My Kalimantan Elective

I spent the first three weeks of my elective placement (31st October – 18th November) in Bethesda Hospital (Rumah Sakit Umum Bethesda), which is located in Serukam, West Kalimantan, Indonesia. It is a small private 90-bed capacity hospital set up by Christian missionaries from the United States of America 50 years ago but is now fully staffed by Indonesians. Located an hour’s drive away from the nearest town of Singkawang and 5 hours away from the West Kalimantan capital of Pontianak, the hospital mainly serves the rural population living further inland of West Kalimantan. The remaining three weeks (28th November – 16th December) meanwhile, were spent in the Medical Department back at Penang Hospital, where I mainly did rotations in Cardiology, Neurology, and Endocrinology.

Entrance to Hospital

My experience at Bethesda Hospital was a very enriching and fulfilling one. I chose to apply to this particular Indonesian hospital together with my batchmate (Grace Wong), who first heard about it from a senior of ours. This hospital was ideal since it fulfilled the objectives I had (as listed above), was located in a neighbouring country, did not require a hefty budget, and did not have a very significant language barrier since Bahasa Indonesia is rather similar to Bahasa Malaysia.

Doctor's Home

Bethesda Hospital is a relatively small hospital, located quite a distance away from the nearest town. As such, the hospital exists like a ‘village community’ itself where all the staff and their families live on hospital premises or in the surrounding villages and only make trips out to the town on weekends about twice a month. In terms of doctors, they only have one specialist each in the field of General Surgery, Obstetrics & Gynaecology, Paediatrics, Radiology, and Ophthalmology. These specialists are supported by eight young General Practitioners, as well as volunteer specialists (e.g. in Internal Medicine and Anaesthesiology) from Jakarta who fly in a few times a month. There is strong nursing and medical assistant support as well, along with a nursing school on site. Together, the staff serve an average of 100-200 patients visiting the clinic each day and also inpatients which fill up about 60-90% of their 90-bed capacity. These patients mainly come from the surrounding interior villages, some from even as far as six to eight hours drive away.

My batchmate and I were the only two medical students there at the time. Our days were usually spent at the morning case presentations, the operating theatre, afternoon clinics, and evening ward rounds. We were not attached to any particular department but instead were free to move around to learn from whichever specialist that was available. As such, we got quite a good exposure to a wide range of cases mainly in General Surgery, Obstetrics & Gynaecology, and Paediatrics (especially Paediatric Oncology). We were also given the opportunity to ‘scrub-in’ and assist in a few simple surgical procedures. The hospital also sends its doctors to satellite clinics in the deeper interior villages e.g. 10 hours away to provide basic healthcare and health education. Unfortunately, we were unable to join these trips as they tended to last an extended period of time (e.g. around 10 days or so).

The range of diseases being treated at the hospital were not very different from those seen back at Penang. The main difference would be that patients tend to present in a more advanced/late stage of their disease since many of them live deeper inside the interiors (many travelled from 6-8 hours away) and as such, it is very difficult for them to have easy and frequent access to treatment and follow-up. Another challenge would be that many still practiced traditional methods of healing and are hesitant to follow a doctor’s advice.

View of the entire hospital premises from a nearby hill

Apart from the issues above, one of the biggest challenges is the lack of monetary resources, which is a problem faced both by the patients and the hospital itself. Although a private hospital, many patients choose to come here because either it is the nearest available hospital to their homes, the service is better, and/or some of them are covered by the government health insurance. The hospital works on the ‘sliding scale fees’ concept, so they never turn any patients away although a large proportion of them are not able to pay fully. The hospital expenses are mainly covered by donations from friends and churches from around the region and other countries. Also, a significant amount of a doctor’s salary is taken away as contribution to the hospital. As such, the doctors here are earning significantly less than what they would have if they worked elsewhere. But as the Paediatric Specialist who had been working here for more than 20 years shared with us, “It’s okay, because here, I can freely serve the patients with all my heart.”

I enjoyed my three weeks here immensely. I got to experience a whole different side of healthcare compared to what I was used to back home. Firstly, I got to learn how the doctors handled the challenges faced above. They demonstrated great communication skills and empathy when talking to patients and explaining to them why a particular treatment was needed. There was great prudence and wise improvisation when it came to using resources like requesting investigations or giving medications. Though the situation was often not ideal, they did their very best to give the patients the best possible treatment with whatever little resources they had. I find that the staff are no less busy, stressed, or faced any less challenges (albeit different ones) compared to an average Malaysian hospital, yet the working environment remains very pleasant, with no angry or nasty words exchanged with one another, very little hierarchy, cynicism, or arrogance. Staff really went out of their way and did above and beyond what was required of them without considering ‘what’s in it for me’. I also got the impression that patients were really seen as people, rather than diseases to be treated, which is something that I myself am guilty of sometimes.

Apart from a one-day trip to town, my friend and I were at the hospital premises for the entire 3 weeks. As such, we got to be part of their already very close-knit community. Days were spent learning from the doctors in the hospital while many evenings were spent watching movies, hiking, playing games, and enjoying a simple meal, home-cooked by the very same doctors. Personally, I felt that in this elective, yes, I gained some medical knowledge; but more than that, I learned more about life and what it really means to be a doctor. It was a humbling experience as I have seen time and time again that it is often those that we perceive as having very little who are the most generous. This trip made me reflect on what kind of doctor I wanted to be, what kind of values I want to carry, and whether I will be able to hold on to the right perspective and attitude when confronted by future stresses and problematic situations. The doctors here at Bethesda Hospital have shown me in such a short span of time that it is possible, and I hope that I will be able to carry the lessons learnt here into my future career.

I chose to spend the remaining three weeks in Penang Hospital’s Medical Department because I wanted to do some extra revision in Medicine in light of the upcoming final examinations. I chose Penang mainly due to convenience, budget, and the familiarity of the environment. I spent a week each in Endocrinology, Neurology, and Cardiology. Overall it was a good time of revision and it allowed me to have a better idea of what I needed to improve on and what knowledge was lacking. Since there were much fewer students and also less time pressure, I was able to get more practice in clerking and examining patients, along with attending clinics and ward rounds. Our supervisor mainly let us do whatever we wanted to do, so this elective was also an exercise in self-discipline, taking initiative, and time-management.

To conclude, I think that the six weeks was a good mix of both new experiences and the familiar. In terms of whether or not I would recommend the elective placements I had to others, I think that Penang Hospital is a good option if one is looking for a familiar environment to revise for the finals, and is able to work on one’s own initiative since no one is going to be babysitting you and making sure you do your work. However, it may actually be better to use the electives period to gain a fresh and wider scope of experience, either at other local hospitals or overseas. As such, if a student was intending to do a placement at Penang Hospital, I would recommend not spending more than 3 weeks here, and take the remainder time to explore elsewhere.

I would definitely recommend Bethesda Hospital if students are looking for a very different but definitely enriching experience, and does not mind spending an extended period of time staying in one place, isolated from the comforts of the city. However, as it is a Christian missions hospital, I would advise that it may be better if the student is a Christian or is open to Christianity and Christian practices as this is very much a core part of the lives of the doctors and other staff. Both the staff and patients are very hospitable and welcoming, and as written above, I think that a student will be able to gain much more than just medical knowledge here.

#reflection #electives