University of Gadjah Mada (UGM), Yogyakarta (Indonesia)
Impressions of University of Gadjah Mada
Erica Leaney – medical student from Sydney Medical School, undertook an Extra-mural at Universitas Gadjah Mada in 2013-14
I undertook a two-week student placement at Universitas Gadjah Madh in the Faculty of Medicine. I was based at Rumah Sakit Dr Sardjito, a large hospital situated conveniently next to the campus. I was placed in the internal medicine department, specifically infectious diseases.
Some of the interesting cases I saw during my placement included:
- TB patients
- Multi-drug resistant TB patients
- HIV patients
- Patients with a whole host of diseases, often TB and HIV (being HIV positive increases the likelihood of contracting TB due to the way that HIV damages your immune system) and occasionally a third infectious disease, such as viral hepatitis
- Snake Bite
- Malaria-induced jaundice
One of the main things that I observed during my time at the hospital was how the patients were mostly poor people from rural areas. This is not to say that infectious diseases were not also endemic in the city, but that for the diseases to reach the level of severity where the patients required hospitalisation generally meant that there was a triad of poverty, lack of health awareness, and lack of education.
Most of the patients I saw from urban areas were in good condition and attending outpatient clinics for routine management of their chronic infectious diseases.
The highlight of the placement for me was spending a day at the HIV clinic. The clinic had 40 patients that day, which was quite a busy day for them. The clinic is where patients are required to attend (on a monthly basis) to collect their anti-retroviral treatments. Every six months the patients are supposed to have a blood test prior to their attendance, so that they can bring the results and the doctors at the clinic may monitor their CD4+ T-cell count (a proxy for measuring viral load). There are a variety of ways for HIV to be transmitted, those I saw at the HIV clinic that day were (from most to least common): unsafe sex, injecting drug use, tattoo and piercing (2 patients).
"As my first prolonged exposure to the health care system of a developing country, two weeks’ placement at UGM provided invaluable learning opportunities, which I will draw from throughout my career. From the three classes of patients and VIP ward in the large city hospital, to the diagnostic and management methods employed by staff in the startlingly resource-poor regional clinics, I experienced why, and when, a core understanding of disease processes is so important.
In Australia, for good reason, we aim to control the environment from which we can issue health care: The essential drugs, devices, scanners, and theatres are constantly available to clinicians so that the desired intervention is possible almost all the time. Being involved with tuberculosis and HIV in Java required a repositioning along that dimension. Patients’ education and financial situation, the budget of the healthcare facility, culturally unique notions of health and sickness, local linguistic variability; the environment in which to provide care was often more unpredictable than the diseases themselves.
Experiencing the healthcare system of Yogyakarta exposed me to a bevy of barriers to, issues in, and perspectives of health, to which we are largely unaware in Australia. The staff and students at Dr Sardjito Hospital and Universitas Gadjah Mada were always eager to help me understand their system and assist with my learning. Perhaps the most valuable insight from the experience was that despite the differences from country to country or hospital to hospital, being a doctor anywhere in the world requires working within these same limitations; financial, communicative, technological, and others. In urban Australia, the bar is just set much higher."
Overview of Elective:
Maternal and Child Health: I spent two weeks in a rural village in Central Java staying with a local midwife. I attended the local medical centre and was involved with early childhood health and immunisation, contraception and family planning, and antenatal care. I was also involved with field visits such as early childhood clinics, general health clinics, primary school visits, postpartum home visits, and leprosy screening in remote villages.
Tropical Medicine: I spent two weeks in Yogyakarta at the Sardjito Teaching Hospital and was involved with infectious diseases, in particular tuberculosis and HIV. I visited regional respiratory clinics and inpatient facilities specialising in tuberculosis diagnosis, treatment and public health. I also visited specialised facilities providing methadone programs, STI screening and needle exchange programs in high HIV risk communities. At the teaching hospital I spent time on the wards with patients with fever/sepsis and other infections, including tetanus and malaria.
General Comments and impressions:
I found the experience very enjoyable – the people are friendly, the food is fantastic, and the culture is fascinating. UGM Faculty of Medicine staff are kind and helpful. Yogyakarta is a great city to stay in, cheap to live in, easy to get around, and excellent for tourism/sightseeing. Indonesian language in the city is helpful, and essential if you want to travel to rural areas.
Seeing healthcare in a developing country has helped me to appreciate the health system we have in Australia, in particular access to diagnostic testing and imaging. Often in the rural areas only very basic blood tests and X-rays are available. Without the benefits of further investigations, doctors have to rely on clinical examination skills much more. I feel that often junior doctors in Australia have many diagnostic tests and imaging techniques at their fingertips, and perhaps are vulnerable to becoming too dependent on them. Doctors should always remember to treat the patient in front of them, and not just a test result. Thorough history taking and physical examination is essential to becoming a “better” doctor, and this experience has definitely reinforced this for me.
I admired the multidisciplinary approach to community medicine I observed in rural areas, including the large role of nurses and midwives in women and children’s health. Many midwives had practices in their own homes, and were always available for women’s and childrens health advice, which meant more of the poorer village women could access medical help more readily than going to a medical centre or hospital. I believe that I will continue to appreciate the importance of all medical and allied health professionals working together to improve patient care and outcomes.
The key cultural lesson that I learned during my placement was that when attempting to address health issues, you must use strategies that will be culturally appropriate. My supervisor explained this to me like this – “I had an elderly female patient who had heart failure as a result of chronic lung disease. She had spent forty years of her life cooking over a wood stove, inhaling the soot every day. Should I buy her a gas stove? How can I afford to buy a gas stove for every single woman like her? Even if I did, would she use it? She has done the same thing every day for forty years, she won’t want to change. We need to come up with something that she will accept.”
Introducing new technologies into healthcare systems in developing countries is not always appropriate or successful. I observed that many midwives had foetal heartbeat Doppler probes in their practices. Often, however, they were broken or the batteries were flat. They were quite often not used, but rather the midwife would use the old fashioned Pinnard stethoscope to hear the foetal heartbeat. In that environment the newer technology was less useful than the older technology.
Medical treatments are heavily influenced by local cultural and religious preferences. This was particularly evident in contraception. Rural women have low uptake of the oral contraceptive pill compared to Australia, but have much higher uptake of long lasting contraceptive injections, implants and IUDs. This is more convenient for women who live far from medical services. Condoms are less readily available than Australia due to widespread religious disapproval. Being aware and sensitive of these issues is very important if you want to provide medical services that will actually be used by the local community.