The full name of our practicum site is the Royal Institute of Health Sciences: Royal University of Bhutan. RIHS is located uphill, next to the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) in Thimphu; it is a convenient 20 minute ride by taxi from R.T.C and offers a quick walk to Norzim Lam. It is about a 20 minute walk from the Changlam plaza bus station. The school offers classes and clinical observations in the areas of nursing, public health, midwifery, and clinical sciences. Attending RIHS provides a great experience for people interested in medicine, public health, and health care in Bhutan.
The school’s mission statement is a follows:
“The Royal Institute of Health Sciences as the only health training institution in the country is dedicated to fulfilling the health human resource requirements of the country and beyond to meet the health needs of individuals, families and communities and be able to face and adapt to the emerging challenges. We strive to contribute to the realization of Gross National Happiness through improvement and maintenance of the health of the Bhutanese people,” (http://www.rihs.edu.bt/content/rihs-mission).
The various programs offered at RIHS are Nursing, Midwifery, Public/ Community Health, Basic and Clinical Sciences, and Continuing and Professional development. Additionally, there are various departments in the school, they include: Senior Management Team, College Academic Committee, College Disciplinary Committee, Research and Innovations Committee, Program Board of Examiners, and a Sports and Cultural Committee. It is also interesting to note that “This is the only health institute in the country where mid-level health workers, nurses and technicians are given pre-service training.” Recently, RIHS has introduced a bachelor’s degree that focuses in both Nursing and Midwifery.
RIHS was established as the Health School in January 1974 with the assistance of UNICEF and WHO. The school is committed to preparing and training students with adequate skills, motivation, and competence to provide comprehensive health care services to the people of Bhutan. The Health School was later upgraded to the Royal Institute of Health Sciences on September 25, 1989. The Institute was under the Medical Education Division with the Ministry of Health until 2007 and eventually became a founding member institute of the Royal University of Bhutan in 2003; as of 2008, RIHS became part of the Royal University of Bhutan. However, RIHS became autonomous after the Royal University of Bhutan separated itself from the Civil Service, (http://www.rihs.edu.bt/content/about-rihs).
Dr. Chencho Dorjee is the director and the head of the Royal Institute of Health Sciences. Prior to becoming the director in 2002, Dr. Dorjee worked as a lecturer at RIHS, in addition to also working as District Medical Officer in Bhutan’s hospitals. Dr. Dorjee has several degrees, including a Master of Sciences in Health Development from Chulalongkorn University in Bangkok and a MBBS, an equivalent to a Doctorate of Medicine, with a specialty in Sexually Transmitted Diseases from Christian Medical College in India.
The director of our practicum program and also the Dean of Research and External Linkages is Dr. Neyzang Wangmo. Dr. Wangmo is very friendly and accommodating, always asking us about our experience in the classes we attend and often mentions being open to suggestions or changes; she does not want us to hesitate about asking to try different experiences of interest. Both Dr. Wangmo and Dr. Dorji have been very enthusiastic about our involvement at the school and appreciate our American perspectives.
Our work at RIHS thus far involves attending various classes, while adding our perspectives to the classroom environment. Eventually, we may be accompanying nursing students at the hospital to shadow their works on rounds. Primarily we observe and find ways to contribute to the class; moreover, we are learning through observation and participation. Because we have only been at RIHS for a total of three days, we have attended three classes. The first class was for first-year nursing students and the other two classes were with the same students, who have already finished nursing school, but have returned to earn a bachelor’s degree in Public Health. We are not however, limited to any particular branch of the school. In fact, to our understanding, we are encouraged to explore all the branches that RIHS has to offer.
One of the most rewarding aspects about our site is the fact that the students and faculty are so accommodating and interested in our perspectives and presence at the school. Not only are we served tea and samosas during our class break, but the professor directly asked students to speak in English so “Our foreign guests can understand the presentations.” Additionally, it is interesting to be in a class with people who have spent at least ten years in the health care field who choose to come back and refresh their skills while continuing with a higher degree; this really shows the dedication of the students as well as the investment of the staff to teach their students.
For future students who are thinking about attending RIHS, they should be flexible and open-minded. Classes in Bhutan function differently than in America, in addition to a sometimes major difference in their knowledge of medicine and the health care system. Many of the products and benefits we take for granted in America are not found in Bhutan, something that we have learned during our three days of classes. Another major yet obvious factor is that the students should have an interest in medicine or health; much of our experience has been sitting in the classroom and learning how medicine is practiced in Bhutan. Students should not only be focused on traditional medicine or a hospital experience, rather they should be interested in the methodologies of the Bhutanese practices of allopathic medicine. They should also be aware that Bhutan does not have the surplus of medical supplies or doctors that America has and because of this, we suggest students to be open-minded. There is also a lack of medical doctors in Bhutan and we have learned that in many hospitals throughout the country, there are technicians working and performing medical procedures that we would never trust anyone except a certified medical doctor to perform. Along with a lack of medical doctors, there is different medical technology. For example, during a presentation on diabetes we asked about the use of insulin pumps in Bhutan and, to our surprise, the teacher and students did not know about their existence.
The examples and information given in the previous paragraph also demonstrate some of the challenges with this practicum. Although attending RIHS classes is extremely interesting, the lack of medical information and technology can be found challenging, especially by Americans who are used to living in a world with almost endless medical supplies and thousands of medical doctors. Because we have grown up with elite medical care, having an open mind due to the less-developed health care system in Bhutan may prove to be frustrating for some students.
After the first four weeks of our practicum placement, we extended our placement location to the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), which is located next to the RIHS campus. The hospital was established in 1972 as a general hospital and was later expanded in 1994, when it was given the name Jigme Dorji Wangchuck national Referral Hospital in honor of the third King of Bhutan. JDWNRH is located in Thimphu and most of the patients are from the area, but the hospital does take referred patients from the other Dzongkhags in the country. The hospital also serves as the clinical training location for the nursing students at RIHS, (Introduction, http://www.jdwnrh.gov. bt/?page_id=14).
The vision of JDWNRH is “To develop into a state-of-art modern center of excellence for health care and medical education,” (Vision & Mission, http://www.jdwnrh.gov.bt/?page_id=17) and their mission is to
Provide holistic healthcare incorporating all four dimensions – promotive, curative, rehabilitative, and preventive services; excellent centre for supra-specialty care and; collaborative institute of medical education and training for medical students and health personnel, (Vision & Mission http://www.jdwnrh.gov.bt/?page_id=17).
The hospital also offers services in: “outpatient and inpatient treatment, emergency care, preventive and promotive care, rehabilitation, and special clinics,” (Services, http://www.jdwnrh.gov. bt/?page_id=20).
During our time at JDWNRH, we have visited all of the wards and service wings in the hospital. There are ten clinical departments including Medical, Surgical, Dentistry, Gynaecology/Obstetrics, Anaesthesia, Paediatrics, Orthopaedic, Ophthalmology, Psychiatry, and Emergency; of these departments, we visited the Medical, Surgical, Maternity, Paediatric, Orthopaedic, and Emergency wards. Additionally, the hospital also has a Physiotherapy wing, Intensive Care Unit (ICU), Paediatric Intensive Care Unit (PICU), and Neonatal Intensive Care Unit (NICU). There is also a pathology lab and a haematology lab, as well as a Dialysis Unit, X-Ray, Magnetic Resonance Imaging (MRI), and Computed Tomography (CT) services.
Each ward is arranged in a similar fashion, whereby there is a front desk and Nurses’ Station at the front of the wards and then a long hallway with six large rooms, three on each side. The rooms are all connected by a single doorway each contains eight beds; there is a single toilet in the last room, at the end of the ward for patients use. At the Nurses’ Station, there is a front desk with all of the patients’ charts and a medicine room where the nurses gather the various medications and fill syringes for the patients. The medicine room was a shock for us at first because none of the medications are locked up and they are all arranged in an open wooden box.
At JDWNRH, our duty is to observe any and all of the clinical work and procedures performed by the RIHS nursing students. The way in which nurses work in Bhutan is very task-oriented, as opposed to the American emphasis on patient assignment and taking care of all of that particular patient’s needs. Each day we were at the hospital, we shadowed and observed different nurses and nursing students. These two factors proved to be a bit of challenge because we never really got a patient history for any of the patients on the various wards we visited due to the task-oriented work; a nurse is assigned one task and performs that task on whichever patients are in need, such as IV changing. For this reason, the nurses don’t know the patients’ histories unless they look up their chart. Shadowing different nurses everyday was challenging because the two new nurses we met didn’t fully understand why we were at the hospital and we would have to explain this on a daily basis.
Observing at JDWNRH has been very rewarding, regardless of any challenges. We are both interested in medicine and we couldn’t have been exposed to the medical system in Bhutan in a better way than visiting the hospital. We have seen different procedures, child birth, and the ways in which nurses and doctors work in Bhutan, creating an eye-opening experience. The hospital is modern and has the equipment with which to help patients, however some procedures are somewhat out-of-date from an American perspective; for example, the surgeons in Bhutan do not do laparoscopic surgeries nor do they have the technologies to be able to so. The nurses and other medical personnel were glad to have us in the wards and to provide a perspective of how medicine is practiced in the United States in relation to the ways in which medicine is practiced in Bhutan.
In conclusion, RIHS is a very accommodating location with a wonderful faculty and staff. We have never felt unwelcome on the campus or in the classroom and the students and faculty enjoy having guests in their classrooms. We are greatly encouraged to ask lots of questions and contribute in any way that we can to offer advice and suggest changes in various areas.
– Nick Emard and Ariel Eaton