Pediatrics!

Mickey and I began our Pediatrics rotation following Dr. Wu, Chief of Pediatrics, around
the wards. There was a 10-year-old patient suspected of Scarlet Fever caused by GABHS.
Although culture result was not available yet, he had a strawberry tongue (it looked exactly like
a strawberry!). Instead of sandpaper-like rash, he had a smooth rash on his neck. We asked Dr.
Wu about the possibility of him having Kawasaki vasculitis, since the patient would also have a
strawberry tongue. Dr. Wu said that the vasculitis usually affects kids around one-year-old, while
children around ten-year-old are more likely to have Scarlet Fever. Dr. Wu then presented an
Airway presentation, explaining the use of SABA, LABA, ICS etc. He also told us that Taiwan
has the lowest birth rate in the world, so less and less medical students choose to go into Pediatrics
now.

In the afternoon, we had a TIHTC event where some of us gave a case presentation about colon
cancer while others shared their experience in the program. The staff also gave us a mini-award
ceremony, including a birthday cake for 4 people (Amanda and Nicole!). They showed us so much
hospitality, I feel extremely fortunate to be part of this amazing program.

The next day, we followed Dr. Wu (a pediatrics cardiologist) and saw a patient with a suspected
case of Marfan’s syndrome. The teenage boy was tall and lanky, and was diagnosed with
pneumothorax. Dr. Wu asked him to perform a couple of maneuvers, including wrapping his wrist
with his other hand and bringing out his arms. He had one Marfan’s syndrome’s clinical symptom,
but did not fit the criteria for diagnosis. We met with Dr. Wang in the afternoon and saw her
giving allergy tests to some children for dust mite, which all came out to be positive. We also
discussed about her research on examining children (especially boys) due to the recent clouding
agent outbreak. We were surprised that we did not see any patient coming in for that this week,
Dr. Wang said that many came during May and early June, it has since slowed down.

We also had the opportunity to follow Dr. Kao, a general pediatrician. He saw a patient with
horseshoe kidney, which is a rare disease where kidneys fused together. This condition increases
the risk for kidney infections, kidney stones, and kidney cancer. Since many patients came in for
stomach ache, we saw many abdominal ultrasounds. There have been cases where teenagers came
in complaining of stomach ache, and the ultrasound showed a baby inside. He said that parents’
reactions have ranged from immediate outrage to disappointment. That must be a difficult position
to be in as a physician.

The pediatricians mainly saw patients with viral infections. Dr. Wu told us that in this case, he
could only prescribe palliative treatment, and often times, he needs to explain to the parents why
he is not prescribing antibiotics. I learned that Pediatrics requires a three-way communication
system between the physician, the patient, and the patient’s parents. The physician not only has to
comfort the patient, he/she needs to comfort the parents just as much, if not more. Dr. Wu and the
other pediatricians were also very clever. Instead of asking the kids to exhale/inhale, he took out
a yellow windmill and asked the kids to blow as hard as they could. The kids were delighted and
thought it was a game. It reminded me of Mary Poppin’s song “Just a Spoon Full of Sugar helps
the medicine go down,” the way he was able to turn a mindless task to be fun and exciting.

I asked Dr. Wu why he chose to become a pediatrician and he told us that after he finished his
rotations, he realized that being around kids made him happy. I thought about all the criteria that
we, as students, try to evaluate before deciding on a future path- salary, schedule, workload –
often overlooking the fact that in the end, we all just want to feel happy and fulfilled in life. Dr.
Wu also told us that the most important trait of being a pediatrician is to be patient, as kids may
not do what they are told. Once, I saw Dr. Wu placing a stethoscope on a child who began to
scream. I couldn’t imagine the sound amplified through the stethoscope, yet Dr. Wu patiently
maintained his composure. Although I saw some screaming kids, I was also surprised by well
behaved majority of the kids were, considering that kids usually do not hide their feelings.

One of my favorite parts of the Pediatrics clinic was seeing babies getting their shots. A one-
year-old came with his grandpa and mom, and grandpa happily said, “Today is his one-year-
old birthday and he is due for 2 shots!” The baby was bouncing, giggling, chuckling and had the

most infectious laughter. He earnestly played peek-a-boo with us, not knowing what was about to
happen. Then it was time. The nurse told the mom to strap him on her thigh as she brought in the
syringe. He sensed exactly what was going on, and his face immediately turned from smiling to
frowning to crying continuously. After he received his shots (his birthday present), we cheerfully
wished the tearful baby goodbye. Although I felt sympathy for him, I couldn’t help but be amused
by the situation and be envious of how many precious moments like these a pediatrician gets to
experience.

Pediatrics Day 3 & 4 Outpatient Clinic and Shenkeng District Public Health Center 29-June-2011 to 1-July 2011

Sorry all, for the delayed update everything these last three days has been like a whirlwind. Now that I am in Hong Kong time to reflect back on the final days I spent in Taiwan.

29-June-2011
Another day in the outpatient clinic today with Dr. Wu, Wen-Chiu in the morning and Dr. Wang, Yi-Jen (Dr. 王怡人) in the afternoon. I am starting to like the relaxing pace of the outpatient clinic. Dr. Wu is a dedicated teacher and always goes over each patient with us. The most valuable experiences were when Dr. Wu would let us listen in on lung sounds on the peds patients; I would have never imagined that the wheezing in the doctoring labs recordings. In the afternoon with Dr. Wang, Sandy and I had more time to talk about the current affairs in pediatrics in Taiwan including the declining birthrate, clouding agent problems and more. In particular Dr. Wang’s research on the clouding agent problem seems to be in full swing, she collected about 50 urine samples last week and has a total about 6000 or so samples and is ready to be analyzed. With previous urine analysis samples as controls I am sure something interesting will come out from her efforts. On our side Karen and Bor-Han will be helping her on Friday to tabulate the latest samples and I am looking forward to seeing the results when they are available.

30-June-2011
We all had a wonderful time, in Yeliu for the beginning of the day. Got to see some natural land and rock formations that seem to be ever changing due to different effects of corrosion. After which we all went to the Shenkeng District Public Health Center for a tour and information session. It is comforting to see that Taiwan seems to have a good amount of money put into public health, judging be the size the number of people that they have on staff, in many offices in the United States it seems there are too many budget cuts in this area. The center has integrated health screenings for different age groups during different set times, a mobile unit and many other services such as tobacco cessation. As expected there is an extensive screening program for TB there is an increased incidence of cases in Taiwan. Overall I felt the presentation the center gave was a good review of all the basics I learned from the MPH program at Touro and it was great to learn about some of the issues that Taiwan has in the public health arena.

1-July-2011
Today was the final day in Taiwan. I can’t believe how fast time has flown by. In the morning after the meeting we ended up following Dr. Wu around the ward, it was good to see that the scarlet fever patient that we saw at the beginning of the week was much improved due to his treatment with Penicillin G. After a quick run the rest of the morning we spent in the outpatient clinic with Dr. Kuo, I-Ting (Dr. 郭怡廷). Dr. Kuo always seemed to spent extra time to talk about every case and gave us lengthy detailed answers to every question that we asked. One of the most fascinating discussions with Dr. Kuo was about a condition known as horseshoe kidney, a congenital disorder that, where the patient has their two kidneys fused resulting in one super kidney. Being a rather rare condition I feel that we were very lucky to be able to see a patient with this condition that was here for a return check-up. In the afternoon we finished our rotation with Dr. Wu. The most interesting highlights included more breath sounds including more wheezing and ronchi both of which are very much like the recordings from lab and a visit to the wards to see a premature baby (30 weeks). Overall I am very happy with the experience I have had in Taiwan and hope that one day I will get to return for some more exchange. It was a pleasure and I will cherish everything I learned.

Pediatrics Day 2 Outpatient Clinic 28-June-2011

I was not sure what to expect as this was the first full day at the outpatient clinic. In the morning we followed Dr. Wu, Yu-Nien (Dr. 吳俞哖), who is a pediatric cardiologist. The whole experience was very different from all the other outpatient clinics that I have been at in Taipei Hospital, the most contrasting difference was that the pace was much slower. It almost seemed to run at the pace most clinics do in the United States. A lot of the time was spent conversing with the parents of the peds patient, building a relationship, reassuring them that everything is going to be okay and patient education. Another interesting difference is the speed that lab results are done, often Dr. Wu would order CBCs, WBCs, X-rays, EKGs and have the patient return in about 20-30 minutes to discuss about the results. Dr. Wu being the only pediatric cardiologist on staff (actually she just retired and works once a week part-time now) get all of the suspected cardiac cases in addition to all the regular general clinic patients. Dr. Wu commented that she gets a lot of the chest pain cases, 60% of which are osteochondritis cases opposed to something more serous involving the heart or lungs. Other than a few cases of sinus arrhythmia Dr. Wu did not have any out of the regular cases. On the other hand Dr. Tsai, Ya-Hui (Dr. 蔡雅慧) next door walked over at one point to tell us about an interesting case of suspected Marfan’s syndrome and also get Dr. Wu’s opinion on the case. It turns out that the patient did not have enough of the criteria for Marfan’s he only had the wrist sign (the thumb and index finger overlap excessively pass the distal phalanx when the wrist is gripped with the opposite hand). His X-rays did show that he had a pneumothorax which was interesting in that Dr. Wu had just mentioned that for patients that are tall and thin we should look out for spontaneous pneumothorax if the patient complains of chest pain. Any case I seem to be having trouble sleeping tonight so I thought I catch up with some of the blog.

Pediatrics Day 1 27-June-2011

8:10 am started the day on the 5^th Floor meeting room situated behind the nursing station at the pediatrics meeting. Over the course about 30 minutes many cases were discussed, the major concerns seemed varied from otitis media, unknown skin rashes to asthma and infant jaundice. The most interesting discussion at the meeting was about a patient with a strawberry tongue, as it sparked a talk about Kawasaki disease and scarlet fever. After the meeting Sandy and I followed Dr. Wu, Wen-Chiu (Dr. 吳文秋), he showed us around the ward including the neonate-infant room and the empty new born room. Dr. Wu commented on the low birth rate in Taiwan (the lowest in the world currently) explained that there had only been two deliveries in the hospital for the entire month which occurred last week. As we continued through the ward I was able to see a real strawberry tongue, I don’t think I will ever forget what a text book strawberry tongue after that experience. At 9:30 Dr. Wu gave Sandy and I a lecture on common Airway problems in pediatrics. There was some review in the lecture including common pathogens that will be encountered, how different seasons and school affects transmissions of infectious diseases. Also the mechanism, treatment, screening and testing for asthma. Dr. Wu had a series of different inhalers and peak flow meters that are used for patient education which he ran us through. The time seemed to fly by in pediatrics for some reason or another as it the end of the day before I noticed.

6/16/2011, 6/17/2011 - Pediatric - Jessica

The last two days at pediatric was fantastic for me! I originally thought that the last two days will be relatively less interesting than the other days because it will be mostly outpatient clinics and thus less time for hand-on patient interaction or preceptor time, I was totally surprised to find myself enjoying every single moment of it! Although I have to admit that sitting in the stools all day long does have its toll on my anatomy, it was well worth it!. Many reasons made the last two day so much fun for me. First, as mentioned before, all of the pediatric department, the doctors, PA, and nurses are all very kind to us and very easy going and fun. Second, the children are just adorable! Although it was heartbreaking to see the actually seriously ill children, it was amazing to see how much endurance and courage the children exhibit against sickness and it was most heartwarming to see how each children recovered so fast after the illness and carry on as if the past few days of pain and suffer never touched them. I especially remember one of the baby girl coming in for vaccination. She smiled like an angel the whole time, even during the needle prick! I think it was this particular trait of children that make pediatric one of the best fields to work on and the pediatricians one of the best people to hang around with. Through working with Dr. Tsai and Dr. Wu, I can really see what it means to be a good physician. I can truly feel their dedication and love toward each and every single one of their patients... even during the trying moments where the patients' family members tried to vend their fear and anxiety toward the child's sickness on the physicians and making the situation more difficult than it has to be. Just like what Karen and I said to Dr. Wu during our last day: I think we are converted life-long pediatric fans from now on!

Pediatrics- end of the week

This week in pediatrics we have seen and learned so many things. We spent 3.5 days in outpatient clinic and saw some of the patients in the hospital. Sitting through outpatient clinic showed us the types of cases that a pediatrician sees on a normal basis. A lot of the cases have to do with upper respiratory infections, asthma, or abdominal pain. Fevers appear quite often, some more severe than others and some more persistent than others. Some fevers last for days and days that are admitted to the ward for observation. Other times the fevers are good and need to be there to help the body heal. This is hard to explain to parents; parents want their kids to be healthy and worry when there is any sign of illness. We saw a few parents who were frustrated with persistent fevers and/or coughs (usually from asthma) that are being treated, but apparently not fast enough. I can understand where the parents are coming from; they will do anything to make sure that the kid is healthy and when treatments don't seem to work it can be frustrating. If I have learned anything from this week, it is that pediatricians have many roles, but first and foremost they act as a health advocate and educator. They must teach the parents not to worry so much and help them to understand their child's illness or symptoms. Children are very resilient and heal very quickly; a stomachache in the morning can be nothing in the afternoon after some treatment. In most cases, parents worry a little too much. I may not be a parent right now, but I think I can empathize. If I were to become a pediatrician, I now have a good idea of the skills that I would need and those that I would need to work on. Being a good teacher and communicator are key and hopefully things that I can improve.

Going to the wards and sitting in the morning meeting taught us about the care that inpatients get and the types of cases that are admitted to the hospital. A baby was finally put in the nursery last night. She is 2 months old and has a urinary tract infection with fever. She was admitted for observation and antibiotics. Young babies with fever are admitted to observe and make sure it doesn't get worse. She lies alone in the baby room, but is receptive to visitors. We were able to read through her chart and spend some time with her. The antibiotics had helped her fever subside. We saw a boy with a viral infection who was waiting for test results. He had a rash, which could be EBV but also had symptoms of adenovirus. We discussed a case of cellulitis in a girl's mouth which resulted from an untreated dental carry. After treatment with antibiotics, her cellulitis had subsided and she was being discharged. Another case we discussed was a boy with pharyngoconjunctival fever (PCF). This was a good opportunity to remember the antibiotics that we studied so long ago and forgotten. He was administered sulbactam with ampicillin (called Unasyn) which in Taiwan must be approved before they can be given. This is to prevent the strains from becoming resistant to the drugs from overuse.

In outpatient clinic we also saw several cases of latent TB infections. In Taiwan, if kids are exposed to an active infection of TB and then have a positive PPD test, they have to go on anti-TB drugs for 3 months. If they retest positive after that time, they have to take an additional 9 months of treatment. Several kids were taking isoniazid for latent TB. One girl will be taking an additional 9 months of drugs because her test was borderline positive. Her younger brother will not have to take the drugs anymore. It was very informative to be able to see these cases, since we studied them in class.

These few days in pediatrics has allowed me the opportunity to learn outside of the classroom and better understand everything that we have been lectured on this past year. I have enjoyed my time in the pediatrics department and look forward to next week in OB/Gyn.

6/14/2011- Pediatric - Jessica

The second day of pediatric was a totally different experience from yesterday. Yesterday was mostly lecture, with occasional opportunities to visit the patients in their hospital rooms. On the contrary, today was all outpatient clinics and with many opportunities to observe real patients. We begun the day with Dr. Wu (吳俞哖醫師), a pediatric cardiologist. Dr. Wu has actually retired recently and is only holding outpatient clinic now for the patients that she has seem over the years and had developed a close relationship with. Dr. Wu is a very easy going and gregarious person and we were able to discuss many things, from medical facts to the Taiwan medical culture. But the most memorable part of it was her enthusiasm and attitude toward pediatric and her patients. After talking to her, I was able to renew my determination of becoming a physician once again and I sincerely hope that one day I will be able to become a physician like her.

During lunch, we learned a surprising news from Yuyu, that our colon cancer presentation has been moved up to next Monday instead of next Friday. We were a little caught off guard by the new due date, since we are still in the preliminary stage of our presentation (Mickey just got the surgery materials today), but I think if we work hard the next few day, we should still be able to have fun and still do a good job on the presentation.

The afternoon was spent in the outpatient clinic with Dr. Su (蘇冠文醫師), a pediatric immunologist. Dr. Su did his research in pediatric respiratory allergies and taught Karen and I many interesting aspects of pediatric allergic diseases, such as the correlation and possible cause of allergic shiner by chronic allergic rhinitis/sinusitis and the epidemiology of  asthma in Taiwan: its strong correlation with dust mite allergy for the Taiwanese people (about 80 %). During our conversation, we found out that he actually studied at the US for a short time and is quite familiar with a lot of the US's health system. In fact, Dr. Su had researched about Touro prior to our meeting and we had a short conversation about the DO profession. Dr. Su also mentioned that this coming Thursday's outpatient clinic feature a three-panel special clinic from the pediatric, developmental rehabilitist, and psychiatric department specifically designed for children with behavioral problem. Both Karen and I think Thursday's clinic will be a great learning opportunity and we are both looking forward for it with excitement.

6/15/2011- Pediatric - Jessica

We spent today in the outpatient clinics again, but with different preceptors. We joined Dr. Wu (吳秋文醫師) in the morning and Dr. Wong (王怡人醫師) in the afternoon. Like Dr. Ho from TCM before, as the director of the pediatric department, Dr. Wu has a heavy patient load and worked past lunch to see all of his patients. Unlike yesterday, where most of the patients were here for the doctors' specific specialties, many patients are just here for general complains unrelated to Dr. Wu's specialty, which is pediatric immunology. Especially after the clouding agent problem started, many of the patient were here for testings to determine possible exposure to the clouding agents. The clouding agents were found in many different type of food/health supplement in Taiwan. Among them, the most worrisome for parents are the contamination of certain brands of probiotics and even a syrup of Augmentin, since many were consumed regularly by their children in an attempt to improve their health. The crisis this time created such scare largely because clouding agents over stimulates femalization of developing children and thus, in a culture where continuing the family bloodline is of the utmost importance, created unprecedented panic among the parents. I have been following the news for the past week on the new development and was quite curious to see the actual effect of the clouding agents on the pediatric patients. To my surprise, contrary to the news coverage, out of the 20 patients examined for the sexual organ abnormalities throughout the last two days, only one patient seemed to have underdeveloped genitals. However, that patient also suffer from hypothyroidism, so the actual effect of the clouding agents cannot really be ascertained at this point without further testings. We also notice several interesting points about clouding agent testing. For example, we were surprised to found out that the test for sex hormones in pediatric children is often inconclusive, since most of the children will be prepuberty, their testosterone levels will be inevitably lower than the normal amount for adults and thus not entirely reliable when it is lower than expected value and require obtaining separate list of standard values for each age group to accurately determine the results.

Other than the clouding agent testings, we also saw many interesting cases. We begun the day with a case of hip dislocation where the child was too old that tissue has grown between the gap that surgery is the only option now. Remembering our training in our pediatric physical exam lab, we were reminded again the importance of early diagnosis of congenital abnormalities like hip dislocation. In addition, Dr. Wu also pointed out that when asked about abdominal pain, many children tend to just point to the umbilical region for diffuse pain and it should not be taken literally as a sign of localized pain around the umbilical area. Similarly, when the child specifically point to a place far away from the umbilical area, it is usually a good indicator for localized abdominal pain.

6/13/2011- Pediatric - Jessica

Today is the first day of our 2nd week at Taipei Hospital! Karen and I will be rotating at the pediatric department this week. I was a little worried about this rotation in the beginning because pediatric covers such broad subjects and many organ systems, such as GI, have not been covered in our curriculum yet. Although I studied with Amanda yesterday to prepare myself, I am still a little anxious about it. However, once I met with the preceptors this morning, I felt much calmer because they seemed so welcoming to Karen and I. We begin the morning with a departmental morning meeting once again. But unlike the internal medicine meeting, we had about 15 cases this morning. The presentation and consequent discussion was so fast that I felt like even I need a translator too! Since it was impossible to translate verbally for Karen while trying to listen in the same time, I tried writing the translation down on the notebook for her, hopefully it was clear enough this way that I didn't just end up confusing her even more! Although all the presentations was concise and short, we actually learned/reviewed many medical facts and treatment conventions.

After the morning meeting, we went to patient round with Dr. Wu (吳文秋醫師). After mentioning that we have a non-Chinese speaker, he graciously agreed to use all English to communicate with us. His English was very impressive and was able to gave us a lecture on pediatric allergies all in English and I hardly ever had to step in to translate. During the round, we actually saw an interesting case. It was a little boy admitted for acute bacterial gastritis. What made the case interesting was it was the first time we get to see real sample of bloody stool. And because it was caused by salmonella infection, mucus were also present in the stool sample. In  addition, the boy also started developed a mild form of upper respiratory infection, possibly nosocomial in origin, which reminds me all over again about the importance of aseptic practice in hospitals to help eliminate cross infection in hospital rooms.

After lunch, while going up the elevator, we notice one interesting phenomenon that is unique to Asian countries. We noticed that there was no 4th floor! At first, I thought it is only that particular elevator that do not have a button for 4th floor or the 4th floor is of special office use only, but when I think about it more, I realized that it is probably because 4 in Chinese (pronounced "si") sounds very similar to "death" in Chinese. Since hospital is a sensitive place where death usually occur, it was probably an attempt at easing the patient's anxiety going to the hospital.

While waiting for our afternoon preceptor, many doctors and other health workers were all very kind and tried to chat with us to keep us accompanied. After that, we spent the afternoon going over an atypical case with Dr. Tsai (蔡雅慧醫師). It was a 10 y/o boy with fever x3d, severe vomiting since morning, and loose diarrhea noticed only once. Physical examination revealed no other abnormalities except decrease breathing sound, positive wheezing, and soft abdomen with localized pain in periumbilical area. We were asked to provide a list of diagnosis on the symptom, of which we  replied pneumonia and appendicitis. Dr. Tsai answered that there are 3 diseases. Diagnosis one, and the potentially most severe one was appendicitis, the second one was bronchpneumonia, probably caused by mycoplasmas, and the third diagnosis was acute gastritis. Although in this case the appendicitis and gastritis were both not yet fully blown to cause all of their characteristic presentations. After the the case presentation, Mrs. Lian, a PA who assists Dr. Wu, kindly showed us around in the department and also showed us the outpatient clinic location that we will be doing our rotation the next day.

Although both of the preceptors today said that their English was not good, both Karen and I thought they were both very good in English and were very impressed by their conversational skills and the ability to explain the complicated clinical scenarios to us in ways that was very clear and easy to understand. We also were very thankful to the PA's and other doctors in the ward who were so nice to us and tried to make conversations even if they were not comfortable using English.

Week 2 Pediatrics

Pediatrics in Taiwan is becoming a dying art. After speaking with a resident today, we found out that around 60 babies were born in Taipei Hospital last year and no deliveries have occurred in the month of June as of today. The neonatal ward and the nursery are empty. The population in Taiwan is getting older and less people are having children, leading to a decreasing patient population for pediatric physicians. I didn't realize that this would be a problem; in the US, pediatricians seem to be in higher demand. The birthrates for 2008 shows that the birth rates in the US are almost twice that of Taiwan. And apparently Taiwan has the lowest birth rate in the world. Dr. Tsai told us that there is a shortage of pediatricians in Taiwan because they work hard and are not paid well. It is not a popular specialty for new physicians. In spite of this fact, the pediatric department meeting discussed 15 inpatient cases in the course of about one hour. It very fast-paced to say the least. But it was very interesting to observe.

After the meeting Dr. Wu took us to see some of the patients. He discussed each of the cases with us and showed us around the ward and the floor. It was very helpful to learn how things are organized and see where everything is. We saw four patients and then Dr. Wu gave us a presentation on airway diseases in pediatrics. His presentation was very informative and a good review of the things we learned in our respiratory classes. He also showed us the different types of inhalers and how they work. Listening to his presentation reminded me how much we have learned in the last year and how much more there is to learn in the clinic.

We later met Dr. Tsai who presented us with a case and asked us to give a diagnosis. It was a 10 year old boy who presented to the hospital with dyspnea and abdominal pain. Jessica and I were able to correctly diagnose the patient with a bronchopneumonia and appendicitis. I really enjoyed applying the knowledge that we have gained in the last year. It was rewarding to know that the hard work in studying everything was actually useful. After discussing the patient, we were able to go and visit him and see how he was. Dr. Tsai said that he was very sickly in the morning. After treatment with IV fluids and antibiotics, his abdominal pain had subsided and he seemed to be in good spirits. It was interesting to see how resilient children are and how fast they can recover from illness.

Outpatient clinic in pediatrics was very informative and great experience to observe. Pediatricians in Taiwan can follow their patients for a longer time than in the US. The oldest patient of one of the doctors is around 40 years old. This patient has been seen by this doctor since he/she was 3 or 4 years old. I found this very interesting since my pediatrician told me to find a new doctor when I was 16. Asthma is becoming a big problem in Taiwan; about 90% of children are presenting with allergies to dust mites which often leads to asthma. I was interested to learn that dust mites are the biggest cause of allergies in Asia, whereas in the US pollen is the biggest culprit. Variation in genetics and environment can be attributed to this difference. Many of the cases in the outpatient clinic had to do with asthma or allergy. This experience has shown me the similarities and differences in diseases between the Asian population and the American population, as well as the differences in health care in Taiwan and the US. I have really enjoyed my time in pediatrics and am definitely considering it as my specialty.