The Pharmaceutical Journal
Vol 269 No 7229 p937-938
21/28 December 2002

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Innocents abroad in Indonesia

A pharmacy scheme between Nottingham and Surabaya universities sponsored by the British Council is now in its fourth of six years and has been outlined previously in The Journal (PJ, 27 May 2000, pp817–9). It was set up by Dr Mo Aslam and Dr Chik Kaw Tan in response to a need to advance Indonesian hospital and clinical pharmacy. Apart from visits to the United Kingdom by Indonesian pharmacists, the main feature of this scheme has been an intensive clinical pharmacy course taught in Surabaya for one week each year. A number of British pharmacists have taught on the course which has now developed into three modules. Topics include medicines information techniques, prescription monitoring and pharmaceutical care planning, interactions, adverse reactions, drug use in liver and renal disease, paediatrics, pregnancy and breast-feeding, hypertension, antibiotics, nutrition, parenteral therapy and formulary development. The course is taught in English to pharmacists from hospitals, community pharmacies and academia. It was originally hoped that students would take each module in turn but, in practice, participants attend whichever modules they choose; the course is often paid for by employers who wish to share the opportunities among several employees rather than send one person on three successive courses.

This year, four of us returned to Surabaya, and here we reflect on our experiences of teaching in a new environment, to an audience whose background is different from ours, in a language that is not their mother tongue. Although, between us, we have various teaching qualifications, as well as years of teaching experience, we found it a challenge; the surprises were many and varied. There must be many other pharmacists who have taught abroad, perhaps with Voluntary Services Overseas or similar schemes, who could contribute their experience and we offer these reflections in the hope that more experienced teachers will share what they have learn.

Learning and teaching

Current educational theory emphasises "adult learning" with its stresses on student-led learning and on "facilitation of learning" rather than "teaching". It assumes that students know what they want to achieve and it requires a considerable investment in time before there are clear benefits. We guessed before we went that Indonesians would be less comfortable with this style of teaching than British pharmacists, and we knew that we had not got unlimited time; the syllabus chosen for us was uncomfortably wide, even in a UK context. However, it was not until we started teaching that we were able to answer some of our other uncertainties about the background, attitudes and preferences of our Indonesian colleagues. We confirmed quite quickly that they expected us to impart information and advice, not just on the topics we had planned but also on anything else that came to their minds — a self-directed, experiential and reflective learning experience was not exactly on their agenda. They had a great enthusiasm for learning and were prepared to devote their time and energies to the purpose; to attend this course was a privilege not a chore. They were good at asking questions, but clinical problem-solving was an unfamiliar activity for many. Nonetheless, many participants wanted more discussions and case studies because these were areas they wanted to move into in their relationships with doctors and patients. Some veterans of earlier modules commented that the systematic approach to case problem analysis taught on the course had been useful in their practice.

Attitudes to doctors' prescribing seem passive in the light of current UK practice, but reminded some of us, rather uncomfortably, of the days of our youth — how far we have moved on in the last quarter of a century. Not only did attitudes resemble those we used to have, but their knowledge of treatment protocols for common diseases was also rather sketchy. This may not be so surprising when one discovers that a single pharmacist may be providing a 24-hour, 7-days a week service to a whole hospital in the private sector, where his or her responsibilities are for purchasing, distribution and staff management rather than therapeutics or patient services. In private hospitals there tended to be better support for clinical pharmacy from senior directors and nurses than from the visiting doctors who were suspicious or dismissive of a pharmacist's role. Many hospitals did not have a recognised prescription chart or formulary.

More surprises

Since none of us had been to Indonesia before teaching on these courses, we did not know what to expect of the practice of pharmacy and how it would differ from current UK practice. Our reactions to the differences ranged from interest to something like a mixture of astonishment and shock. One of us had travelled in other developing countries and had experienced pharmacy in a range of circumstances and so production, distribution and prescribing practices akin to our own in the early 1970s were no big deal, but others found it demanding to adjust to practices which challenged current UK values.

Language ability varied; generally the Indonesians spoke several languages and we did not. As we had anticipated, the participants could read English quite well, it was just us they could not understand. We had all put a lot more into handouts than we would have done for a British audience, and that turned out to be a good move, but we found we needed to be even more careful to make what was on our visual aids match exactly what we said. We found that having one person teach while another wrote difficult phrases or technical terms on a white board helped the class. Similarly, answers to questions were best written on the board, at least in summary. Some of us also prepared handouts summarising questions and answers that had arisen in the sessions and those went down well.

We had not fully anticipated how differences in our respective practices would affect teaching. Substituting hydrochlorothiazide 25mg for bendroflumethiazide 2.5mg and EKG for ECG was easy, but teaching on interactions without mentioning warfarin or lithium was more tricky, and choosing antibiotics in an environment where the economic crisis has made sensitivity-testing a rarity was positively challenging. The different range of common diseases, combined with a general weakness in pharmacists' knowledge of signs and symptoms, made designing case problems different from our UK experience.

Another feature of the Indonesians' enthusiasm to learn was their opportunistic tendency to arrange extra seminars at the last minute. After all, you have travelled a long way and have PowerPoint discs so you must be an expert! That was generally fine, but we did find that a title could be interpreted in many ways. In future, we would ask for learning objectives, to make sure we had got the same idea as the audience. (We had not appreciated, for example, that "counselling on antibiotic therapy" might mean "counter-prescribing antibiotics".)

It was also useful to put some effort into ascertaining who might be in the audience. We were not used to senior medical staff and hospital directors turning up to seminars for pharmacists in the UK but this was common in Indonesia. Likewise, we got used to proceedings starting with introductory speeches in Indonesian and to exchanging gifts at the end (NB: take several BNFs, they always go down well). We also learn that participants having a short chat with each other in the middle of a session was not a sign of boredom, incomprehension or rudeness but a feature of a society that places a high value on relationships and social interaction.

We expected that we might accidentally break some social mores and cause offence, but in fact we found our hosts tolerated all our mistakes most graciously. We did try hard not to use our left hands for issuing handouts or passing food, and we generally avoided pointing or beckoning with a crooked finger, but it was harder to remember to ask one of our helpful "gophers" to get us a drink of water when the instinct was to get our own as we would at home.

It doesn't end on the aeroplane

Our Indonesian colleagues have high aspirations and it has been a privilege to try to help them. We hope we have done so out of a spirit of mutual development because we can still remember when UK pharmacy needed help from overseas colleagues and, after all, even now we are hardly perfect. We did not want them to think that UK pharmacy was some high state that they could not imagine reaching. Rather, we hope Indonesian pharmacy will progress faster than we did as a result of learning from our collective mistakes.

Going abroad to teach does not end when you get on the aeroplane to come home. There are friendships to continue and e-mail questions to answer. The collaboration is continuing with a book written by both British and Indonesian pharmacists to be published in Indonesian, and one of us has investigated setting up a discussion group to look at some case studies. Indonesian colleagues will come to the UK from time to time and perhaps some UK pharmacists can provide one-to-one intensive tuition in Indonesian hospitals. We brought back lots of memories, plenty of photographs, and gained experience as a result of this exchange. We trust others who get involved in this or other schemes will find it as fruitful and enjoyable.