Amina's Report
I spent my elective at a rural clinic in Thailand, established to support the healthcare needs of the refugees from Myanmar. It was set up in 1989 from a small house it is now a large complex of inpatient and outpatient wards. There has been political unrest in Myanmar from 2nd April 1948, this clinic has been set up to meet the demands of refugees. There has been ongoing political unrest in Myanmar. The clinic is separate from the Thailand Government Hospitals, it run solely on donations, patients can contribute to their health needs what they can afford but are treated regardless of their financial contribution. I arrived at the Mae Tao Clinic just before 9am on my first day, I was introduced to the staff members responsible for different departments. Then by 9:10 I was allocated to my first rotation. It was a very immersive experience.
This experience forced me to work on my non-verbal communication skills. The main language of the clinic was Burmese which I found incredibly difficult to learn. I found pronunciation of the words tough as I had felt I couldn’t create some sounds with my mouth. It was hard to support patients through difficult moments when I lacked the linguistic ability. I however had to develop very good non-verbal communication. I soon realised that a smile is one of the most powerful tools to building rapport.
On my first day, I supported a pregnant woman during labour. There was a lady who had been in labour for a while. She had no family in the room, no partner. It was only the staff there to comfort her. I did not even know the language so felt disappointed with myself for not learning some key words to comfort her. I tried to stay by her side and hold her hand as she would allow. I wanted her to know she could use me for support even though we didn’t share the same language. They had to give her an episiotomy. I gave her my hand and didn’t let go till she had given birth. They taught me how to say “push” in Burmese, တွန်းရန် pronounced twann raan). Which I tried to say at appropriate times. By this time, you could see she was so tired and in so much pain. She continued to push and eventually the baby came, she was so relieved but still in so much pain due to the episiotomy. They sutured in the delivery suite and practiced breast feeding. She gave birth to a healthy baby boy 13:11. It was such a privilege to have experienced this birth. It was an honour to have been in the room. I spent some time after talking with the staff trying to learn Burmese and Karen and asking questions about the clinic. So much can be communicated without language.
The language barrier provided a significant obstacle even with a medic offering to translate for me. This lady came in with characteristic signs of PID, abdominal pain, foul smelling discoloured discharge etc. This conversation was particularly difficult as the lady started to tear as she spoke about her relationship and how she was mistreated. It was very difficult to see her in this state and not have the words to comfort her.
To aid diagnosis, I performed a speculum exam, and I can finally understand there comes a time where you just know what you're doing, therefore you are not as nervous and can calm the patient with your demeanour. I remember my first speculum and being so nervous, it’s amazing to see how much better you can get at something over a few months. Piecing the history and examination together the most likely diagnosis was pelvic inflammatory disease, which she received treatment for. Before she left, I asked if she could do a pregnancy test, my supervisor looked at me with shock as she said that she is not pregnant. Although agree she was most likely not, I asked if one could be done to be sure. In a pregnant woman of childbearing age, I would hate to miss that, I think Bristol has drilled that into me. Also, my own personal experiences as my sister were sent home without a pregnancy test told that she had reflux when in fact it was an ectopic pregnancy that she needed surgical management for. I hope it is something that I never miss. This experience taught me how to advocate for investigations that you want your patients to have, no one wants to miss anything, if you inform a senior, you are worried about a particular diagnosis, most times they will either reassure you or take you suggestion on board.
I have practiced medicine in a resource rich environment, I have been very accustomed to single use equipment and have learnt the importance of infection control measures. I had concerns initially about the sanitation of the clinic due to lack of resources. I had read online that when it started, they used a rice cooker to sterilise instruments. Things have obviously moved on from that time. I was shocked at the level of resourcefulness that was shown in the clinic. Short term catheters and oxygen tubes were sterilised and then used again on different patients. It challenged me to the contrast in the UK of single use equipment. It would be underheard of to have reused a catheter on another patient, it would be seen as unhygienic. To them this was the norm. The only equipment that was disposed of was gloves, they were only used were necessary. Washing of hands and hand sanitizers were promoted and staff responsible for infection control would frequent the wards. This experience made me question the idea of single use equipment. I think there should be major rethinking on what could be used again, which could have such a major impact on the plastic consumption of the NHS.
Being in a resource poor setting has meant that you have access to less diagnostic investigations. The paediatric consultant spends most of her lunch break, reading journal articles that discuss interesting cases. Looking for links or clues that could help point to a suitable diagnosis for her patients. A child presented with hemihypertrophy, which I had never heard of before, she quickly does some reading to ascertain if there were any links between that and congenital CMV that the child had. She then formulates a differential for Beckwith-Wiedemann Syndrome, which fits with the child's current presentation. However, there is no genetic testing available to confirm this diagnosis. There was another child presenting with dysmorphic facial features, microcephaly, and torticollis. The lack of investigations makes it very difficult to be certain about a diagnosis. Observing this type of practice made me understand, firstly the importance of a thorough clinical exam, you must have examined enough patients to be confident when something is not normal. Secondly the importance of continued study. I think being able to do these things well will help me go very far and be a very confident and capable clinician.
This whole experience has completely transformed my outlook on life. I don't think I had ever properly considered the struggle of refugees. It may be because I have been so far removed from it that I haven’t reflected on how hard it must be to have your life completely upturned due to war or political instability.
My parents were refugees, and they fled the civil war in Sierra Leone. This civil war destroyed their home, and they lost family members. I was born here in the UK, far away from the atrocity of war. I've grown up in comfortability away from the harsh reality of war. I've been able to plan. I have not experienced the loss of immediate family. I have not experienced the impact of war.
The difference between the healthcare received in the Thailand government hospital and the clinic are stark. You see so clearly how much money plays a big part in health care. They have plans to open and accident and emergency department soon. This experience has made me keen to get involved with international medical work.
People just like me, are experiencing the effects of war. It was inspiring to see how hopeful people were despite their current situation. During this experience I met two medical students from Myanmar, they fled the military leadership in Myanmar, so they were not able to complete the medical studies in Myanmar. They are unsure if they will ever finish their medical training, as they are not able to go back or they would be arrested. They are also not allowed to go anywhere in Thailand as they are classed as illegal immigrants. It was saddening to hear, the amount of uncertainty they have about their future. This is just one story, during my time I heard so many. I heard about people who had family who were imprisoned for life for protesting the military leadership. The clinic has their own church which I attended. It reminded me of this verse “After I looked, and there before me was a great multitude that no one could count, from every nation, tribe, people and language, standing before the throne and before the Lamb. They were wearing white robes and were holding palm branches in their hand”- Revelation 7:9. There was no translation available, and the service was in Burmese, so I couldn’t understand or partake in much. It was clear that these people were praising the same God that I worship. I was in awe. It was such an amazing experience, to see where language or geography may divide us, we are united by our faith.
I wondered how receptive people will be to Christianity as Buddhism is the main religion in Thailand and Myanmar. It was encouraging to see how open people are to faith conversations and there was freedom to practice your faith freely. I witnessed many people despite being Buddhist would often accept prayer from Christians during times of difficulties or at celebratory events. These experiences have ignited a passion in me to work with refugee populations, I am currently seeking opportunities in the UK to get involved in. This experience has been truly transforming, I am keen to go back and visit them to see how they are all getting on. During my time there, strangers became like family.
Caroline's Report
I did 6 weeks of a clinical placement in Thailand from 4th September to 13th October 2023. For the first 2 weeks I worked in the Child Outpatient department. The Child outpatient was structured such that there would be 6 desks spread out in a room with a medic at each desk. One desk is dedicated to a receptionist and nurses’ station where patients’ vital signs would be taken, and they would be directed to one of the medics. The most common clinical conditions were Dengue Fever, Viral Wheeze and Pneumonia. I often performed Hess tests on children, it would be common to see multiple petechiae become visible upon completing the Hess test. The children’s outpatient unit acted as a general practice like clinic.
If a child was deemed seriously unwell, they would be transferred to the Children’s inpatient unit. I later spent two weeks in this inpatient unit. I found that there were not many diagnostic tools or treatment options. As clinicians did not have access to a more advanced diagnostic tool such as X-rays or CT scans. As a result, this meant that it was sometimes difficult to distinguish severe bronchiolitis from pneumonia. Consequently, to be on the safe side antibiotics were prescribed wherever it was suspected pneumonia would be present. Occasionally a child’s condition would deteriorate, and the inpatient unit could not provide sufficient treatment. In such cases they would be referred to Mae sot General hospital. The Challenge in these moments would be some patients would not be able to afford the hospital fees. Thus, they would not go on to receive the assistance required.
A sad example of patient’s not being able to afford optimal care was with a 10-year-old boy with acute lymphocytic leukaemia. Due to not being able to afford Mae Sot General Hospital and the conflict in Myanmar he had not been able to receive consistent treatment for his condition. When he came to the clinic was now a palliative patient on chemotherapy for pain management. There were several occasions where his chemotherapy treatment was delayed as the clinic had not received orders on time. The patient sadly died within weeks of arriving. Additionally, there was a child with cyanotic heart disease who was receiving oxygen supplementation in the clinic. However due to not being able to afford hospital fees they were yet to have an echo to diagnose the type of heart disease let alone receive any corrective surgery. Occasionally the clinic can sponsor treatment for seriously unwell individuals or help sign them up with charities that aid medical care. There are quit stringent qualifications for this. So not all patients in need are able to receive support.
I spent my final two weeks in the Medical Outpatient department and the Reproductive Outpatient Unit. While in these two departments I practiced consulting and conducted examinations. Some issues I ran into in the Medical Outpatient department were loss to follow up often meant conducting blood investigations were often redundant. Bloods would not come back till two weeks; patients often did not have time to attend follow up clinics. Thus, treatment often had to be directed by clinical presentation, additionally it meant doctors at times might overprescribe to mitigate worst case scenarios where lab results might have indicated more conservative treatment would be appropriate.
Church Life
I really enjoyed attending the Burmese church services as they were very lively and wholesome. The youth had a strings orchestra and keyboard player which provided the soundtrack for the songs. Some of the hymns sang where familiar such as ‘Be thou my vision’. It was quite engaging for myself as a beginner Burmese speaker to be in a service where a lot of singing took place, as I was able to enjoy the music and partake after hearing the lyrics multiple times. Individuals were kind enough to translate the sermon message to me so that I could follow the teaching. All the church members had a great appreciation for the clinic and often donated towards the clinic through the church tithes.
Reflection on Experience
During this 6-week clinical placement my aims were to become more comfortable with responsibility for patient management in a clinical setting. Additionally, I wanted to gain a greater perspective of differing medical practices around the world. Things that surprised me were, despite being in a more rural setting with fewer medical resources the level of health care offered was very proficient and effective. There were some managerial and operational measures practiced in the clinic that superseded that in UK hospitals. For instance, there was a large emphasis on sustainable practice as well as infection control. Clinicians had to bring two pairs of footwear to hospitals. There were shoes used for the outdoors and moving between different clinic buildings and indoor shoes to be used in internal hospital settings. Whilst simular practices are conducted in the UK, in the UK this is limited to only having different shoes for operational rooms. Additionally, they use hand towels in bathroom settings instead of tissue paper, these hand towels are used once then placed in a basin to be washed before re-use.
In my role as a medic at the clinic I became aware of the challenges associated with the use of translation in consultations. I found there were times where my questions were not accurately being translated because the translator did not understand their relevance and so sometimes skipped the question. This was quite prevalent in scenarios were the translator had a medical background. Other times there might not have been a direct translation for the words being used and so comprehension was challenging. In scenarios where the translator had a medical background, they would occasionally jump the gun and ask the patient additional or follow up questions to my initial questions before I had the chance to ask them. This made it tricky to pace myself through consultations and keep track of my consultation structure. Additionally in such scenarios the translator might negate to report the negatives so sometimes it would not be clear to me that a patient was not experiencing a specific symptom and I would have to repeat questions to ascertain clarification. In scenarios like this due to having built rapport with the translators and clinic team and the fact I was a volunteer, I did not always find it easy to be assertive and request that they simply translate and refrain from power phrasing, summarising, or consult.
Due to it being a rural healthcare setting, I found that you were pushed to learn on the job fast. I was being asked to interpret ultrasound scans and have quite a hands-on experience in clinical settings. This great for professional development and my work was supervised by a senior and so I was able to receive assistance and talk through management before
treating a patient. This provided me with the ability to challenge my medical knowledge but also feel safe to practice knowing a senior official was approving the work and making corrections were necessary.
There were also multiple times throughout my placement where we had to conduct literature reviews in the event patients presented with peculiar symptoms or were not responding to the normal treatment pathways. This highlighted to me the importance of medical research in guiding healthcare practices. For the future of the clinic a research team and acute medical unit will be set up. I and another colleagues had advised staff on how they might proceed with this. We had also been in talks with the new emergency consultant on what areas would be best to start upskilling the clinic.
Take away’s from my Experience.
I was amazed by the resilience, faith and courage demonstrated by the Burmese healthcare staff and patients in the clinic. Despite many of the patients and clinicians having to flee to Thailand from Myanmar due to the military regime, they remained hopeful and were always looking to extend charity and hospitality to others. Many staff invited me and another medical student over for meals at their homes and invited us to family celebrations such as birthday parties. Sunday church services were filled with songs of thanksgiving to God and tithes were collected to support the work at the clinic. There was a large sense of community. I felt very inspired by the Burmese people to practice daily gratitude and be more mindful of where I can be of service to others particularly in the little things and not limit charity to only grand gestures or monetary donations.
From my experience, it really highlighted to me the importance of doctor’s not just focusing on the physical issues a patient has but also appreciate the social context of things. While there can be a strong emphasis due to time to treat stresses in people’s lives with medication, in the long run a supportive social infrastructure and community can provide the more long-term solution. Therefore, I would like to encourage more holistic approaches to healing in my clinical practice where appropriate. I have also learnt about the importance of communication and how lack of comprehension on the clinician or patient side can really hinder good medical practice. Often when discussing language barriers in medicine we look at it from the aspect of the patient not being able to understand us the clinician, however it is important on the clinician side to do all you can to bridge the gap. For instance, send patients a text message summarising your consultation allows them to follow up or digest information better as they can paste your text into google translator. Thus, where language barriers exist, I will be more conscious of how I can ease the process as often a person translating alone does not always mean that comprehension issues are resolved. I will be mindful to brief the translator before a consultation where possible and explain the importance of translating directly and not power phrasing or attempting to decipher themselves what information appears most relevant to maintain the authenticity of the doctor and patients’ communication.
