Thailand Medical Adventure - 6 - Tha Muang Hospital and Complementary & Alternative Medicine

Complementary and alternative medicines in Thailand:

I was initially drawn to Thailand because of their governmental initiative to promote Traditional Thai Medicine in the country.  I had spoken to Dr. Tip over the past year and she mentioned they have Thai medicine at Tha Muang hospital.  So I was obviously excited because of my upcoming East West Primary Care Fellowship at UCLA beginning July 1, where I will be learning traditional Chinese medicine (TCM) and specifically acupuncture. 

Let me give you the lay of the land for CAM therapies at Tha Muang.  On the actual hospital campus, about a 1 minute walk from the main entrance is a clinic dedicated to Thai Massage.  It is about 200 baht for a Thai Massage from fully trained practitioners.  From what I understand there is a 4 month training at minimum.  One of the schools is a-pai-pu-bet university.  The actual clinic is beautiful, with a large air conditioned communal massage area with curtains and 6 beds full of Thai local people.  They also have a “spa room” that looks nice.  They tell me that some of the patients get funding to get massage when it is a work related injury.  It is so interesting to have this beautiful little oasis at the hospital.  When I first arrived to visit the clinic, they were all very excited.  Before I knew it I was in the Thai massage outfit (little button up shirt and Thai tie pants) and on the bed with a tall Thai woman.  I have had Thai massage before.  It is unlike any other massage I have experienced.  Most westerners I think expect a nice relaxing Swedish style massage.  Well this can be relaxing but hurt like hell!  It seems like they are focusing fingers and elbows along set pressure points.  A huge focus is on the lower legs, stretching the hips, and shoulder cuff region.  The masseuse also gets pretty intimate, with holding your leg over theirs and getting deep into the groin.  It is all very professional and clearly they are well trained.  It has been hard to learn about their technique because of major language barrier, but is something I will read later.  I do know that Thai people see massage as a common and vital technique to maintain good health.

The second major offering is the Traditional Chinese Medicine Unit which is another even more beautiful clinic underneath the inpatient ward building.  It is a newer building with sliding glass doors, beautiful long windows with wood blinds, two tone large panel wooden floors that are very welcoming.  It is run by a lovely women, who’s name I cannot remember.  The 1 and only practitioner is Dr. Mai whom I spoke about above.  There are also two skilled assistants who are part of the orchestra of care delivering needles to Dr. Mai without missing a beat.  She was trained at a Thai university in Bangkok.  It is 6 years of intense Chinese medicine training and she spent 2 years in I believe Shanghai perfecting her skill.  Needless to say she knows what she is doing.  She sees about 10-15 patients in the morning and equal number in afternoon, depending on volume.  For the first few days she had a fun students doing a community elective.  Her name is Cheer and she is a student at Dr. Mai’s alumni university.  She was my dedicated translator, and helped me buy my first Pad Ka Prao for lunch.  Mm, it’s a spicy pork dish with basil.  She unfortunately had to leave after my first week because her rotation was concluding.  Dr. Mai practices both Chinese and Japanese style (with and without the plastic sheath to help reduce pain during needle placement).  I received a session by Dr. Mai and Cheer, and I have to say I prefer Japanese style.  I am a bit of a needle-a-phobe and have very sensitive skin.  It is really subconscious too, I just have little uncontrolled jolts when the needle enters.  She only practices in her clinic, but said on occasion her colleague from inpatient will call her for a session on the floor.  It is about 100-150 baht per session with her, not sure if that is the cost of new patients.  Her main patient base is from internal referral, and signage in the entrance to the hospital.  She said many Thai people are afraid of needles, but still many will seek out her care.  It is amazing because here is a clinic that is managed and owned by a government hospital, and Dr. Mai is salaried.  Many of the patients have musculoskeletal complaints, including shoulder pain, parasthesias, sciatic pain, OA of hips and knees.  But also patients with general stress, vertigo, edema.  The clinic is not isolated from the overall system.  She enters patient information into the hospital electronic record and also has the patient chart with all encounters (OPD, ER, lab results) and writes both an electronic and paper note.  She is so organized with her notation, notation of points to be needled, and even her pen is both a highlighter and pen combo.  =D.  One day I will be like her.  After seeing about 6-7 patients for history, pulse palpation, tongue evaluation and other examination, she places needles and provides occasional cupping to the patients in order.  She routinely uses electrical stimulation as well.  I love the clinic.  It is so calm, orderly, and patients are full of smiles and relaxation. 

I asked about her goals for the clinic, and she wants to be able to bring TCM into the community.  There is already a network of primary care units as they are called in the multiple villages where doctors from Tha Muang visit on specific days to provide continued care.  I hope she is able to join in with this, because the community would definitely benefit.  I provided her with the East-West medicine informational handouts for patients to perform acupressure massage at home.  I hope this will be of use.  This clinic seems more focused on set number of visits, and less on teaching self-acupressure stimulation.

I cannot go on without telling you a few more interesting things from my time at the clinic.  First, Dr. Mai wears hello kitty slippers at work =).  It is so cute.  I mean the big fluffy ones.  No one seems to wear.  The helpers are wearing Barbie brand sandals haha.  Definitely in Asia, and I love it.  One of the common diagnosis is Office syndrome!  Amazing.  So true.  We took care of a patient with contractions from motorbike accident with right sided paralysis.  It is so sad to see this type of patient, and is not the last.  Finally, some of the cupping dr. Mai actually nicked the skin to produce bleeding. I have never seen that before.

Another aspect of the CAM offerings is that in these Primary Care Units (called PCU), some have signs for Traditional Thai Medicine.  I asked around and found local women who had trained in Thai massage providing massage to their community.  Price of 250 baht for 2 hours!  Pretty good.

The pharmacy at Tha Muang hospital and also the PCU’s are stocked with a small number of government approved Thai medicines for common complaints. 

It is amazing that they offer these.  It is part of the free formulary for Thai residents.  I am not sure about the process of approval and safety monitoring, but I have to believe it exists since they all seem standardized and made in Thailand.  I asked the interns if they actually prescribe the medications, and they said they do use them.  They did not actually perceive them as Thai herbal medicines, but just another kind of medicine for cough, URI symptoms, and indigestion.

In the hospital there are some CAM techniques used.  Dr. Tip showed me her newborn unit and taught me about their offerings specific to Tha Muang and promoted by the pediatricians and nurses.

-ginger juice is made fresh by the nutrition department for post-delivery mother nausea.  And is also used as a lactogogue.  It tasted amazing actually.

-nurses perform regular breast massage to help produce milk

-heat light therapy to the perineum to promote healing, a few times a day initially.  I am new to this technique for wound healing.  Regardless, patients reportedly state it reduces pain and has no clear side effects from what I can tell.

-herbal ball?  Apparently the OBs recommend a ball made of Thai herbs for aromatherapy and massage of the uterus to help it contract.

Update:  I had the opportunity to visit a different community hospital, similar to Tha Muang, that has adopted additional Thai medicine therapies and services.  I cannot remember the complicated name but it is located about 20km from Tha Muang.  Eiot is a pharmacist at Tha Muang who offered to take me there.  She is someone I met early on who was just always smiling and full of energy.  She speaks good English and has welcomed into her pharmacy unit, and was there for the songkran water fight!  She has two small kids, 2 and 4 years old.  I had no clue as to what we would find though… We showed up at a small more wooded area with an open air hospital.  We walked down a long shaded walkway to a clinic with two woman, one in uniform and the other in a polo shirt.  This was the Thai medicine clinic for the hospital.  It is a large complex with a front check-in, triage area and clinic for their practitioner, large 8 bed Thai massage unit, spa room, multiple showers, steam room, oil massage room?, and a large stock of Thai herbal medicines.  Much to my surprise, they actually produce many of the herbal remedies on site!!  This is a governmental community hospital producing herbal medicines for their own patients…  The head women is the supervisor and a younger maybe, 30s year old woman is the “oriental practitioner.”  She studies at a traditional medicine University for four years.  It is hard to figure out what type of medicine she practices, but it sounds like she talks with patients, teaches them body movement therapies, refers for massage, and uses herbal remedies from local Thai plants.  They have a number of teas, professional appearing single plant pills.  Everything was in Thai which made it difficult.  Most of the treatments seemed to be for cough, indigestion, hemorrhoids (not sure why there are so many treatments for hemorrhoids!  Isn’t everyone having diarrhea from all the curry =D, there should be no straining!!), insomnia, and others I assume but was hard to sort out.  The massage room was busy with clients.  They said many are from the community and walk in directly, but many are referred from outpatient clinic.  They have some inpatients come as well.  It is 100 baht for 1 hour here, if you are part of the governmental plan.  I explain the payment structure later.  But for age 16 to around 60s, they are part of governmental plan, younger than 16 is on special pediatric plan, and they have a better coverage elderly plan.  I was not able to see the herbal formula production plant but it was right next door.  They seemed to be cleaning it after today’s production.  They have a medical herb garden with little signs explaining the plants, but the majority is brought in as raw material from the rest of Thailand and then prepared and packaged at the hospital.  I couldn’t understand why a governmental hospital would spend energy doing this.  Turns out the Thai Government provides grants and incentives the more a hospital adopts traditional Thai medical practices.  So the hospital gets both government grants and money from selling the products on site.  They were very cheap, 50 baht for a package of the tea.  Unlike the typical governmental pharmacy, they are not covered by the Thai government.  It seems like a bit of a tricky situation when a hospital is making its own medicine, and then selling it.. Given the low prices, I don’t feel it is a predatory situation.  This local community is more connected with their Thai medicine roots and also were more amenable than other communities. 

Few side notes about the labor and delivery at the hospital.  I have become close with Yada, an wonderful and caring individual who has been a labor and delivery nurse for 10+ years. She is also married to a policeman locally.  She has been my host and as she call me, her new brother (and I am to call her my new Thai sister, I pinky swore that I would tell my mother when I arrive home =)).  She has been taking me out to dinner, dropping food off at my apartment, showing me around kanchanaburi.  It has been absolutely lovely and she is so warm, sweet and fun.  My experience would not have been the same without her and her lovely friends, grandkids that I have met as well. 

Anyways, So Dr. Tip has been struggling to promote breastfeeding at the hospital.  There are the young and old mothers, described as average age 16 and the second hump is 30s.  And many do not plan to breastfeed but use formula.  It seems there is a major advertisement campaign and money used to promote use of formula.  Even stating that formula is better for the baby!  No surprise, I went to a local convenience shop and an entire wall was dedicated to formula!  So sad.  Dr. Tip is working relentlessly to improve the situation.