Ms. M is a 45-year-old female with HIV who presented to Siriraj Hospital with altered mental status and fever. As we watched her writhing in bed in four-point restraints, it was clear to the hematology consults team that she was not herself. By this time, she carried a presumptive diagnosis of thrombotic thrombocytopenic purpura based on her clinical picture, thrombocytopenia, and schistocytes on her blood smear. It should have been simple enough to start treating her with daily plasmapheresis. However, we had not bargained for the disruption created by the 6-day long national holiday that was Songkran - Thai New Year - that was beginning the following day. Plasmapheresis is not available over the weekends or on national holidays at Siriraj Hospital. Our recommendation to the team was to support Ms. M. with daily plasma infusions until such a time as plasmapheresis became available. It was clearly suboptimal therapy and we knew her risk of mortality was significantly increased. Nevertheless, such was this woman's luck: her chance at cure held hostage by a national holiday.

It would be easy to paint a dismal landscape from the above situation and label Siriraj Hospital as the bad guy; however, it represents the blessing and the curse of providing health care for a majority of the population in a setting of limited resources. The fact is that resources are always limited - some countries seem to feel the squeeze more painfully than others. But, it is the way we choose to allocate those resources that clearly sets one health system apart from the other. Siriraj has every advance of modern medicine you can imagine: state of the art imaging centers, MRI, multi-slice CT-scanners, you name it! Siriraj is a well-recognized name in Thai medicine. The >2000-bed hospital provides care to millions of Thais a year, rich and poor alike. However, where CT imaging is available on an as needed basis over the holiday weekend, plasmapheresis is not. It happens to be an artificial dividing line of what Siriraj Hospital has determined it can and cannot pay for. For us in the United States, we may not have as much of an apparent challenge with needing to allocate scarce resources; however, with the millions of our population lacking access to care, we are not very different from the folks at Siriraj Hospital. We have simply made a different choice.

The scenario painted above and many similar ones have been eye-opening and life changing. Many times, I have been forced to become introspective, asking myself whether, given the same resources and unique patient populations, I would make different choices. I find myself appreciating many things in Western medicine that I have taken for granted and thinking critically about similar challenges we share but are yet to solve. When I walked off the plane and into Thailand, I knew I would be a different physician heading back to the States. But I was not really prepared for how much my perspectives would change. Given another opportunity, I would do it again.

Toyosi Fatunase is an Internal Medicine Resident at Duke. She rotated at Siriraj Hospital in Bangkok for 2 months.