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
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
YACHUD
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
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!
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
Breakfast
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
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
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