ABROAD
Thailand: Trends in Medical Services HEALTH CARE is one of the pressing problems in Thailand, a country of 42 million people with only 5000 doctors. Half of the doctors are in the capital city of Bangkok and its suburbs, with its four million people; the other half are in provincial areas. Approximately 400 doctors are graduated yearly from the four medical schools. Because of the Western influence on the schools the trend of young doctors is toward clinical training for higher qualifications, either in Thailand or in Western countries. Very few want to go to the rural areas. This attitude has a great impact on the national health program. Adequate medical care can be provided only in urban centers where medical treatment is up to high standards, especially in the well-equipped university hospitals with all medical specialties and subspecialties. Modern medicine thus serves only certain sectors of Thai society, which represent a small percentage of the population. In the rural areas, which have a majority of the population but a minority of the doctors, health care is insufficient; general practitioners are in great demand in these regions. Several measures taken by the government to overcome the problem have included increasing paramedical personnel to help with the preliminary care of patients, population control, health education to people, prevention of diseases, and operation of mobile medical units. Yet with the rapid increase in population, medical needs cannot be met locally. Patients travel several hundred miles from rural areas to Bangkok, only to be seen in the hospital outpatient clinics for a few minutes! To provide proper care to the nation with this limited manpower, the Thai Medical Council has taken steps to raise the number of doctors in the rural areas. Only a limited number of doctors completing rotating internship in the general hospitals in Bangkok are allowed to continue their residency training. A greater percentage are obligated to spend at least 2 years in the provincial hospitals where they will acquire skills and learn the existing problems in the areas to which they are assigned. They may return for further specialty residency training after they complete their terms. Those truly devoted to rural care may stay on permanently, returning to Bangkok only for special training they believe they need for the particular community. Therefore, the training trend is now toward training of general practitioners, general internists, and general surgeons. Less foreign clinical training will be expected. This approach has been criticized by a number of doctors on the supposition that it may downgrade medical standards. These trends are an important turning point in Thai medical history. Are we moving to the right direction? The measures taken by the Medical Council appear to be appropriate and realistic. Clinical training for higher
qualification has disadvantages in that it takes time and requires training in approved hospitals that are urban, not rural. Western clinical training is unrealistic in many aspects for medical care in tropical countries. No matter how much sophisticated training a doctor may have or how well qualified he may be, his skills are useless if he cannot serve his society's needs. Service rendered has merit only if it is useful within the framework of the country's economy and ecology. The step taken by the Medical Council is a direct approach to the problem; it goes straight to the need of people in the rural areas, who are the majority in the country. Continuing education is being reinforced to maintain medical standards. Seminars or lectures on topics of current interest, arranged in rural hospitals by a team of doctors in an academic field, not only supply continuing education but also relieve feelings of professional isolation. Similarly medical libraries give useful support in rural hospitals. A medical knowledge self-assessment program such as that run in the United States by the American College of Physicians should be developed to sustain modern standards in practice. At the medical school level, teaching continues in conventional form, with 2 years of premedical and 4 years of medical curricula. The training and teaching are modified, however, to meet indigenous needs, with more orientation toward the rural community. Students now spend a few weeks in the rural areas during their course of preventive medicine, while interns spend 1 elective month in rural hospitals. Herbal medicine is being further explored; some combination of traditional medicine and modern medicine may have some success in our national health care. The medical schools carry on teaching, patient care, and research, but their research is inferior. The reasons for this are multiple, but lack of adequate technology plays a large part. Medical faculties are well informed on principles of investigation and interpretation of results but do not know enough about laboratory techniques. With research in medicine today being technology-dependent, technical know-how becomes vital. Technicians at present can do only ordinary laboratory work. This important point has been overlooked because of the general trend in training toward clinical medicine. Medical research therefore remains inferior despite support from the National Research Council and grants from various sources. To stimulate progress in research, more attention is being given toward raising the level of technological competence. For this need, Western research training is preferable for us to its clinical counterpart. Technology must be imported; clinical training can be acquired in our country with better applicability. These new trends of medicine in Thailand for better health care need adaptation, devotion, and effort. The launching of a number of projects by university students Abroad
Downloaded from https://annals.org by Tulane University user on 01/18/2019
527
for medical development in the rural areas is one step of evolution toward reality that indicates concern of our young people for the survival of our nation. National health care on this new approach is likely to come to
bloom. (VISITH SITPRIJA, M.D., PH.D., F.A.C.P.;
of Medicine, Chulalongkorn Bangkok, Thailand)
Hospital
The Vocation of the Physician The vocation of a physician is the spirit of true Christianity in action. It consists not alone in healing the sick, in soothing the afflicted, and recalling the wandering intellect, but also in cherishing a love of peace and moderation amongst all men, and in promoting moral and intellectual improvement. The practicing of the healing art is an occupation intrinsically dignified. It cannot be divested of this quality by the humble condition of the practitioner, or by the repulsive nature of many of his duties; still less by the lowly condition of his patient. In the most abject human being, the true physician recognizes a fellow-man; in the most exalted, nothing more. The offspring of the highest and lowest come under his care alike, naked and helpless. The screen which, in after life, conceals many of their weaknesses and some of their virtues, ever open more or less to the medical observer, is for him removed by sickness and misfortune. Before the man of healing the trappings of greatness are laid aside, and the cloak of deformity is dropped; beauty puts off her ornaments, and without a blush modesty raises her veil; and when, at last, man is about to take his plunge into the abyss of eternity, he strips off all disguise, and stands revealed in his primitive nakedness and helplessness. Surely they who hold such relations to society should be learned, discreet, and wise, trained by liberal studies and by illustrious examples to be ever true to the cause of humanity; elevated by education, as by education alone they can be elevated to rise above all that is sensual and sordid . . . ALEXANDER H. STEVENS, M.D., LL.D.
A Plea of Humanity in Behalf of Medical Education, annual address delivered before the New York State Medical Society, 6 February 1849, 4th ed. New York, H. Ludwig and Co., 1849
(Submitted by H. E. Holling, M.D., F.A.C.P., Philadelphia, Pennsylvania)
528
October 1976 • Annals of Internal Medicine • Volume 85 • Number 4
Downloaded from https://annals.org by Tulane University user on 01/18/2019
Department
Medical
School,
Thailand: Trends in Medical Services HEALTH CARE is one of the pressing problems in Thailand, a country of 42 million people with only 5000 doctors. Half of the doctors are in the capital city of Bangkok and its suburbs, with its four million people; the other half are in provincial areas. Approximately 400 doctors are graduated yearly from the four medical schools. Because of the Western influence on the schools the trend of young doctors is toward clinical training for higher qualifications, either in Thailand or in Western countries. Very few want to go to the rural areas. This attitude has a great impact on the national health program. Adequate medical care can be provided only in urban centers where medical treatment is up to high standards, especially in the well-equipped university hospitals with all medical specialties and subspecialties. Modern medicine thus serves only certain sectors of Thai society, which represent a small percentage of the population. In the rural areas, which have a majority of the population but a minority of the doctors, health care is insufficient; general practitioners are in great demand in these regions. Several measures taken by the government to overcome the problem have included increasing paramedical personnel to help with the preliminary care of patients, population control, health education to people, prevention of diseases, and operation of mobile medical units. Yet with the rapid increase in population, medical needs cannot be met locally. Patients travel several hundred miles from rural areas to Bangkok, only to be seen in the hospital outpatient clinics for a few minutes! To provide proper care to the nation with this limited manpower, the Thai Medical Council has taken steps to raise the number of doctors in the rural areas. Only a limited number of doctors completing rotating internship in the general hospitals in Bangkok are allowed to continue their residency training. A greater percentage are obligated to spend at least 2 years in the provincial hospitals where they will acquire skills and learn the existing problems in the areas to which they are assigned. They may return for further specialty residency training after they complete their terms. Those truly devoted to rural care may stay on permanently, returning to Bangkok only for special training they believe they need for the particular community. Therefore, the training trend is now toward training of general practitioners, general internists, and general surgeons. Less foreign clinical training will be expected. This approach has been criticized by a number of doctors on the supposition that it may downgrade medical standards. These trends are an important turning point in Thai medical history. Are we moving to the right direction? The measures taken by the Medical Council appear to be appropriate and realistic. Clinical training for higher
qualification has disadvantages in that it takes time and requires training in approved hospitals that are urban, not rural. Western clinical training is unrealistic in many aspects for medical care in tropical countries. No matter how much sophisticated training a doctor may have or how well qualified he may be, his skills are useless if he cannot serve his society's needs. Service rendered has merit only if it is useful within the framework of the country's economy and ecology. The step taken by the Medical Council is a direct approach to the problem; it goes straight to the need of people in the rural areas, who are the majority in the country. Continuing education is being reinforced to maintain medical standards. Seminars or lectures on topics of current interest, arranged in rural hospitals by a team of doctors in an academic field, not only supply continuing education but also relieve feelings of professional isolation. Similarly medical libraries give useful support in rural hospitals. A medical knowledge self-assessment program such as that run in the United States by the American College of Physicians should be developed to sustain modern standards in practice. At the medical school level, teaching continues in conventional form, with 2 years of premedical and 4 years of medical curricula. The training and teaching are modified, however, to meet indigenous needs, with more orientation toward the rural community. Students now spend a few weeks in the rural areas during their course of preventive medicine, while interns spend 1 elective month in rural hospitals. Herbal medicine is being further explored; some combination of traditional medicine and modern medicine may have some success in our national health care. The medical schools carry on teaching, patient care, and research, but their research is inferior. The reasons for this are multiple, but lack of adequate technology plays a large part. Medical faculties are well informed on principles of investigation and interpretation of results but do not know enough about laboratory techniques. With research in medicine today being technology-dependent, technical know-how becomes vital. Technicians at present can do only ordinary laboratory work. This important point has been overlooked because of the general trend in training toward clinical medicine. Medical research therefore remains inferior despite support from the National Research Council and grants from various sources. To stimulate progress in research, more attention is being given toward raising the level of technological competence. For this need, Western research training is preferable for us to its clinical counterpart. Technology must be imported; clinical training can be acquired in our country with better applicability. These new trends of medicine in Thailand for better health care need adaptation, devotion, and effort. The launching of a number of projects by university students Abroad
Downloaded from https://annals.org by Tulane University user on 01/18/2019
527
for medical development in the rural areas is one step of evolution toward reality that indicates concern of our young people for the survival of our nation. National health care on this new approach is likely to come to
bloom. (VISITH SITPRIJA, M.D., PH.D., F.A.C.P.;
of Medicine, Chulalongkorn Bangkok, Thailand)
Hospital
The Vocation of the Physician The vocation of a physician is the spirit of true Christianity in action. It consists not alone in healing the sick, in soothing the afflicted, and recalling the wandering intellect, but also in cherishing a love of peace and moderation amongst all men, and in promoting moral and intellectual improvement. The practicing of the healing art is an occupation intrinsically dignified. It cannot be divested of this quality by the humble condition of the practitioner, or by the repulsive nature of many of his duties; still less by the lowly condition of his patient. In the most abject human being, the true physician recognizes a fellow-man; in the most exalted, nothing more. The offspring of the highest and lowest come under his care alike, naked and helpless. The screen which, in after life, conceals many of their weaknesses and some of their virtues, ever open more or less to the medical observer, is for him removed by sickness and misfortune. Before the man of healing the trappings of greatness are laid aside, and the cloak of deformity is dropped; beauty puts off her ornaments, and without a blush modesty raises her veil; and when, at last, man is about to take his plunge into the abyss of eternity, he strips off all disguise, and stands revealed in his primitive nakedness and helplessness. Surely they who hold such relations to society should be learned, discreet, and wise, trained by liberal studies and by illustrious examples to be ever true to the cause of humanity; elevated by education, as by education alone they can be elevated to rise above all that is sensual and sordid . . . ALEXANDER H. STEVENS, M.D., LL.D.
A Plea of Humanity in Behalf of Medical Education, annual address delivered before the New York State Medical Society, 6 February 1849, 4th ed. New York, H. Ludwig and Co., 1849
(Submitted by H. E. Holling, M.D., F.A.C.P., Philadelphia, Pennsylvania)
528
October 1976 • Annals of Internal Medicine • Volume 85 • Number 4
Downloaded from https://annals.org by Tulane University user on 01/18/2019
Department
Medical
School,
