Wednesday, May 8, 2019

Chiang Mai, Thailand Rotation

Sigrid Collier, a medicine-dermatology PGY5 resident at the U of MN, recently traveled to Chiang Mai, Thailand - here is a snapshot from her experience!

Day 3, Thursday April 11
    The experience has been amazing so far. The attending and residents are super helpful in explaining what is going on! I have seen more variants of lupus in the last 48 hours than in my entire residency. Yesterday they let me take their pathology quiz from two weeks ago, and it was amazingly helpful in reinforcing my pathology learning. It was also very challenging. There was a histopathology case of penicilliosis, which looks a lot like leishmaniasis or histoplasmosis! 
     It is interesting in contrast to my time in Tanzania where there is no access to dermatopathology and very limited access to systemic medications. Here they try to reduce costs by using medications like cyclosporine, acitrein, methotrexate, and azathioprine, but they still have access to anti-TNF (etanercept, infliximab, and one patient today on golimumab) as well as ustekinumab (Anti IL-12/23) and secukinumab (Anti IL-17). 
     I am amazed at how much they know about medications that they do not use frequently. The attending’s knowledge is very up to date on the newest medications coming out for psoriasis (anti- IL 23, guselkumab, tildrakizumab, and risankizumab) and atopic dermatitis (anti IL-31, nemolizumab). 
     I have also learned several new things, such as the association between pustular psoriasis and anti-IL 37 receptor mutations. I learned about adult onset immunodeficiency with anti-interferon-gamma antibodies. This is associated with neutrophilic dermatoses (such as AGEP-like reaction and sweet’s like reaction). Today we also discussed the association between pemphigus foliaceous, thymoma, and myasthenia gravis (Something that I don’t recall learning, and couldn’t find in Bolognia, but is definitely reported in the literature).
    Overall this has been an amazing experience so far. I will say that I am always worried that I am violating some cultural norm without realizing it. I often notice that my voice is just (accidentally) a little louder than those around me, and my movements are a little more abrupt and less confined and careful. I am often probably bowing at the wrong times and in the wrong way, but I am sure I will learn over the next month. 

Thursday, February 28, 2019

Tanzania a month in has been full of life. The rainy season is approaching and everything is extremely green. This month has been full of exciting clinical medicine along with some fun weekend trips. 
The most exciting one has been my safari last month. One of the highlights of it was the Ngorongoro Crater which is a large volcanic caldera that is home to hundreds and thousands of animals. From herds of zebra, buffalo, wildebeest, to multiple prides of lions, and uncountable hippos and giraffes! We even spotted a few rare rhinos. The crater is a unique habitat such that predator and prey  reside in surprising close proximity to each other. Since there is an abundance of water and grazing land, the prey has no desire to leave and thus neither does the predator. The species of predator, such as lions, have been so stagnant that the amount of interbreeding is causing weakness in the lions genetic structure. It was a fascinating and exhilarating place that is a great treasure!
Simba all grown up
The Ngorongoro Crater from the rim

Tuesday, January 29, 2019

Hello from Arusha! I have finished my first 10 days into my second attempt here and so far I am anatomically intact. Mentally, however, it has been a whirlwind. My days begin with a beautiful 3.5 mile walk from my village of Il Boru to Selian Hospital. The walk itself summarizes life at the hospital such that I am able to see the wide economic divide first hand. From the playful smiles of poor young kids in tattered uniforms walking to school yelling muzungu (foreigner) and asking for fist bumps to the Land Rovers that careen by spraying dust over us, it is quite the experience. 

The days at Selian are generally similar to the structure of US internal medicine wards. We conduct rounds with two medical interns, one registrar (someone who has finished intern year and is working as a staff), and the nursing staff. The key difference lies at the end of every patient interaction when the medical team's plan to order tests and medications needs to be conveyed to the patient and their family. The difference in that conversation between the US and Selian lays plain the inability of the family to afford basic diagnostics that are taken for granted in the US (such as a urinalysis or a chest xray). This is somewhat complicated by an intermittent lack of resources at Selian to perform these diagnostics. 

Such difficulties make the practice of medicine very challenging and sometimes frustrating and this is evident among the interns and the rest of the medical team. However, the reliance on history, exam, and most importantly local epidemiological data make the practice both exciting and educational.
Selian Hospital is a major safety net for the Masai population and the poor around Arusha and the medical team truly cares about the patients and I am lucky to be here working with and learning from them!

A hungry baby goat on the walk to the hospital

Selian hospital

Saturday, January 5, 2019

We Belong to Each Other

“If we have no peace, it is because we have forgotten that we belong to each other.” - Mother Teresa

I have spent a lot of time over the last few months learning about palliative care in global health. One of the projects I am working on this year is to create an online course in palliative care and medical ethics from a global health perspective for the residents and fellows here in Chiang Mai. I will admit that I knew very little about global health aspects of palliative care when I started, and even less about building a website! But now after immersing myself in this topic for a few months, I feel like I have a better understanding of what it takes to build a successful and sustainable palliative care system. If I had to summarize the most important component of a successful system in a single word it would be: community

The quote above comes from Mother Teresa, who might be considered one of the very first advocates of palliative care in global health. She was famous for her personal and organizational outreach to patients dying of diseases that carried great social stigma (HIV/AIDs, leprosy, TB) at the time. Instead of retreating from these patients, she reached out her hands to touch, her ears to listen and her heart to love them as best she could. In doing so, she resisted the strong currents of an increasingly modern society which preached a gospel of individualism, capitalism and distraction rather than service, compassion and presence.

Unfortunately, many healthcare systems around the world are based on individualism and capitalism. This can lead to a variety of problems when it comes to the equitable delivery of healthcare, but perhaps even more importantly, it obscures the truth of our interconnectedness as human beings and the incredible power of community. In the “Public Health Strategy for Palliative Care” promoted by the WHO there are four aspects to palliative care development: (1) policy (2) drug availability (3) education and (4) multi-level implementation. The model is visualized as a pyramid with community care as the base and with primary palliative care (all healthcare professionals) and specialized palliative care (palliative care experts) care at the top. 

At the heart of many palliative care initiatives in low and middle income countries are community volunteers. The Neighborhood Network in Palliative Care (NNPC) in Kerala, India is just one example of a successful community-owned program that is run largely by volunteers. Founded in the year 2000, it is based on a philosophy that problems associated with chronic and incurable illness are considered to be “social problems with a medical component”. Community volunteers complete a standardized training program that includes an introduction to palliative care, the role of the community, cancer basics, last hours, and others and use this knowledge in the community to help identify problems and intervene with support from physicians and nurses. 

As of 2014, this program has grown to have more than 15,000 trained community volunteers, 50 physicians and 100 nurses. It is almost entirely community-funded with most neighborhood groups (80%) managing to raise the money needed to deliver care locally through donations and local government support. I think it is important for Westerners to learn about programs like this because in the US people are often set in their ways of viewing healthcare as a commodity (i.e. something that can be bought and sold). But as Mother Teresa and the volunteers in the NNPC and countless other programs demonstrate, it can also be something that is freely given. At the very least, we need to realize that there are different ways of approaching medical care and that it might be beneficial to “think outside the box” (i.e. Western culture) sometimes. 

In order for a palliative care system to be successful, I would argue that it needs to be built around principles of inclusion and connection rather than individualism and consumerism, with the community serving as the foundation. Additionally, we need to improve our ability to conceptualize the end of life as simply another part of the life continuum, not something that is separate and needs to be hidden. I am reminded of a quote which I believe was initially intended for individual people, but I would argue that it also applies to the development of systems and institutions

Watch your thoughts,
For they become words,
Watch your words,
For they become actions,
Watch your actions,
For they become habits,
Watch your habits,
For they become character,
Watch your character,
For it becomes your destiny.”  


Sternsward J, Foley KM, Ferris FD. The Public Health Strategy for Palliative Care. Journal of Pain and Symptom Management (2007). 33(5): 486-494.

Kumar S, Numpeli M. Neighborhood network in palliative care. Indian Journal of Palliative Care (2005). 11(1): 6-9.

*Movie about Kerala program:

Photos: Around Chiang Mai

The Ping River at dusk (east of the Old City).

The city was decorated in lanterns for Loy Kratong Festival (November). 

Just another smiling life-size statue in Chiang Mai. We need more of these in the US.

Dinner with Thai family medicine residents and visiting resident from HCMC.

Sunday, November 18, 2018

On Blessings and Ceremonies

I arrived slightly late to the VDU (ventilator-dependent unit) one Friday morning in October only to find that the area had been transformed - from hospital ward to makeshift Buddhist temple. The change had occurred in preparation for the celebration of the 1-year anniversary of the VDU. There had been a similar ceremony one year prior when the unit opened, a common occurrence in Thailand where Buddhism is so deeply connected to everyday life. The current ceremony was an opportunity to celebrate the work that had been done in the previous year and to offer blessings to those who had passed through the VDU - patients, families, providers - and those that would pass through in the future. 

The floors of the large VDU lobby were covered in red and yellow wicker mats, at least six or seven consecutive rows, and there was a Buddhist altar and five empty cushions lined up against the wall. The Thai resident I was working with informed me that for an event like this it was important to have an odd number of monks, hence the five cushions. She also pointed out a white thread that was strung around the perimeter of the room near the ceiling. This thread is referred to as “sai sin” and is thought to carry merit and protection. It is used in many Buddhist ceremonies, including weddings and funerals, and is occasionally passed around to everyone in attendance, serving as a physical connection among the people, the monks and the Buddha. 

The ceremony included traditional Buddhist chanting in the ancient Pali language, as well as sprinkling of Holy water by the monks, and offerings of gifts of to the monks. Attendees included the family members of current and former VDU patients, nurses from the VDU and critical care department, and the chair of the critical care department, all of whom participated together in these activities. It was really a beautiful event and something that I found to be quite unexpected in the hospital and of course very different from our daily practices in US hospitals.

One of the things that I enjoy most about palliative care is the holistic approach that it offers to patients. Cicely Saunders, the founder of the modern hospice movement, emphasized the concept of “total pain” which includes physical, emotional, spiritual and social pain. The WHO also defines palliative care as a holistic discipline that includes “impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Unfortunately, most physicians focus on physical pain and symptoms because this is the approach they were taught in medical school and residency. But of course there are many types of pain and suffering that medications and procedures cannot fix. 

Technology cannot answer the question of why an otherwise healthy young man is in a terrible motorcycle accident and is now brain dead, or why a mother with three young children develops metastatic cancer. Technology cannot advise you on how to deal with the painful emotions and existential questions that arise in these situations. This requires human connection, deep listening, and for many people, the wisdom and comfort provided by a spiritual or religious tradition. I think this is one of the reasons I really appreciated the ceremony in the VDU that day. It offered something that was comforting, uplifting and impossible to achieve with technology alone. 

I’ve read a number of articles about end of life care in Thailand this year, many of them written by Dr. Scott Stonington, a physician and anthropologist (MD/PhD) who spent a number of years in Thailand doing research in end of life care. In his article titled, “On ethical locations: The good death in Thailand, where ethics sits in places” he describes a discussion that he had with the daughter of a Thai woman who was nearing the end of life. The daughter explained why Thai patients feel that it is better to die at home than in the hospital.

She said, “The hospital is not sacred (saksit). We would make merit (tham bun) and we would put money in her hand and ask for forgiveness (kho khama), but the merit would not get to her as well.” 

Dr. Stonington reflects on her words, and how the highly technological environment of the ICU influences the end of life experience,

We sat together for a moment, and I looked around and saw some of the unsacred in the space around us. The hospital room was an open ward, and half the patients were on mechanical ventilators. The air was sterile and filled with the beeps of machines. Nurses scuffled around with gloves, wheeling blood-pressure check units to the beds of almost corpse-like patients, strapped as modern cyborgs into the life-machines of medical innovation.

I do not want to speak negatively of the impressive technology we now have available to sustain life, but I do want to emphasize the fact that technology is only one aspect of the care that is needed at the end of life. Although I did not take the time to elaborate about the day to day work in the VDU in this post (as it is already getting quite long!), I will mention that the VDU at Suandok Hospital does an excellent job of providing holistic care to patients on long-term ventilators and in the last stages of life. 

I feel grateful that I was able to spend time in the VDU and see this unique approach to care - the warmth and brightness of the VDU contrasted starkly with some of the chronic ventilator-dependent hospitals and nursing homes we have in the US, where patients often seem isolated and lonely. I think key aspects of this were the close involvement of family, the fact that patients were not rushed (many stayed for a month) and the affectionate style of relating to patients that I have noticed among Thai nurses and physicians (it is part of the culture to use kinship terms, e.g. "grandmother", "aunt", "father" when speaking to patients).

I spent a month with first year internal medicine resident "Proud" (nickname) in the ventilator-dependent unit (VDU). 

Proud asked me to sit and take a photo with the fruit plate shortly after I arrived. These little fruits are actually a special This dessert made of egg yolk and sugar (อร่อยมาก).

Pouring Holy water (blessed by monks, I think?) at VDU ceremony. 

Candles and incense at Wat Phra Singh, a famous temple in the Old City.

Elephant (ช้าง) at Wat Phra Singh.

Thursday, October 25, 2018

From Lanna to Isaan

When I tell Thai people that I have lived in Chiang Rai and Chiang Mai, they often ask me if I speak “คำเมือง” (kam meuang) which means the Northern Thai dialect. Unfortunately I have only learned a few words of คำเมือง since most Thai language resources are written in the central Thai language. As with most countries around the world, each area of Thailand has a unique history and sub-culture. The Northern part of Thailand is known for it’s relaxed pace of life, beautiful mountains and caves, and the ethnic diversity of the hill-tribe people. This area of Thailand is often referred to as “Lanna” (ล้านนา) which means “land of a million rice fields”. The famous Lanna kingdom thrived in the North of Thailand from the 13th to 18th century. Walking around Chiang Mai, it is easy to feel the ancient roots of the city, visible in the old city wall and gates and the numerous temples, many of which have been around for several hundred years. 

The Old City of Chiang Mai is surrounded by an ancient wall with four gates and a moat. This is a picture of the west gate ("Suandok" gate), towards the hospital. For an even more detailed history of Chiang Mai city click here.

I had the opportunity to explore more of Northern Thailand a couple of weeks ago when I travelled to Chiang Rai province to visit friends from the University where I used to work. When my Thai friends ask me what I like to do in my spare time, I tell them that I love nature (ชอบธรรมชาติ chawp thamachaat) and I’m not really a city person (ไม่เป็นคนเมือง man ben kon meuang) so I was thrilled to be able to spend some time in the mountains of the North. I took the bus to Chiang Rai city which is located about three and a half hours Northeast of Chiang Mai and met up with my Thai friend. On Saturday we traveled to Doi Mae Salong which is a small Chinese-Thai village with a fascinating history and beautiful views of terraced tea plantations and mountains. 

This is the famous Chiang Rai clock tower near the center of town. At night there are beautiful light displays.

Chiang Rai is a very "artsy" city with it's famous White Temple, Black Temple and now this Blue Temple. This was my first time visiting the blue temple, well-worth the trip.

A view of Doi Mae Salong village from the temple at the top of the mountain. This might be my favorite place in Thailand. 

We climbed 719 steps to reach the top. No, we didn't count them all - we were told that number by a group of school boys we met coming down the mountain. 

The next day we travelled to Chiang Khong, a small city on the banks of the Mekong River across from the Lao city of Huay Xai. Chiang Khong used to be a popular city for tourists taking the “slow boat” to Luang Prabang, Laos (a UNESCO world heritage site) but we were told this route has become less popular as more bus routes have become available. Chiang Khong is a sleepy town where time moves slowly alongside the unhurried flow of the Mekong river. I was sad to leave both of these places and return to the hustle and bustle of Chiang Mai, which my friend now calls “the second Bangkok” because of the rapid changes it has undergone in the last decade. I agree that Chiang Mai is not the same city that it was 10 yrs ago - there is much more traffic and modern businesses - but it does still retain a certain charm that is difficult to find in Bangkok.

"You do not really have places like this in the US, do you?" - quote from my Thai friend who lived in the US for a year as a Fulbright scholar. The peace and quiet of Chiang Khong is hard to match in the Western world.

We arrived in Chiang Khong quite late, went for a walk along the river in the dark. After eating delicious Mexican food. I can share the story of that restaurant later if you like...

During September, I had the opportunity to travel another region of Thailand - the “Isaan” region (also referred to as the “Northeast”) - to the city of Khon Kaen. I was fortunate to attend a conference called “Palliative Care in the ICU” (synchronicity?!?). The conference was led by a critical care physician from Australia and a pediatric pulmonologist from Khon Kaen who is one of pioneers of palliative care in Thailand. The Karunruk Palliative Care Center at Srinagarind hospital in Khon Kaen is now one of the most well-known and well-respected palliative care centers in Thailand. This trip to Khon Kaen was my first time visiting the Isaan (อีสาน) region of Thailand, although I had heard about it quite a bit when I was an English teacher in Chiang Rai. 

There are certain stereotypes about Isaan that my Thai students would sometimes incorporate into their role plays - for example, that the region is poorer, less educated and less developed compared to other parts of the country (not sure if this was entirely appropriate for them to do but it seemed to be light-hearted with no hurt feelings). Certainly Khon Kaen has a different feel from other parts of Thailand. It is less “Westernized” with fewer English signs and chain restaurants, and feels more agricultural. Somewhat surprisingly, there is also a huge emphasis of dinosaurs given the discovery of many dinosaur fossils in the region (see article "Khon Kaen Land of Dinosaurs"). There is a rich history in the Isaan region that is a fusion of Thai, Lao and Cambodian cultures. Many people actually say that Isaan culture is more similar to Lao than central Thai culture (the Lao capital of Vientiane is a short 2 hr drive away). 

One of many beautiful and creative city parks in Khon Kaen. I was amazed by how many lakes and ponds there were, reminded me a bit of home.

Altars are common in Thailand, I liked this lakeside altar with elephants and incense.

Inside the beautiful 9-story Phra Mahathat Kaen Nakohn temple. Each floor has different artwork (e.g. paintings, sculpture) and things like traditional Isaan musical instruments. 

Outside Phra Mahathat Kaen Nakhon temple. I recommend visiting if you go to Khon Kaen!

View of Khon Kaen city from one of the upper floors of Phra Mahathat Kaen Nakohn.

**If you have any interest in the history of Southeast Asia and six minutes to spare, I recommend watching this interesting video that shows a time lapse map of all the kingdoms that existed in this region over the course of ~2000 years. Another great resource on Southeast Asia is the University of Wisconsin Madison’s Center for Southeast Asian Studies. I'm planning to write more about the projects I’m working on in Thailand next week, I thought I'd dedicate this post to the cultures and landscapes of Thailand.

Friday, October 5, 2018

So What is the Problem?

I spent the last week in the “VDU” which is short for “Ventilator-Dependent Unit”. It is a unique ward that could be described as a combination of an in-hospital LTAC and a palliative care unit. One of the primary purposes is ventilator weaning, both for patients that are able to be weaned off the ventilator while in the hospital and for those who are ventilator-dependent now requiring 24 hr care. The latter group of patients are destined for home as there are no LTACs that can care for patients on ventilators in Chiang Mai. The time they spend in the VDU (usually about a month) is focused on training the family to provide all of the care the patient will need at home. Some families are able hire a home care provider (e.g. nursing assistant) to help but most will take on the responsibilities themselves.

The resident I was working with that day received two new consults for patients to transfer to the VDU. The first patient we saw was an elderly woman who suffered a large stroke with poor neurologic outcome. She had been in the stroke unit for the last 7 days without improvement. Our attending told us that the family had a meeting together yesterday and they all agreed that the patient would not want long term, 24-hr care. “But… they want her to be extubated in the hospital.” Pause. I noticed a sense of hesitation and concern in his voice.

I waited for the follow-up question. “What would you do in the US in this case?” he asked. I was a bit confused at first, thinking to myself, “What do you mean? We would extubate of course. Isn’t that what the patient and family wanted?” In fact, I thought this case was particularly straightforward since the patient previously said that she did not want long-term life-support and the family was in agreement. But I could tell that this path was less well-trodden here. I ended up telling him what we would typically do and that, “Sometimes we call it ‘compassionate extubation’…we do this quite often in the US, probably almost every day in the ICU.”

He told me that legally and ethically it is difficult to extubate patients in the hospital in Thailand so they do not do it. They can refrain from intubating in the first place (e.g. DNI) if the patient and family have stated their preference for this and they can switch to providing only supportive cares (e.g. no antibiotics, fluids, pressors) but extubation is not usually an option in the hospital. Some families take the patients home and extubate them there, perhaps in the presence of a monk, but the family typically needs to learn how to provide some of the home cares for the patient before making this transition.

This case made me pause and realize how much we take for granted as simply “the way things are” in our own culture. We forget that the laws and norms we have today are a result of past events and lessons learned gradually over time. It also reminded me that one of the great privileges of immersing ourselves in another culture is that we are able to learn more about our own. I will be curious to see how the culture and legal system in Thailand evolves in the coming years around this topic. Certainly, whatever decisions are made will be based on their unique history and experiences, and likely the growing influence of palliative care philosophy here. 


Cute little monk statue at forest temple "Wat Umong" not far from the hospital.

Tamarind fresh from the tree!

Happy to be wandering through the medicinal plant garden at CMU. 

One of many "wisdom signs" at the local temples.

Chiang Mai, Thailand Rotation

Sigrid Collier, a medicine-dermatology PGY5 resident at the U of MN, recently traveled to Chiang Mai, Thailand - here is a snapshot from her...