My decision to undertake elective in Thailand was made to help broaden my horizons on ophthalmic conditions and practices. Additionally, I hoped to improve my Thai medical vocabulary to communicate with Thai patients fluently. As I got an opportunity to share with the local medical students what the UK healthcare system is like, I believed that doing my elective abroad also benefited the communities.
Background
During my fourth year of medical school, I got an opportunity to have a placement in an ophthalmology department. I was able to observe a cataract operation, where an ophthalmic surgeon led a dedicated surgical team to carry out the extraction of nuclear cataract in an elderly patient. This experience gave me an invaluable and realistic insight into the world of ophthalmology, where a high level of patience, manual dexterity and teamwork is required. Witnessing this kind of commitment, and the way that medical knowledge is applied to practice, made me consider doing my elective in ophthalmology. As I did my medical training in the UK, for my elective I wanted to go out of my comfort zone and immerse myself in a new environment. Moreover, I wished to interact with students and trainees in other countries to learnt what their training system is like.
Why Bangkok?
In contrast to the UK, the private sector plays a big role in providing care to people living in Bangkok, Thailand. In recent years, Bangkok has undergone swift urbanisation and improvement in hygiene. This makes the conditions encountered in Bangkok a mixture of tropical conditions, and conditions that are commonly encountered in developed countries, such as diabetes and hypertension. Having the opportunity to learn new Thai medical vocabulary and encountering a wide array of conditions are some of the reasons I choose to do my elective in Thailand.
Which hospital?
For my one-month elective, I arranged an elective placement in an ophthalmology department at Lerdsin Hospital, Thailand (Figure 1). The Lerdsin Hospital is publicly funded and located just outside the centre of Bangkok. Since there is a lack of funding for primary care within Thailand, most patients will need to come to the hospital to see the doctor. One of my goals was to compare the availability of resources and treatments in the UK healthcare setup against those used within Thailand’s public healthcare framework.
Figure 1: Chris Terajet and the ophthalmology team at the hospital.
Ophthalmic training in Thailand
In Thailand, the duration of most undergraduate medical training is six years. Additionally, the majority of medical schools in Thailand use a traditional teaching method to train their students. Following the undergraduate training, the recent graduate doctor must undergo one to three years of internship (an equivalent of a Foundation Programme in the UK). It worth noting that different speciality training programmes at different hospitals require a different duration of internship. However, most of the ophthalmology residency programmes in Thailand require the medical intern to complete at least three years of internship.
In contrast to the national recruitment into Ophthalmic Specialist Training in the UK, medical interns are required to make an application to each hospital. In comparison to the UK’s seven-year speciality training program, the ophthalmic residency program in Thailand lasts only three years. Furthermore, the surgical experience requirements are different in the UK and Thailand. For instance, ophthalmology trainees in Thailand are required to have a few surgical experiences in extracapsular cataract extraction, whereas trainees in the UK do not. Talking to different ophthalmology residents, I also learnt that their curriculum is based on the American Academy of Ophthalmology (AAO). After completion of speciality residency, trainees can then choose the subspeciality they wish to do their fellowship in.
Experience
As Lerdsin Hospital is a teaching hospital, I spent the first two weeks attending lectures and placements with the medical students from Rangsit University (Figure 2). Whilst I was attending their lectures, I was surprised by how much ophthalmology knowledge they need to cover at an undergraduate level. In addition to being taught how to do a basic ophthalmic examination (e.g. visual acuity, pupillary examination), we were shown how to use a Schiøtz tonometer as well (Figure 3). Before this elective, I thought that the Schiøtz tonometer had been replaced by a newer device, such as Goldmann tonometry. However, I was told that Schiøtz tonometer may still be in used in some hospitals in rural regions of Thailand. Therefore, the trainees in Thailand need to be able to recognise how intraocular pressure could be measure if they were to be allocated in a less developed region.
Figure 2: Teaching session about different eye drops with medical students from Rangsit University.
Figure 3: Visual acuity chart in Thai alphabet.
For my last two weeks, I spent most of my time sitting in different clinics with the consultant. This included cornea, glaucoma, general ophthalmology and paediatric ophthalmology. One of the things I noticed was the lack of confidentiality being provided to the patient. As the number of available consultation rooms was disproportionate to the number of patients seen on a daily basis, it is quite common that more than one patient is being seen in the same room at the same time. Occasionally, the consultation may take place in the public waiting area instead. Talking to the consultant I learnt that this does not just apply to the ophthalmology department but also occurs in other departments in the hospital. The reason that the consultation was done in a space lacking privacy was due to the lack of funding available to public hospitals outside the centre of Bangkok.
Additionally, I was able to interact with the patients and listen to their experiences of the healthcare system. I came to realise that many patients travelled a long distance from their homes to be seen by a doctor. Some of the patients I met could not afford proper transport and their mode of transportation was a songthaew (local public truck). Sometimes patients needed to wait long hours due to a delay in consultations. This experience highlighted how health inequality is not just about the inadequacy of resources, such as the number of doctors and equipment available (although that is clearly the case here too), but also about how the social system allows the entire population to have access to healthcare.
Recently I contacted one of the ophthalmologists I got to know during my elective. I learnt that to tackle the current pandemic, the ophthalmology department has adapted to make handmade slit-lamp shields (Figure 4). The slit-lamp shields were made using a plastic tube and sheet.
Figure 4: A handmade slit-lamp shield in one of the consultation room.
Conclusion
Overall, this elective really helped to enhance my awareness regarding the intricacies of practising medicine in a different healthcare system. I believe that this elective has allowed me to make a lasting friendship, as well as given me a new perspective on healthcare.
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