When Worries Become Lessons

Guest blog by Felona Gunawan

Sometimes I wonder what life would be like if I never moved to the United States. It was partly to satisfy this curiosity that I decided to go to Sukadana, Indonesia for my rotation as a Johnson and Johnson Global Health Scholar. I was both nervous and excited. Nervous because I was not sure what to expect: will people still be able to understand my elementary level Indonesian? Have the social and political climates changed much from when I moved in 1999? How much can a doctor with Western training that depends so much on technology contribute? Thankfully, a lot of these fears quickly dissipated soon after my arrival in Sukadana. Not necessarily because these challenges were not present, but more so because of the amazing and dedicated staff and community. Moreover, my experience in Sukadana has allowed me to reconnect with the humanitarian aspect of medicine that is often lost in the practice of Western medicine.

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Worry #1: Will people still be able to understand my elementary level Indonesian?

I am thankful that my parents never stopped conversing with me in Indonesian. While I could not comprehend 100% of the conversations, especially those in the local dialect, I was able to understand enough to get the big picture. I appreciated being able to understand the patients during the clinic encounters, especially the cultural context of their understanding of illness and health, which can be lost in translation. Being able to speak Indonesian also allowed me to contribute by teaching the medical staff (nurses, TB direct observed therapy workers), as well assisting with a translation project. The latter consisted of transcribing and translating interviews that were done to evaluate the clinic’s health and conservation programs from the perspectives of patients, clinic staff, and community members. This gave me a much deeper insight and appreciation of the clinic’s impact on the surrounding community.

Worry #2: Have the social and political climates changed much from when I moved in 1999?

In the recent years, the Indonesian government created a national health care insurance system with the goal of providing universal health care. The system is still relatively new and far from perfect. In one particular case, we had a critically ill patient who needed ICU care. However, we learned that she could not go directly to the hospital 2 hours away if she was going to use the national insurance. First, she had to be evaluated and obtain a referral from a government clinic, which would cause a significant delay in her care. The ASRI clinic is working on changes that will hopefully improve patient care within the health care system, but not without challenges. Without going into too much detail, I would say that I was definitely glad to see some positive changes within the social and political climates since 1999, but there is definitely still progress to be made. I am amazed by the perseverance and passion of the staff I met at the clinic. I have learned from them the importance of persistence in the face of what seems like insurmountable challenges when one is fighting for a worthwhile cause. Moreover, the leaders there would say that they would not have been able to accomplish all of this without the help of the community.

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Worry #3: How much can a doctor with Western training that depends so much on technology contribute?

This question quickly changed to “how much can a Western-trained doctor who depends so much on technology learn from volunteering at ASRI clinic?” The answer is: a lot. Many of the common diagnostic tools such as blood work and imaging were not available when evaluating a patient either because we did not have the equipment, or often because the cost is prohibitive for the patient and family. For this reason, I definitely learned to rely more on history and physical exam to diagnose an illness and became more comfortable with accepting uncertainties. In fact, there were times when the patients still improved despite not getting the recommended studies that would have been performed in the US, which made me wonder about how much of what we do in the US is superfluous. Of course, there were cases when not having a particular study or medication greatly affected patient care. I remembered wishing for a CXR in the middle of the night as we are trying to figure out whether a patient’s shortness of breath and wheezing is from a cardiac or lung etiology. We also had a case of a patient with severe diabetic complication (ketoacidosis) from a necrotic gangrene infection, who desperately needed broad spectrum intravenous antibiotics and insulin, which we did not have in the clinic. In these situations, I learned to be innovative from my Indonesian colleague doctors. I came to appreciate the many ways that ultrasound can be useful as a diagnostic tool and learned to think outside of the box, such as crushing oral medications and delivering them via a nasogastric tube to an unconscious patient when the intravenous form is not available.

In addition, practicing medicine in Sukadana allowed for a certain simplicity that made me better understand the impact of a patient’s illness on his or her family. In the US, it is so easy to get distracted by an overflow of information, the computer, and documentation, that the human experience of medicine is forgotten as the patient turns into a "virtual" patient. Oftentimes, treatment plans are created without regard for the patient’s insurance and ability to pay, believing that this is out of the realm of a doctor’s responsibility as long as he or she provides care according to the most up-to-date guidelines. However, in Sukadana many of these distractions are removed. Patients often come with their family, and in order to come up with an acceptable treatment plan, the doctors almost always inquire about their socioeconomic status. More often than not, the family is very involved with a patient’s care, always by the bedside with family discussions preceding any major medical decisions. This concept of understanding the patient as a whole person and the sense of familial support are things that I often miss while practicing medicine in the US.

It is interesting sometimes to see the path that life takes you. I am glad that my curiosity led me to Sukadana. One never knows how certain life experiences can be useful in the future. I am thankful for the opportunity to volunteer at ASRI clinic, particularly for the useful life lessons and the chance to further develop my medical skills.

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About Felona Gunawan

Felona is a Johnson and Johnson Global Health Scholar and an Internal Medicine Resident at Yale. She volunteered at the ASRI clinic from August through September 2016.

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