6/24/2011- Respiratory and Thoracic Medicine - Jessica

Today is the last day of our shift in the respiratory and thoracic medicine department. We are with Dr. Chien again in his outpatient clinic. As before, Dr. Chien discussed each case with us after each consultation and Sandy and I were able to not only learn more new medical facts and clinical practices as well as review the things we have learned before from both Dr. Chien and back in Touro. In addition to clinical facts, we also talked about the general differences between the medical environment in US and Taiwan, from the national insurance Vs. private insurance, the different working environments, and even to the different social status doctors have in the two nations. Among all of the things we discussed, the most memorable part is the different social status the doctors here have as opposed to Taiwan. Although in Taiwan, doctors are still considered one of the most respected occupations, the image is rapidly changing now. As the national insurance policy started to take effect, the extremely affordable health care that sometimes disproportionally favored the patients than the health workers made the services from doctors seemed insignificant and relatively lower in value. The negative reports from the news about some bad practices from corrupted or incompetent doctors did not help either. As a result, the image for doctors start to deteriorate lately. For example, just in the three weeks I have observed so far, I have seen at least one patient treated doctors disrespectfully in each week of rotation. The first week in TCM, I have seen a patient have a fifteen minute argument with the doctor for prescriptions that did not fit her condition and symptoms. During the pediatric week, I saw a patient yelling at the doctor since the day before in the ER department and again the next day in the outpatient clinic. I can't say these situations never happened in the US, but it will be very rare. Combined with the already low salary of  the doctors in Taiwan compare to other countries and the fact that health care budget is limited and many hospitals are forced to absorb the difference by themselves when the government subsidies fell short, many incoming students are having second thoughts on entering the profession now. Although the Taiwan national health system is famous for its affordable coverage to all citizens and its extreme convenience for the patients (see my previous blog about my "trip" to the dermatologist), it is arguably based on the expanse of health workers and hospitals. I hope in the future the Taiwanese government can revise to a more balanced system that benefit both the patients and the health workers, since I really think the national health system in Taiwan is really successful in improving general public health and making it affordable and available to all citizens and I hope that it will still be around for the generations to come.

6/23/2011- Respiratory and Thoracic Medicine - Jessica

Due to Dr. Yu's ER schedule today, Sandy and I shadowed Dr. Tseng (曾常新醫師) instead doing patient rounds. The first case this morning was already out of the ordinary for us. We ran into Dr. Tseng just as we were going to knock on the door of the internal medicine morning meeting room. Right from the beginning, we can tell from Dr. Tseng's expression that he was somewhat stressed and preoccupied by something. After explaining that we will be following him today, he explained the situation to us: he had just receive the news of the death of a patient due to sepsis in the ICU ward and was hurrying to the ICU to meet with the family and deliver the news. When I first heard him say "a patient expired this morning", my brain went blank for a second before the thought finally sank in and I finally understood that a human live has just slipped away unbeknown to me all through this morning when I was so busy struggling through the morning commute crowd to get to the hospital from home, my thoughts spent on mundane things that have absolutely no importance in comparison to someone's life. When we arrived at the ICU, the patient laid there motionless, her face and skin an indescribable shade of pale. As Dr. Tseng went over the patient chart with us, I couldn't help but notice how the son gently stroked his mother's forehead with teary eyes and his face filled with sorrow and yet still managed to show such love and tenderness. My eyes teared up at the moment, in fact, just typing about it now is making me emotional still. Even though I knew death is something that all of us will experience one time or another during one's life time, especially for us working as health workers, it was still hard to see it. No matter how much preparation we had in doctoring courses about loss and grief, I think death is something that we can never train ourselves to be truly unaffected by it. I may not even know the patient at all, the only connection between the patient and I based on the couple pages of notes and test results on the chart, her death still saddened me and affected me on a human level. Although the fact that her face was peaceful and her son was by her side to send her off her final journey comforted me and I can only assume that it was a painless transition and suffering was limited to the bare minimum on both the patient's and family's sides.

After talking to the family and documenting the time of death and other necessary paperwork, we continued our morning round with Dr. Tseng. In one of the wards, we joined with a cardiology doctor to visit two patients hospitalized for heart conditions. One of the patient's case was very interesting because a 24 hour EKG report was done on the patient and revealed a >4sec prolonged period between heart beats. Although the arrhythmia can be a side effect from the current infection, but a pacemaker may need to be installed if the arrhythmia persists.

After a quick lunch, Sandy and I returned once again to Dr. Lin's outpatient clinic, looking forward for the surgery video he promised for today. However, when we arrived Dr. Lin was no where to be seem. The nurse told us that due to personal matter, Dr. Lin will be slightly late for today's clinic. Not thinking much of it, Sandy and I just sat and chatted for about 10 minutes in the room. But when Dr. Lin arrived, he seemed flustered and distressed. Dr. Lin informed us that due to a family emergency, he is suspending his afternoon clinic for any further appointments and will see the patients who already had the appointment made as soon as possible and leave immediately after. He apologetically asked us to leave early this afternoon and said that he will show us the videos later next week on a more convenient time. Not wishing to add to his distress and seeing him pressed for time, we replied quickly that it was of course fine and wished the best for him and his family before we left. Although we were able to get a much needed rest this afternoon, Sandy and I were still quite worried for Dr. Lin and sincerely hoped that everything will work out for Dr. Lin and his family.

6/22/2011- Respiratory and Thoracic Medicine - Jessica

Today was a exciting day for Sandy and I. We had a "field trip day" today! Instead of going to outpatient clinic today in Taipei hospital, we were going to meet with Dr. Chien in a special outside clinic for in 名權西路 called "中華民國防癆協會" (Taiwan Anti-Tuberculosis Association). The clinic used to be only for TB cases only, but with the national insurance change couple years ago, now it is a general clinic; although it still has more TB cases due to its renowned expertise in treating the disease. Since we need to be there at 8:45 am today, Sandy and I woke up early and had our first encounter with the Taipei rush hour crowd this morning. Although I knew the MRT is often very busy during the rush hour and that "personal space" is a strictly American thing and often does not apply to Asians, we were attacked by surprise when all of the crowd rushed into the MRT car and squeezed us against each after we got into the car. It was so crowded that we didn't even need to hang on the handrails for balance; we were squeezed so tight against each other that it was impossible for us to move, let alone falling down. Even though we were a little intimidated by the morning commute crowd it was still a good experience, it gave us a new facet to the Taiwanese culture that we have not had the chance to see before.

We met with Dr. Chien at the clinic and begun our day with observing Dr. Chien in the outpatient clinic. Many of the patient were here for previous TB infection follow up and asthma, only 1 or 2 patients were here for general illness like upper respiratory tract infections. Dr. Chien graciously introduced us to the staffs of the clinic and asked the head nurse if she had the time to give us a brief tour and history of the place after the clinic. Dr. Chien then proceed with the clinic and taught Sandy and I more about TB (we saw a real-life case of MAC today!), asthma management, and also more practice on interpreting patients' spirometry (we also had the chance to try it ourselves too) results. After the clinic, the head nurse kindly took us around the facility and gave us a brief introduction of the place and its history. One interesting thing we learned was the selling of stamps in the past to gather funds for TB patients who could not afford the long and expensive treatment course of TB before national health insurance became available to all citizens in 1995. It was especially interesting to me because I also recalled my aunts recounting the tale of patriotic stamp buying during there school days and was able to make the connection too. We also learned about the patient distribution and patient number change in different seasons. For example, as the weather have became quite sunny and drier in Taiwan, the number of patients significantly decreased in this clinic, as most of the patient population (ex-TB, asthma, upper respiratory infection) has less symptoms or fewer chance of infection at this time. However, during the winter months, the clinic will be filled with patients. The head nurse told us as many as 200 patients will be seem in one morning during the peak time!

6/21/2011- Respiratory and Thoracic Medicine - Jessica

Today is the 2nd day of the respiratory rotation. We will be following Dr. Yu (游承翰醫師) today in the morning and Dr. Lin (林振嵩醫師) in the afternoon. Dr. Yu's morning shift was in the ICU, although we were here yesterday with Dr. Chien, we still find the ICU quite eye-opening for us. Dr. Yu is a very friendly person, easy going and made us felt very welcomed. He went over two patients' charts with us and went through the process of developing the diagnosis and treatment for each patient. It was very helpful to hear the thought processes behind the diagnosis and treatment course, since it really drives home a lot of the medical background we learned during class as well as the differential skills we developed. We then followed Dr. Yu around in other wards for each of his patients. Again, he explained the condition of each of the patient to us and was very helpful again in reinforcing the things we have learned in school as well as teaching us new clinical information that we have not covered yet. Dr. Yu was able to taught us many things in one morning. For example, we learned about the various aspects of the endotracheal tube, including its adverse effects, limitations, and the different ways the patients family arrived in the decision of whether to replace with tracheotomy, to leave it in, or to remove it. We also learned about the various multi-drug resistant pathogens that is common in Taiwan. We were shaken when we heard about the extended-drug resistant pathogens that does not response to almost all of the antibiotic we know and were even more surprised to see 2 patients in the ward to already have the infection. Dr. Yu's teaching style worked very well for me for some reason, probably because he present each case like a puzzle that require us to take in all the information and arrive on the right diagnosis and treatment that makes me retain the information better. Thus, I was quite sad to hear that we won't be able to have our Thursday morning shift with him again as scheduled because of his ER shift that morning.

In the afternoon, we joined Dr. Lin (on a side note, I found it interesting, although somewhat inconvenient when it comes to blogging, that there are so many Dr. Lin's and Dr. Chen's that sometimes I confuse even myself while typing :P ) at his outpatient clinic. Coincidentally, I have actually met Dr. Lin last Saturday during the community clinic and shadowed him during that time in the physical examination station. From our conversation that day, I have already learned that he is one of the few MD/PhDs in the hospital, with current research in mitochondria genetic. It was a change of pace for me because Dr. Lin is the first surgeon I have encountered during this internship. However, I was surprised to find that most of the patients in the clinic today were here for certification of their previous injury/hospitalization for insurance/school/work purposes. Only few of these patients were here for thoracic problems, mostly for uncomplicated fractured ribs that can be healed spontaneously and only required supportive care (NSAID, painkiller...etc). One interesting thing we heard today was that a 6 week monitor period should be used when dealing with rib fractures, since sometimes fractures undetectable through x-ray before may show up later as the pain subsided and the patient starts to move around and caused the fractures to be visible now.

One other highlight of the day was our first-hand experience with the Taiwanese medical system as the patient. Since I started to have skin allergy on my face and arm a day after the community clinic (probably the dust...etc in the basement of the activity center), I decided to go see a dermatologist today before the itchiness eclipses all of my sanity. Even though we have been hearing a lot about the Taiwanese health system being very convenient for the patients, it was still very surprising for us when we finished the whole registration (walk-in), waiting, consultation, paying, and finally getting all of the drugs in less than 30 minutes. The grand total turned out to be about NT$320, including the appointment fee, doctor fee, drug fee, and a week's worth of 4 types of drug (2  different strengths of corticosteroid cream, oral anti-histamine, and topical anti-histamine lotion).

6/20/2011- Respiratory and Thoracic Medicine - Jessica

After pediatrics, we now move on with the third week of our internship. The first day in the respiratory and thoracic medicine was spend with Dr. Chien (簡林禎醫師). We begun in the morning meeting room and Dr. Chien went over a list of his patients, going over the important clinical histories for each patient and brought us to the wards (including ICU!). Since Taipei hospital is a regional hospital, they often receive many acute patients. And since dyspnea is often one of the most common symptoms, Dr. Chien has patients of many different etiologies, from cardiogenic, infection, to trauma. During the morning session with Dr. Chien, we learned many interesting features of respiratory and thoracic medicine, including common drugs used, standard asthma treatments, typical and nosocomial pneumonia...etc. The most interesting aspect of the morning was going over each case and the path Dr. Chien took to arrive at the diagnosis from the symptoms and eventually to the treatments. Each case is like a puzzle, except that this time it is no longer child's play, each puzzle has human lives at stake and a mistake is often not an option.

In the afternoon, we observed Dr. Chien in his outpatient clinic where we saw many latent TB and minor pneumonia patients here for treatments. Again, Dr. Chien taught us many things during his outpatient clinic. After each patient, Dr. Chien would turn around and explained to Sandy and I the previous encounter with the patient. It was a great learning experience because we are able to connect what we have learned in the textbook to real patients and see how the disease/treatment course affect each patient's live.

Unfortunately, due to the case study presentation, we need to leave early in order to be on time for the meeting. When we informed Dr. Chien about the meeting this afternoon, he remarked that it seems strange that we would have a meeting like that at that time, since they (the directors of each department) are meeting with Superintendent Lin at the exact same time! In that case will we be presenting in front of all of the directors of the departments? Although we were a little unnerved by that realization, fearing that we will be late for the meeting, we hurried along to Yuyu's office as instructed last week. As we were descending down the stairs to Yuyu's office, Sandy and I tried to sooth each other's nerves and cautiously reminded each other to be on our best behaviors if we are indeed presenting in front of such important audience! However, we met with the rest of the GHP group in the stairwell and was informed, to my relieve, that the meeting had been postponed due to schedule conflict. I felt both relieved and yet disappointed by the news. I am relieved because I felt like I will have more time to prepare myself for the presentation to make it better but I also feel disappointed because I think it will be a great experience for us to present in front a group of physicians on top of their field; it will be a great educational experience for our future when we are doing it for real during rotations.