looked very similar to his. We all burst out laughing and somehow made it to Best’s actual car and to the movie theater at the mall in time for the showing, despite our uncontrollable laughter.    

Watching American Sniper in a foreign country in English, but with Thai subtitles, was a remarkable experience. At first it took us both a minute to pick back up on listening to the American-Texan accents, since we haven’t heard many American voices besides each others lately. This powerful story left the us both so grateful for the heroes and families who serve our great nation. It was moving to see although we were the only Americans at the movie there was complete silence as everyone exited the theater, showing the impact that this story had universally and the respect for the United States. We are of course forever and always so proud to be American!

Friday has been very bittersweet with the sadness of the 6 of us exchange students going our separate ways today. We truly couldn’t have asked for a more sweet and fun group of international students to share this experience with. Airi and Risa will return to Japan on Sunday. Camellia and Hannah will head to Bangkok Saturday for a few days of studying at community and hospital pharmacies there, and we are headed to Chiang Mai today for the weekend. We started off the morning biking to the Talla Noi for a great breakfast of coffee frappes and fresh pineapple. Then we met at the Faculty of Pharmacy to do our patient counseling scenario role plays. The 6 of us decided to coordinate for our last day together and wear the elephant pants we have each gotten as souvenirs while we were here. We received sweet parting gifts of fun University of Tennessee mugs and pens from Camellia and Hannah and yummy Japanese snacks from Airi and Risa. We then presented our role-play scenario of comprehensive diabetes care counseling to a patient with uncontrolled diabetes initiating insulin therapy. In our scenario, Erin played the pharmacist and Megan was the patient, Miss Saaep Laai (which means ‘very delicious’ in the Isan dialect of Thai). Our role-play presentation was video recorded and they will use this video in the future to help their students learning patient counseling techniques in English.   

Breakfast of champions


Best exchange student group ever! Elephant pants love

With our amazing professors

After our teary goodbyes, Best and Tony took us to the main bus station in Maha Sarakham and helped us to purchase tickets to ride the pink bus to Udon Thani, a larger city farther North so that we could catch a NokAir flight to Chiang Mai. The pink bus was a like a large charter bus in America and made several stops along the way at large and small bus stations. The total bus ride time was about 4 hours and was a little bumpy, but we enjoyed seeing more of the rural scenery of Thailand. The bus dropped us off at the large mall in Udon Thani and we took a quick 15 minute taxi-ride to the airport. We have gotten a little rusty on our airline travel skills in the 2 weeks since we’ve flown and walked up to security with our full cups of coffee we had just purchased, but I guess we look very trustworthy and they let us walk right through with our coffees in hand!  Our flight to Chaing Mai was just 55 minutes and NokAir lived up to its motto ‘We fly smiles.’  The taxi from the airport to our hotel was very easy thanks to our friend Boss who wrote the address for every place we are going in Thai, so all we had to do was simply show this to the taxi driver. We are so excited to be in Chiang Mai and can’t wait update you on our weekend adventures!     

Our awesome chauffeurs

Flight to Chiang Mai

Bus to Udon Thani airport

1 comment:

  1. Very nice! Try all of the food! Mango sticky rice coconut milk dessert thing I think it's called Khano nee mamuang or like that