Tuesday, February 3, 2015

นวัตกรรม [innovation]

Monday morning we felt like local Bangkok students heading out to the last site of our International Pharmacy rotation here in Thailand at Roen-ya Pharmacy, an independent community pharmacy. After using google maps the night before to determine the approximate location of the pharmacy, we decided the best approach would be to take a taxi directly there. (Travel Tip for future students/travelers: If you use the maps application on your iPhone and drop a pin at the location then click the pin, the address pulls up in Thai and English. We used the screenshot of this to show the taxi driver and this made it very easy for the driver to understand where we wanted to go without us having to attempt to write in Thai). The taxi ride was very affordable (under $2...cheaper than us both buying BTS Sky Train passes!) and we arrived at the pharmacy located on the street corner, just on time at 9 AM despite the rush hour traffic.

As soon as we walked into Roen-ya, we were greeted by the pharmacist Dr. Katha and shown a place to sit while he provided medications and counseling to a few patients who walked in the doors behind us. We picked up right away that this is an exceptional pharmacy with the number of drug references and therapeutics resources lining the shelves, as well as prestigious pictures and awards in Dr. Katha’s office located in the back of the pharmacy. We were excited for what the two days would entail. After another pharmacist arrived, Dr. Katha was ready to speak to us. We spent the next few hours discussing the healthcare system in Thailand and Dr. Katha graciously shared his insights and impressive endeavors to improve direct patient care through community pharmacies in Thailand.


Awards and Graduation photos

During our discussion with Dr. Katha, he emphasized that a huge burden on healthcare in Thailand, much like the United States, is the many patients with uncontrolled chronic conditions such as diabetes mellitus and dyslipidemia who end up requiring acute care at a hospital rather than receiving adequate primary care. He feels that the Health Promotion Hospitals (local outpatient clinics operated by nurses) that serve to provide primary care to local patients in the villages are not adequate for patients with chronic illnesses, because physicians and pharmacists only visit these Health Promotion Hospitals once a month. However, patients seek care at these health promotion hospitals because the district or provincial hospitals are inconvenient to get to and overcrowded, meaning the patients wait a long time and are rushed through their visit with the physician and pharmacists. These patients then only seek care at the larger hospitals when they are very ill. Dr. Katha even stated that the prescriptions patients have filled at a Health Promotion Hospital are simply ‘remade’ as only a pharmacist or physician has the expertise to truly ‘refill’ a prescription.  Dr. Katha is very passionate about the role community pharmacies can play in caring for patients with common illnesses.

Inside of the pharmacy

However, Dr. Katha expressed that there is a major shortage of pharmacists who practice in community pharmacy to provide services to the public. Of the ~13,000 pharmacies in Thailand, only 5,000 actually have a pharmacist present in the facility, despite the new Good Pharmacy Practice Act and Quality Pharmacy Designation (hand symbol) that requires a pharmacist to be on site at all times. Dr. Katha's pharmacy has had this distinction for 12 years, which is as long as the program has been in place. Another problem is that these 5,000 pharmacies that do have a practicing pharmacist are mainly located in major cities, so majority of the community pharmacies in more rural areas of Thailand are without a pharmacist to dispense medications such as antibiotics. Dr. Katha contributes the lack of pharmacists entering into community practice to the pharmacy schools curriculum focus on hospital pharmacy practice. He explained that 2,000 students graduate pharmacy school in Thailand every year, but less than 10% go into community pharmacy. He stated that even though the major chain pharmacy in Thailand, Boots, offers huge financial incentives to community pharmacists, this has not been enough to increase the number of community pharmacists. This is a contrast to America, where we have many pharmacists in the community setting, but the limitation to patient care is lack of reimbursement for several clinical services that pharmacists can provide and lack of time available for pharmacists to perform these services. We are both excited about the future of provider status for pharmacists in the United States with the recent introduction of The Pharmacy and Medically Underserved Areas Enhancement Act within the House of Representatives and the Senate.

The Quality Pharmacist hand symbol

Pharmacists in the community can dispense this without a prescription

It was interesting and exciting to hear about the four special projects Dr. Katha, the former president of the Community Pharmacy Association in Thailand, has developed to engage in improving primary care from his own pharmacy.  The first and largest project Dr. Katha and Roen-ya Pharmacy implemented was a smoking cessation program that began 12 years ago and has developed in the Thai Pharmacy Network on Tobacco Control. Dr. Katha was inspired after attending a conference at the University of Illinois-Chicago and came back to Thailand where he voluntarily collected data via a survey to determine the need for smoking cessation program and the willingness of patients to enroll. After receiving encouraging feedback, he then expanded to a pilot program with 15 community pharmacies providing counseling and free bupropion therapy to 76 smokers, of whom 30 successfully quit. With this data and the large need for smoking cessation across Thailand, which has 12 million smokers (half of whom are heavy smokers), Dr. Katha was able to obtain funding from the National Health Security Office of Thailand, which enables him to train pharmacists who wish to provide smoking cessation services and provide reimbursement to their pharmacies for the pharmacists counseling efforts and medications (which are now nicotine replacement gum and nortriptyline). Dr. Katha said the difficulties of this program are that these is no funding to promote that pharmacists can provide this service and it is hard to identify patients to enroll. We were able to empathize as this also a common problem we face in the United States.  It was very impressive that Dr. Katha has been able to create such an impactful program and continue to expand this program with his own efforts!

Counseling patients

While wrapping up our discussion, Dr. Katha shared that his wife was also a pharmacist and would be happy to speak to us about her high-ranking position in the Thai FDA. We were a little caught off guard though since we had asked before during our visits to many healthcare facilities across Thialand if there was an FDA or similar federal agency in Thailand, and we told that there was not, but there truly is! Dr. Katha’s wife was a very sweet lady and who provided us with lots of information on Thailand’s FDA. The Food and Drug Administration (FDA) oversees food products, medications, household products, traditional medicines, cosmetics, medical devices, and food supplements. The major focus of the FDA is on regulating manufacturing, importing and sale of these products. Products must be manufactured in compliance with the Good Manufacturing Practice. Medication products must also go through a pre-marketing process, where they are registered and approved and then a post-marketing process where and inspector goes out to investigate the products and also ensure that products are only being advertised with the approved advertisement. The FDA in Thailand, while it has similar practices, seems to have a much less stringent and expensive drug approval process than the FDA of the United States and is also much smaller with many small subcommittees overseeing the major activities.

After our full morning of learning at Roen-ya Pharmacy, we had to taxi back to our hotel to tend to Megan’s eyebrow, since the wound dressing has to be changed every 24 hours. Erin did a wonderful job carefully cleaning the area and reapplying new gauze and tape with the very nice supplies Bumrungrad had provided. Due to Megan’s still healing injury and upcoming residency interviews, we treated ourselves to afternoon at the spa in the nearby Siam Discovery Mall. We were completely pampered with the most perfectly executed and affordable manicures and pedicures we have ever received.

Spa day!

Since sitting in a large comfy chair being waited on literally hand and foot is very tiring, we worked up quite an appetite! Trying to make the best of our last meals in Thailand we decided to take a spontaneous tuk-tuk ride from the mall to the restaurant that several blogs and websites claimed to be the BEST pad thai in Bangkok and cannot be reached by Sky Train! The tuk-tuk ride was a really fun way to experience the true traffic and wild drivers of Bangkok and enjoy the gorgeous weather. (Traveler tip: Tuk-tuks are fun, but metered taxis are definitely the more affordable way to get around. The tuk-tuk ended up being much more expensive that an metered taxi even after bartering the driver down to half his original price quote!)


Our spontaneous quest for pad thai led to even more spontaneous fun! The infamous restaurant Thipsamai wasn’t quite open we got there. There was an army of employees buzzing all around setting up the tables and cookware along the street and they told us they would open at 5 PM, so with about 30 minutes to spare we spotted an adorable looking coffee shop across the road. This turned out to be a coffee shop located in the lobby of a Trip-Advisor award winning hostel where travelers can stay for 400 baht (~$13) a night. We enjoyed our tea and hazelnut frappe in the coffee shop/hostel lobby filled with a bulletin board of travel letters and bookshelves of Thailand travel books. We met two guys from Germany both named Yan, who were sitting next to us sharing travel tips with each other and Corinne, a backpacker from California. She walked into the hostel with a freshly painted henna tattoo on her arm. All three of our new friends were craving Pad Thai too, so when 5 PM rolled around we all walked over together and jumped in the line that had already formed to wait for our turn to taste the deliciousness.

Not open yet!


So. Much. Pad. Thai.

Niras Bankoc Hostel and Coffee

The five of us enjoyed eating a the small table along the street and sharing Pad Thai and travel adventure stories together. One of the Yans had just arrived in Bangkok from a few months in Australia and even came to dinner with a fork in his pocket because he doesn’t like using chopsticks! We were impressed! The menu at Thipsamai isn’t very big and offers only a few versions of Pad Thai (shrimp or vegetarian). We both opted for the delicately egg-wrapped shrimp version and while it was very good we still think our ‘pad thai lady’ at the Talla Noi in Maha Sarakham has the BEST IN THAILAND, (hers just has more flavor!).

Bangkok's best Pad Thai

Our new friends! Loved this spontaneous dinner party!

We said farewell and safe travels to our friends and grabbed a taxi back to the hotel, with a little stop at Swensen’s in MBK across from our hotel for some scoops of macademia nut ice cream of course!
Tuesday morning we woke up and watched our last sunrise over Bangkok from our 11th floor window as we got ready for our last day of block 7 rotations and last full day in Thailand. We enjoyed a great breakfast from the buffet in the hotel lobby and resourceful Erin bought cups of ice from a street cart outside for 5 baht a piece and made us take-away iced coffees for our taxi ride to Roen-ya Pharmacy.

Take-Away iced coffee. 30 cents for BOTH. Going to miss this.

Dr. Katha was not there for our second day at Roen-ya, but we had a great day learning from the pharmacist Dr. Im (which means full in Thai) who graduated from Mahasarakham University’s Faculty of Pharmacy. Dr. Im instructed us just to look at the products in the pharmacy during the morning and then said he would lead a discussion in the afternoon. We enjoyed looking through the pharmacy shelves behind the counter and noticing that most of the herbals and medications organized by indication were manufactured in Thailand or imported from Germany or Switzerland. There were a few international trade names we didn’t recognize and put our Lexicomp app to work looking up several medicines including Glibenclamide (gylburide) and Aescin (horse chestnut used for swelling due to venous insufficiency).  Dr. Im was kind enough to answer our questions about what a lysozyme 30mg tablet would be used for. The answer is that is a natural enzyme used for inflammation, nasal congestion, and sore throat when a patient prefers a natural remedy. Dr. Im explained that the mechanism of action is not well understood and also showed us a few other enzymes products such as Proctase-P for tosilitis. When asked what one the big thing that patients come in and ask him about, Dr. Im told us that they want to identify what medicines they are taking that they have purchased elsewhere. Dr. Im uses the MIMS (Master Index of Medical Specialities) Indenta Product Identification Chart, but says that so many capsules and tablets in Thailand have no distinguishing marking that he is usually unable to identify them and often has to recommend that the patient simply stop taking and select a new medication to recommend to the patient.

It was then time for a lunch break and for Dr. Im to get a few more things done around the pharmacy, so we wandered to the post office around the corner to mail one last post card to Megan’s Grandma who enjoys writing and receiving letters. It is only 15 baht (~50 cents) to mail to the USA. The post box had two options for mail, "Bangkok" and "Other Places," which we got quite the kick out of. Across the street and a few blocks down was the Big C supermarket center which had a food court where we had our last lunch in Thailand. Feeling adventurous, we both tried the roasted duck fried rice, which came with the delicious and simple peppery broth we love. We felt extra cool and local walking through and eating in this area of Bangkok called the Khlong San District, as the streets were bustling and the city was alive!

When we got back to the pharmacy after lunch, Dr. Im sat down with us and did a great job teaching us about the three other special projects that they do at Roen-ya Pharmacy and also taught us how they conduct a patient interview and make medication recommendations. First, Dr. Im described the Health Screening Project they conduct. At Roen-ya Pharmacy they can screen any patient over the age of 15 years old for diabetes, hypertension, and obesity. The pharmacist can input the screening data into an Internet program managed by the National Health Security Office and then be reimbursed 40 baht (~$1.30) for each report they submit. They can submit up to three reports per patient, the first being the initial screening report, the second the intervention report, and the third the follow-up report. The pharmacy typically screens 5 patients a week and primarily patients come and receive screening here because they have seen the monitoring instruments (blood pressure cuff, glucose meter, etc.) in the pharmacy or have heard from a friend. Also, the pharmacy can receive a 40 baht reimbursement if a pharmacists provides counseling and education to female patients on oral contraceptives and emergency contraceptives or if they offer a referral for a patient to get a pap smear, provided the pharmacists submits the education and referral reports. It is neat to see that pharmacists are able to be reimbursed for their clinical services in Thailand and also that the importance of always making sure you “document document document” as we are taught at the HSOP is universal in healthcare.

Next, Dr. Im described the Home Health Project that they conduct from Roen-ya Pharmacy for 6 to 7 areas in the Khlong San District (he was even nice enough to draw out a map for us!). The pharmacy collaborates with the local community leaders and healthcare volunteers to identify and visit patients at home who have chronic disease. The pharmacist or 6th-year pharmacy students (the last year in the Thai curriculum) on rotations speak with the patient, complete a through interview, and develop a care plan using the Home Health Packet. This packet includes the number of times the patient was visited, an informed consent page, a map of patients home, the patient's social history, past medical history, medication history, monofilament test record, vitals and lab values if available, and pharmacist counseling profile. The pharmacist then inputs all the data into an Excel form and can be reimbursed 800 baht (~$25) from the National Health Security Office. Pharmacists and pharmacy students from Roen-ya were able to complete visits and make positive interventions for over 150 patients in the area last year. Again, we were impressed by the engagement of Roen-ya Pharmacy in community health endeavors and the support from a national office to recognize the value in care that the pharmacists are providing.  

Map of the streets that the pharmacy visits for MTM services/
Home Health Care in Khlong San District

After a few breaks for Dr. Im to provide medications to patients that entered the store, we were ready for our final topic discussion of patient interview and counseling. Dr. Im described that the first step when a patient presents with symptoms of a common illness is differential diagnosis. He told us that most commonly, patients present with an assortment of symptoms such as fever, runny nose, sore throat, muscle pain, and cough which he grouped as "URI" or upper respiratory infection symptoms. He then let us put our clinical skills to the test and come up with a list of possible illnesses the patient could be experiencing from allergies to pneumonia. Then, he walked us through how to make a differential diagnosis. For example, between influenza and dengue fever (a mosquito-borne virus), you look for more severe muscle pains and a higher fever with red spots appearing after a few days with dengue fever and this would require referral to the hospital. If you had come to conclude that a patient had tonsillitis due to swollen lymph nodes and visible pus on the tonsils, you would then follow guideline recommendations to assess if the patient needed an antibiotic. A huge problem is Thailand is infections and resistance to antibiotics, because the 8,000 community pharmacies that don't have pharmacists on-site at all times over-dispense antibiotics to patients that simply have a sore throat. 

After differential diagnosis, the next part of the patient interview is called “WWHAMAD” which means you ask the patient Who, What, How, Any other problems, Medications, Allergies, and Diseases. We enjoyed sharing how we are taught the similar SCHOLAR MAC  (Symptoms, Characteristics, Hisotory, Onset, Location, Aggrevating Factors, Remitting Factors, Medications, Allergies, Conditions) method for conducting patient interviews. After gathering all information that you can from the patient, you are ready to make a recommendation that is the safest, most efficacious, and affordable for the patient. For tonsillitis, the pharmacist would provide you with the 1st-line medications amoxicillin or penicillin V. Azithromycin or cephalosporins would be considered second line. Dr. Im told us that in two years he has only dispensed 30 antibiotics as a pharmacist because he will only dispense to patients who have a clear infection or have a written paper from their physician that states they need an antibiotic. He doesn’t want to contribute to the over-prescription of antibiotics and create resistance. We agreed with his practice!

After saying our farewells and thank yous to Dr. Im, we headed back in the taxi to our hotel. This time we had a fun taxi driver who kept saying, “You love Thailand? I love Thailand!!” and we would respond, “We love Thailand!” To celebrate the end of block 7 and really just an excuse to have them one more time, we each got one of the incredible mango smoothies from the café in the little side street by our hotel before heading up to our room to pack. Words can't describe the heavenly taste of these amazing treats. We spent the rest of the day singing along to Erin’s awesome playlist of music (the same playlist we made for the roadtrip to climb the mountain a few weekends ago) and reminiscing over our treasures and souvenirs while we packed our bags! All of our belongings and new additions fit and we are hoping the weigh-in at the airport tomorrow will go well! For two girls who did a lot of shopping, packing was surprisingly flawless.

We finished the day out by blogging and catching up on emails in the hotel lobby. We then stepped out on the streets of Bangkok for our last snack/dinner adventure.  We opted for banana rotee from a streetcart by our hotel, which was wonderfully warm and sweet. We walked all the way to Siam Paragon where we entered the most incredible food court we have ever seen! We couldn’t believe we hadn’t experienced this yet during our time in Bangkok. This food area has restaurants, coffee shops, and dessert places from all over the world. (Travel tip: If you’re craving Subway, Mexican food, frozen yogurt, Krispy Kreme, burgers, and many other American foods in Bangkok this food area has it all!) We just decided to continue our snacking and walking plan and got Erin her first taste of Chicago’s famous Garrett’s popcorn! This fancy mall had a small version of this store, and it was funny that Erin was introduced to American culture in Bangkok.

Caramel Macadamia Nut (left) and Buttery Classic (right)

Our last stroll back to the hotel was bittersweet. We both are immensely grateful for this life-changing and inspiring opportunity to study and travel across Thailand and feel that Bangkok is our favorite ‘big city’ in the world. Erin is now definitely going to respond to the question “Where are you from?” with “I’m from Bangkok!”

Fan-wan (sweet dreams in Thai) from Bangkok one last time! Looking forward to making our last post when we’re back in the United States after living February 4th for 31 hours! Time is so relative!

Khab kun ka (thank you in Thai) for following along on the adventure of our lives! We can’t wait to see where our pharmacy paths take us next! 


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