Neurology - Last day

I went to the ICU and saw the old lady whom I first met on day 3 in the ICU. She was still in a semi-coma state. The nurses were washing her. She was still being monitored closely.

We then went to ward run and saw the patients we did the last couple of days. They were more stable.

My day ended with the conference in the afternoon. The presentation was about ARDs of AED and SJS. The discussion was in Taiwanese so I did not understand much. But there was handout of the main points so that helped.

I had some time to reflex on the neurology rotation week. I feel so blessed to have been able to come to Taiwan to intern. My preceptor was amazing and I learned a lot from him. Ms. Yu Yu, Jessica and Angie were so kind. I cannot ask for a better first week than this.

6/6~6/10/2011 - General TCM - Jessica

I think Dr. Ho (何彥頤醫師) is one of the most memorable doctor I met during this trip not just because he it the first main preceptor I met during this trip but because of many reasons. If you ask me what I remembered the most about Dr. Ho, it would be his efficiency and his personality. Mickey and I was shocked during our very first day in Taipei hospital because of Dr. Ho. In one single afternoon outpatient clinic, Dr. Ho tended to around 80 patients, including regular office visit AND acupuncture rounds! Since I still have some recollection about the Taiwanese health system, I already knew that the patient load for Taiwanese physicians are very high compared to the US, I never expected it to be so heavy! Even though there were more patients than usual that day because Dr. Ho's Monday clinic was canceled due to a national holiday (Duan-Wu), the sheer number of patient was still unbelievable to Mickey and I. But what surprised us even more was Dr. Wu's ability to handle that amount of patient and still manage to connect with his patients in a personal level and even knows many of his patients' names and medical conditions by memory! What impressed us even more was Dr. Ho's ability to still keep his sense of humor throughout the entire shift and helped ease the stressed atmosphere with his good natured jokes. Even though he used mostly Taiwanese to communicate with his patients and I could only understand about 65% of it, I can already feel the sense of trust between the patient and the physician even during such short patient encounter. And I think that is what make Dr. Ho unique among physicians.

Of course, as a TCM doctor, Dr. Ho stood out even more for Mickey and I: since he is the only doctor we have observed throughout this trip that utilize manual diagnoses and treatment on patient. During our rotation, Mickey and I were able to observe and video tape Dr. Ho's treatment and even had the privilege of trying it ourselves. Considering how busy Dr. Ho is everyday, we were really grateful for his time and patience to all of our questions and request of video filming him. Mickey and I have learned many things from Dr. Ho, from patient interactions to tips on palpating skills and I sincerely hope that we can collaborate even more in the future to exchange knowledge between TCM and OMT.

TCM rotation and excursions 10-June-2011

Jessica and I started the day with Dr. Chen, Chien-An (Dr. 陳建安 ) of the TCM department to observe his acupuncture clinic for about an hour before we saw Dr. Chen, Chun-I (Dr.陳駿逸)from oncology walk in borrow some acupuncture needles from Dr. Chen, Chien-An to teach our other classmates that are rotating with him about acupuncture and its role in cancer treatment. Dr. Chen, Chien-An saw that it was a great opportunity for Jessica and I to learn more about acupuncture and told us to follow Dr. Chen, Chun-I to learn from him for the rest of the morning. We ended up meeting up with Amanda, Bor-Han and Sandy, and was given a very interesting power point presentation about acupuncture. I found it interesting that many of the concepts used in acupuncture could be found in our lectures from the OMM department, such as those regarding nociception. It appears that there is the theory that acupuncture works as a gate control to modulate pain. In other words you feel the sensation of the needle upstream which interrupts the pain signal downstream. Dr. Chen, Chun-I is very enthusiastic about evidence based medicine and believes that more research should be done on TCM. For his presentation he used most of the research that were done from peer reviewed journals that were done in English and noted that there was much more research that has been done in Asia but he felt that some of the publications were reviewed under the same rigor. The most exciting part of the morning was that we all given the opportunity to practice acupuncture on each other on points located in the upper and lower extremities, it almost felt like a mini-lab much like those that we are accustomed to in the OMM department at Touro.

In the afternoon Jessica and I went down to Dr. Ho’s clinic. At one point he jokingly told a patient that he doesn’t do more Tui Na because he patients have a hard time following his aftercare directions, such as not to cross their legs and not to place their feet on foot rests. Interestingly enough one my nursing friends sent me an article about leg crossing inducing lumbar scoliosis from a Taiwanese newspaper a few months ago and asked me to if it was possible to translate it to English. In any case here is the original Chinese version, I have not had time to translate it to English yet. By the way if anyone is interested in the project let me know.

After the first hour with Dr. Ho, we ended up getting excused to follow Dr. Chen, Chun-I again and had a very interesting presentation about acupuncture use as an adjuvant therapy in oncology. It appears that acupuncture is great at reducing some of the adverse effects of radiation and chemotherapy such as nausea and helps with overall recovery. I am excited that he allowed us to keep the power points that he presented and told us that it would be okay to present the material to the rest of the school if wanted at some point.

Overall the experience in the TCM department was a very exciting an interesting experience for me. I had some difficulty due to language barriers but I feel I was still able to get a lot out of my experience there and feel honored to have had such a great opportunity to learn from many amazing preceptors I have encountered so far.

Neurology - Day 3

On Thursday, we went to NCV/EMG lab but there wasn't any study so the doctors in Physical Therapy dept. showed us around their facility. Again, the head of physical therapy told us that some patients do come in more than they should. So we asked how they determined who get tx if the patient # becomes more than the facility could accomodate for each session, and he told us that they prioritize patients (who will get the most of out this, who could really improve from the tx's, severity, etc).

We went to meet with the superintendent at 11. That was pretty cool. He's so nice. He is a busy man and he took time to meet with us students.

In the afternoon, we went on ward run. I saw the same patients I did on Monday. They all seemed to be doing better. They were more alert this time.

In the ICU, an old female patient suffered ischemic stroke, most likely due to her A.Fib. She was being monitored carefully to prevent edema which develops 4 days, and she had been in the hospital for 2 days. I learned about neurological index: eyes are rated 1-4; best verbal respponse 1-5; best motor response 1-6; arms 1-5 (There are more categories but I didn't get them all down).

I also learned about:

Cogwheel rigidity (def from medical dictionary): muscle response with cogwheel- like jerks to the use of force in bending the limb (e.g. Parkinson)

Lead pipe ridigity: a state of inflexibility and stiffness that remains uniform throughout the range of passive motion --> associated with disease of basal ganglia

I would go on youtube to watch how the techniques are performed

On brain CT, old stroke appears as dark as CSF while new stroke is darker than brain matter but lighter than CSF

Plasticity develops 1-2 weeks after stroke

Later that day, we went to EMG lab

Indications for NCV include: CTS; ulnar neuropathy; peripheral neuropathy; brachial plexopathy; radiculopathy; myasthenia gravis; muscle disease

Indications for EMG include: radiculopathy; neuropathy; muscle diseases; motor neuron diseases

6/10/2011- General TCM, Oncology TCM - Jessica

Today is the last day of our first week of rotation. Mickey and I, along with other groups, bought some small gifts to our respective preceptors. I left the gift I brought from the US at home, so Mickey and I bought some chocolate covered strawberries yesterday while grocery shopping at Carefour supermarket (next to IKEA) for our preceptors. However, we noticed that the preceptors in general showed great resistant to receiving the gifts. We were wondering if it is a hospital policy thing or just because it is inconvenient for the doctors to eat food during office time.

We started the day with Dr. Chen (陳建安醫師) who we rotated with before on Wednesday. However, he had a busier schedule today compare to Wednesday, so when Dr. Chen (陳駿逸醫師) from oncology came visit, Dr. Chen graciously agreed to take us in. Coincidentally, Dr. Chen (from oncology) also studied TCM, in fact, he and Dr. Chen (from TCM) were upper and lower classmen (學長弟) and he is about to teach Amanda, Bor-Han, and Sandy acupuncture basic principles today. So we end up tagging along with them and was given a quick overview of acupuncture. We were introduced to the basic acupuncture principles and some basic well-known acupuncture points. We were even given the chance to practice needling (on self or each other of course)! The whole experience was just eye-opening, fun, and interactive. We learned the points and its basic therapeutic effects and how to evaluate if the needle has reached the right point through the phenomenon of De Qì (得氣, the sense of numbness, pain, or tingling during needling that indicate successful stimulation of the acupuncture point). After observing so many days of acupuncture, I was very excited to be able to finally try it myself. Although it seemed a little traumatic for some of us, but I think all of us learned a lot during the session and actually had a lot of fun too.

We went to the basement restaurant again today for lunch and YuYu met us there to inform us that the schedule remained unchanged after all. We discussed a little bit more with YuYu about possible sight-seeing places for this weekend. Since both Amanda and I won't be around this weekend, the responsibility of tour guide rest solely on Bor-Han, and I was able to relieve my sacred duty! Toward the end of lunch, YuYu came again to inform us that there was a surgery meeting that we were welcomed to join. We all hurried there and learned about an adverse effect of phenytoin (Stevens-Johnson syndrome) that is significantly more prevalent in the Han-Chinese population.

One interesting thing was Amanda helped us figure out the exact price of the lunch set there. Although it is not that related to the academic experience, for the sake of future students who are fixated at eating good food like me, I will include the information here as well: the basic set for $NT50 includes rice, soup, and 4 courses (1 main entree/meat dish + 3 vegetable/side dishes), each additional entree cost $NT20, and each additional side dishes will cost $NT10 more.

In the afternoon, we started by following Dr. Ho again, observing his outpatient clinic until around 3pm. And then with Dr. Ho's permission, continued the morning acupuncture introduction with Dr. Chen in the remaining time. During this time, Dr. Chen continued with his introduction to acupuncture and also briefly covered some scientifically proven ways acupuncture can be used to support cancer treatments. I was surprised by how much research has already been done on acupuncture by the western medical field as well as by how enthusiastic Dr. Chen is at teaching students. I sincerely feel that we are very lucky indeed to be able to have preceptors like Dr. Chen who is truly committed to teaching the students and still feel such passion toward his field of study even after these many years.

Oncology rotation Day 3 & 4 (June 9-10, 2011)

June 9, 2011

An interesting case was presented in the morning meeting of internal medical department. The patient is a 35 years old male who was found loss of consciousness by the side of road. He had lost contact with his family members for five months, and they said he is alcoholic. The patient was sent to ER with sign of jaundice and high fever. His coma got worse over time since admission. The brain CT scan and chest x-ray looked normal. One of the attending physicians pointed out that aspiration pneumonia still cannot be ruled out in this case since the early stage of pneumonia can show no sign on chest X-ray of dehydrated patient. The most interesting thing in this case is that his eyes were found gaze toward the left and his neck tended to rotate to the left too. Because it was time for our appointment with pathology department, we didn’t get the chance to learn more about this interesting case.

Since Dr. Chen had a speech in Kaohsiung, we were arranged to visit the pathology department. We met Ms. Bai, one of the technicians working in the department. She gave us a tour of the lab and talked about how they prepare and examine samples histologically and cytologically. She also mentioned a simple and rapid staining method called Liu’s stain. It allows physicians to make cytological diagnosis faster than regular Papanicolaou stain. We later got chance to meet Dr. Hsieh, the director of pathology department. She gave us a brief presentation about the department. Since we would have our orientation at 11 am, we told her that we would be back in the afternoon so that we can learn more from her.

During the orientation, we had a formal meeting with Dr. Shui-Lung Lin, the superintender of the hospital. As the head of Taipei hospital, he gave us a warm welcome and said that just let him know if we have any need or question. After the meeting, Ms Yu-Yu Lin held a fancy banquet for us in a nearby restaurant. We really appreciated TIHTC for all the freebies and treats they provided.

We went back to meet Dr. Hsieh after the big lunch. At same time, Jessica and Mickey joined us since they cannot continue their TCM rotation temporarily due to some miscommunications between their TCM preceptors. Hsieh told us that an excisional biopsy of colon carcinoma was just sent in for pathological diagnosis. She said her technician would show us the process to prepare that specific sample and will go through the slides under microscope with us. She also suggested that we can go to interview the patient so that we can get both laboratory and clinical respects of this case. We took advantage of this unique opportunity and went visiting the patient. With the translation of a very kind nurse, we were able to interview the Taiwanese-only patient. The patient is a 63 years old female. The sign of colon cancer started from trace amount of blood in stool to tarry stool and finally to hemorrhage in two and half years. Patient said she usually cooked her own food and denied high fat diet. She reported no family history of cancer. For past surgical history, she reported one surgery around the neck and three abdominal surgeries for ovary, appendix and colon. The chief complaint she had now is lower extremity pain. When we wanted to ask the patient more about the diagnosis for her illness, she said her family members were informed except herself. And since she was weak and tired after this big surgery that cut off a region of colon, we decided to end the interview early.

After interviewing the patient, we went back to pathology department and hold a case discussion between five of us. Dr. Hsieh walked in and proposed that we can make PowerPoint slides for this colon carcinoma case and have the presentation to her and other physicians two or three weeks later. We accepted the challenging job and started to discuss how to present the case from the views of different specialties such as pathology, surgery, and oncology.

June 10, 2011

Today’s case presentation started with the same unconscious alcoholic male. The presence of WBCs in CSF sampled by lumbar puncture indicates meningitis. The finding of Gram (+) cocci and low glucose level in the CSF combined with elevated intracranial pressure suggested that it’s bacterial meningitis. For treatment, high dose of empirical antibiotics such as Penicillin G + Ceftriaxone + Vancomycin should be used first to stop the progress. Unfortunately, because acute bacterial meningitis is a disease with high mortality, the patient passed away within two days due to septic shock. One thing I learned from this case is that a patient’s situation can get worsen rapid without any detectable signs. In this case, the CXR and CT scan looked normal but his meningitis progressed so quick that killed him within one day. That’s why it’s important to think about what can be worst and provide patients treatments (e.g. high dose of empirical antibiotics) ahead to prevent the progression to the worst situation.

After the case presentation, three of us gathered in Dr. Chen’s outpatient office. Out of our surprise, Dr. Chen walked in with Jessica and Mickey. It turned out that their preceptor, Dr. Chien-An Chen from TCM department, wanted our Dr. Chen to teach them about the role of TCM in oncology. Since the office was too small to hold six people, we went to pathology department and used their conference room. Before talking about the use of acupuncture in oncology, Dr. Chen gave us a presentation introducing the ten most commonly used acupuncture points. We not only learned about the indications of each point but also got the opportunity to practically find those points and insert the needles on each other. This valuable experience helped me gain more understanding about acupuncture and prepare me for later TCM rotation.

Right before we went to have lunch, we went through the histologic slides prepared from the colon carcinoma excision biopsy under microscope with Dr. Hsieh. She explained to us why she made the diagnosis T2N0MX. T2 indicated that tumor invaded the muscle layer already. N0 means no lymphatic metastasis noted. The X in MX means undecided because you cannot make diagnosis for metastasis by just looking histologic slides. This diagnosis will be useful later in our case presentation about this colon carcinoma patient.

After having lunch and auditing neurology conference, three of us met Dr. Chen and finished up the acupuncture introduction presentation. Jessica and Mickey later joined us again for Dr. Chen’s presentation about the role of acupuncture in cancer patient management. In his presentation, he showed us several published studies demonstrating the positive effect of acupuncture to relieve radiation or/and chemotherapy side effects such as nausea and vomiting. He also suggested us to perform similar studies if we are interesting in the field.

In this oncology rotation week, I gained more understanding about cancers and learned how to clinically apply what I learn to make diagnosis and provide treatment. I feel so lucky to have Dr. Chen as our preceptor for oncology rotation. It’s not only because his ample knowledge in both fields of oncology and TCM but also because of his philosophy and attitude in treating his patient that makes him loved and respected by them. He is the perfect example for me to become a good physician in the future.

Oncology Day 4/4 - Sandy

Today we went to the Internal Medicine meeting at 8:00am, then Dr. Chen presented an Intro to Acupuncture lecture to us in both morning and afternoon, and we attended a Neurology case presentation meeting after lunch.
During the Internal medicine meeting, the physicians followed up on the case from yesterday. It was a 35 y/o man, left home for 4-5 mo, came to the ER where his consciousness deteriorated. Today we learned that the patient had died of Gram + Strep meningitis. The way to differentiate bacterial from viral meningitis is that glucose level is low in bacterial infection while in viral infection, glucose would be normal level and protein level would be high. The physicians emphasized on how crucial it was to manage the patient if meningitis was suspected. Suddenly, practicing medicine became so real. I saw how a misdiagnose could lead to significant consequences, and this provided a valuable reminder to me.

Dr. Chen’s Acupuncture presentation included both lecture AND lab (informally), and it was quite possibly the most fun experience I have had so far. We learned about the 10 most common acupoints and we immediately put our learning to use. After Dr. Chen confirmed the location of the acupuncture sites on us, we began to prick each other with needles. The pricking itself did not hurt, it was when we had to push in the needle, swirl slightly and move up and down that we began to feel pain and subsequent numbness. It was hilarious when we tried to poke each other, as each poke ended in a crescendo scream for the other person to stop moving the needle. Borhan even pricked at an acupoint that would help him with his pregnancy! The acupoints were so similar to Chapman’s and tenderpoints that Osteopathic Medicine could be the Western version of Traditional Chinese Medicine (TCM).

We returned to the Pathology lab where we saw slides from the colon cancer patient from a day ago. We discussed with Dr. Hsieh about the characteristics on the slide and decided to rate the cancer as T2 (invasion to the muscle) N0 (no nodal abnormality), the metastasis staging was left to the clinician. Dr. Hsieh then discussed our scholarly activity on Colon cancer, and proposed a plan where each of us would role-play as a Pathologist, Oncologist, Director, Family Physician…etc and tape the presentation. We thought it was a great way to practice our presentation skill.

After lunch, we followed Nicole and Karen to their Neurology meeting where the physicians discussed some potential side effects from anticonvulsant drugs. The most interesting case was discussion on Carbamazepine-induced Steven Johnson Syndrome. East Asians are most susceptible to this disease because many carry HLA-B*1502 gene. Due to these potential side effects, it is best to follow the philosophy “start low, go slow” when giving patients drugs, and that was the lesson of the day.

The extraordinary in the ordinary

Internal medicine meeting 8-9am

Case 1: We followed up with yesterday's case--unconscious alcoholic with hypovolmia and electrolyte imbalance. Lumbar puncture showed gram + cocci, which most likely was streptococcus pneumoniae. The CSF fluid also showed other signs of bacterial meningitis--high CSF pressure 23 (normal range is 9-18), low glucose level (bacterial consumption of glucose), high WBC count. If it were viral CNS infection, the CSF would have normal CSF pressure, normal glucose level, and possibly high protein level.

There was also RBC in the CSF, so the attending asked the resident for ddx from gross examination. If an elevated number of red blood cells is present equally in all bottles, this indicates a subarachnoid hemorrhage. If the number of cells decreases per bottle, it is more likely that it is due to damage to a small blood vessel during the procedure (known as a "traumatic tap"). CSF also had RBC (normally found in CSF)--its presence indicate bleeding; ddx are subarachnoid hemorrhage, stroke, or traumatic tap. We've ruled out traumatic tap with the resident's observation, how to discern stroke from cerebral hemorrhage? Since WBC may enter the CSF due to infection (viral, bacterial, fungal, and parasitic), allergy, leukemia, hemorrhage, traumatic tap, encephalitis, and Guillain-Barré syndrome, the RBC count is used to correct the WBC count. WBC corrected with RBC will help determine if the CSF display merely bleeding conditions. If the RBC to WBC ratio of CSF is similar to that of patient's blood, then we can conclude that the tainted CSF (elevated RBC, WBC)was caused by bleeding. But if the ratio is dramatically different, with WBC/RBC ratio much higher in CSF, the etiology is mainly infectious. It's incredible how much information and analysis rest within a seemingly ordinary procedure such as lumbar puncture!

Another interesting point was that with bacterial infection, neutrophils is most likely elevated. However, the CSF sample showed elevated lymphocytes. I was thinking perhaps it was a super-infection (both bacterial and viral) or a chronic infection with acute presentation (meningitis). The attending said that it could be a TB infection transitioning from acute to chronic course, which would have a higher percentage of lymphocytes than most other bacterial infection.

He then emphasized how imperative it is to determine the etiology of meningitis: bacterial, viral, fungal, or parasitic. With bacterial meningitis killing people in matters of hours to a few days, doctors can not risk to prescribe the wrong category of treatment. It is very rare to administer antibiotics, antiviral, and/or antifungal simultaneously, so the clinical picture and preliminary lab results must help decide the pathogen. Unfortunately, even with the diagnosis of bacterial meningitis and Penicillin G/Vancomycin/Ceftriaxone, our patient died of septic shock.

We also discussed 2 new cases. I hope to meet and interview these patients. Will propose this to Yu-Yu.

Chinese medicine acupuncture 9-11am
Acupuncture-CINV 2-430pm

Dr. Chen taught us 10 major acupoints. He said the ultimate goal is to enhance and optimize the flow of Chi. The points were mostly on our upper and lower extremities; knowing our anatomy was quite helpful in locating the points. He explained that each acupoint is analogous to the station of the rapid transit, leading to acupoints upstream and downstream of itself along the transit line. This is the basis of how an acupoint on the anterior leg can affect bowl movements and reproductive health. The techniques go beyond accurately locating the acupoints, which vary from one person to another based on primarily size. They include swiveling the needle, pulling the needles in and out, depth, and angle. The introduction to principles of acupuncture correlated well with several osteopathic principles. Some acupoints resemble counter-strain points; others resemble Chapman’s points. It'd be very exciting to share what we learn from Dr. Chen with the OMM department and our class in the fall! Dr. Chen agreed to let us shadow him during his evening outpatient clinic on Tuesdays, just need to clear with TIHTC. This may open doors to our shadowing other specialty doctors in the evening clinics across the board, including OB/GYN, pediatrics, cardiology, and surgery.

Pathology review of Colon Cancer section from yesterday 11-12pm

With the teaching microscope, 5 of us had a tour of the slides prepared from the resected colon tumor. We started with the normal tissues and contrasted that with the malignant ones. The latter showed loss of polarity, disorganization, disproportionate cell type, invasive behavior, and invagination into glandular lumen. She also showed us the lymph nodes from the serous layer of the colon. Fortunately the nodes displayed beautiful germinal centers without glandular invasion. She also briefly reviewed the cancer staging system of TNM (tumor size, lymph node involvement, and distant metastasis). Finally, she recommended the framework for our case presentation.

Dean: organize power point, host and direct and case presentation
Family physician: prepare, present epidemiology, H&P
Surgeon: prepare, present operational findings, course of hospitalization
Pathologist: prepare, present pathology findings/diagnosis
Oncologist: prepare, present out-patient treatment--chemo, and or radiation
Chinese Medicine Doctor: prepare, present adjunct, supportive therapy
Students: prepare and ask questions

Her gracious guidance is heart-warming and inspiring. Jessica, Borhan, Mickey, Sandy, and I are quite excited about this project. We would love for Karen and Nicole to participate as well--we especially need good questions at the end of the presentation. Dr. Hsieh has already invited big shots including Superintendent Lin to grace our 1 hour case presentation happening in 2,3 weeks!

Neurology conference--Adverse Drug Reaction of Anti-epileptic Drugs 1230-2pm

Case 1: phenytoin intoxication
Patient had liver and renal insufficiency. Phenytoin has zero-order kinetic. Patient was not able to metabolize/deactivate the phenytoin prescribed. Hence she suffered altered consciousness. After admission, neuro-surgeon reduced and ultimately discontinued phenytoin.
Clinical Pearl: Start low, go slow (Monitor serum drug level for metabolically compromised patients) Dr. Lin taught us take caution with renal or hepatic insufficiencies last fall!

Case 2: Stevens-Johnson syndrome with carbamazepine
A study with 44 East Asian subjects showed that all patients w/ SJS had HLA-B*1502. So physicians could prevent SJS by taking careful PMH and FH and genetic testing for HLA-B*1502 before using carbamazepine and phenytoin in high risk population. However, genetic testing costs 3000NT while carba. oral costs only 2-3 NT dollars, so the national health insurance refuse to pay for the testing. The presenter pointed out that often once SJS presents with rashes and blisters, nearly 50% of patients will die from it. It is unclear if discontinuation of the inciting medication can stop the course of severe inflammation. We also learned to distinguish TEN (Toxic epidermal necrolysis) from SJS. SJS distributes throughout the body diffusely while TEN concentrates on the chest and neck; SJS normally involves 2 or 3 mucosa: oral mucosa, conjunctiva, and genital area.

Amputated man in the hall

I rode the elevator with a man yesterday. His painfully deformed gouty finger joints burned a vivid image in my mind. I felt so sad to see it. Debilitating diseases we learn on paper and in discussion happen to REAL people. Today I recognized that same man in the hall, lying on a gurney. He looked so sad and life-less. I took another glance at him and realized that his short stature was due to bi-lateral above knee amputation. A wave of sadness grabbed me; I tried to share this with my colleague as if somehow we could commiserate--somehow I can take comfort in finding others who feel the same shock. One colleague thought positively, "At least he had a whole life ahead of him. We can focus on being thankful that he is not dead." Another colleague said, "but how about quality of life? Disabled, poor, and possibly with less disability support/ infra-structure than in the States. How good can his life be?" Both view points are valid. Caring for those who have survived severe life-changing medical conditions is an important lesson to for us to learn.

neurology last day

The last day in neurology was very interesting but short. We went on rounds in the morning and visited all of the same patients that we had seen the last few days. Most of them hadn't had a lot of change. The only one that had significantly changed had moved into the ICU because he needed ventilation. A couple of the others were being transferred to rehabilitation because their conditions were stabilized. At lunch a neurosurgeon gave a seminar on case studies of drug overdose and Stevens-Johnson syndrome. He lectured really fast and in Chinese. It was interesting and it gives me something to research so that I can understand it better.

6/9/2011-general TCM & Pathology - Jessica

After attending the morning internal medicine meeting, we went to Dr. Ho's outpatient clinic again. As before, his clinic was very busy and we rarely had time to ask him questions. But we did manage to slip in few questions in between. We asked if there are certain precautions we need to consider when needling the patients to avoid infection. Dr. Ho replied that first, the patient's hygiene is very important. For example, although alcohol wipes are often used, most time in outpatient settings, the needles are applied through the cloths, extra precaution need to be applied if the patient's clothes are soiled or poor personal hygiene is noted. However, since he knows most of his patients well, he does not need to worry about that often. Another important point to consider is if the patient has diabetes, which will prolong healing time and increase risk of infection. We also learned that since many of his patients are elderly patients with many of the chronic metabolic and cardiovascular disease, the goal for him is often to control and lower the condition enough using Chinese medicines to at least lower the amount of western medicine needed or even replace them to control the disease.

One of the highlights of the day was meeting with Dr. Lin and Superintendent Lin. It was great to have the chance to convey personally to him how thankful we are for the wonderful opportunity. We were each given a bag of gifts along with many much needed maps for tourist information! The TIHTC treated us again today to a wonderful lunch, there were so much food that even though all 9 of us (including Dr. Lin and YuYu) entered the restaurant with empty stomach, we could not finish all of the food. And the food was so good that even though we were probably all stuffed all the way up to our epiglottis with food, we still want to bring the left-over home! Once again, their hospitality really touched me and will always be part of my fondest memory of Taiwan.

This afternoon, due to a miscommunication, Mickey and I were not able to rotate in the afternoon TCM outpatient department. So we went to the pathology department with Sandy, Bor-Han, and Amanda. I was expecting to see a bunch of stained slides and huge amount of microscopes in the beginning. But what I saw first was actually the actual preparation of the tissue samples. Even though I knew that the slides must be made into slides from sample tissue somehow, but seeing it in real life is a different story. Just looking at the biopsied knee joint, it was hard to imagine that it once belong and was functioning within all that flesh and tendon of a living human being. But after the initial shock, I felt like it allowed me to gain a new respect to the job of a physician; that no matter how little one's interaction with the patients is, a physician's job, no matter in which specialty, will cause tremendous change in the patients' lives. Although the change is for the better or worse will solely depend on how serious the physician takes his or her job and how dedicated he or her is to the patients.

TCM Rotation Day 3 general clinic, pathology lab excursion 9-June-2011

It was a much shorter day with Dr. Ho due to the meeting we all had scheduled with the superintendent Lin before lunch. None the less it was another interesting morning filled with observations that have accumulated over the past few days. One thing I noticed is that the patient population Dr. Ho sees included many elderly which mostly seemed to be concerned about edema, hypertension, hyperlipidemia, hyperglycemia and a few musculoskeletal complaints. In those of working age most of the complaints were musculoskeletal and the few pediatric patients he has seen were either for neurological issues or were GI related (such as constipation). Interestingly one patient came in today that wanted use TCM to control his hypertension so he could reduce the dosage of his current western hypertension medication, which got me thinking about drug interactions between TCM and western medicine. It seemed that there are varying opinions about how to handle the drug interaction situation. Dr. Chen opinion was that there was very little research about the topic and he wanted to know more about it too, but with the currently knowledge available he would recommend caution when combining methods. Dr. Ho recommended a 1 hour gap between Chinese medicinal herbs and western medicine while Dr. Hsieh recommended a gap of at least 30 minutes between medications. In my own experiences I have always been told to leave a 4 hour gap between medications so I thought it was interesting to see a much shorter gap being recommended here.

In the afternoon the TCM department was too busy to accommodate Jessica and I, so we ended up going to the pathology lab, meeting up with Amanda, Sandy and Bor-Han. We ended up learning about how they prep specimens and other various things including having the chance to do a brief patient interaction with colon cancer patient through a nurse translator about her experiences that she had in the hospital and the course of her disease. We are all currently poised to do a case presentation about this patient to the pathology department within the next two weeks. I am planning on including something OMM related maybe about post operative care or an OMM perspective to the lower extremity pain she was having due to touch.

Also we finished editing parts of the TCM treatment video and added some subtitles although we had trouble uploading it or attaching it to e-mails. In any case it should be a fun exchange between TCM and OMM when we are able to get everything uploaded.

Humility and hospitality

Today we met several "big shots" of the hospital, including the head of the entire hospital, Superintendent Lin, who is also a famous breast cancer surgeon. He was a fellow at Hopkins back in the States. He greeted us warmly and was not the least bit condescending, as one would imagine someone as important and busy as he was. The head of pathology department, Dr. Hsieh was also very kind; she asked each of us to introduce ourselves and to share our stories of why we are pursuing medicine. She told us that we are welcome to drop by the pathology department to observe and learn whenever there's a break during our scheduled rotations. Her readiness to give us the opportunity to learn and explore was amazing.

This morning's internal medicine case presentation provided a contest for us to apply many pathophysiology principles we had recently learned in school! Case was a 38 yo alcoholic homeless male who was found unconscious and brought in by the EMT. His consciousness had been deteriorating since admission to the hospital. His pupils are reactive to light but unequal size. His neck had a peculiar tone, his head rotated to the right. His ABG showed respiratory alkalosis with metabolic compensation. Chem panel showed hyponatremia, hypokalemia, hypo-albunimia, and hyper-amonimia, hyperglycemia. He was tachycardic with 113/80's blood pressure. So we suspected that he was in hypovolumic shock, consistent with the decreased skin turgor and prolonged capillary refill time. The hypo-albunimia and declined liver fxn may have contributed the lower effective circulating volume, with decreasing oncotic pressure. Patient had a high fever with a normal chest radiograph, which could be deceiving, because dehydrated patient may not show sign of pneumonia (interstitial markings, patchiness). We also inspected brain CT, which showed one darker region in a slide, but was not conclusive. Brain CT is good for detecting cerebral hemorrhage, intra-cranial pressure, and infarction. The doctors were really welcoming today and suggested that we do a 2-language presentation. I translated pertinent information to the group while the presenter spoke in Chinese. We then discussed mostly in English. I was very thankful for how much they tried to accommodate our needs, they even joked that this would be a great chance for them to learn case presentation in English from us. That was very kind of them.

At 9am, we went to the pathology department. Technician Bai showed us the state of the art equipment, including automated sequential slide stainer, automated sample sectioning machine, rapid freeze machine, among others. The director made a brief presentation on the study of pathology and emphasized that we don't focus on remembering all the information that came our way because the knowledge base of medicine will be ever-expanding and changing. Instead she recommended that we observe doctors' interactions with patients, the role, schedule, and life-style of each doctor we observe. She let us follow the technician to observe tissue processing. We saw a segment of tumor-ridden colon and degenerative erosion of tibial head. We watched the steps of fixing, drying of the colon tumor. To our surprise, Dr. Hsieh also graciously arrange for us the opportunity to interview the colon cancer patient. Five of us went to the patient, who spoke only Taiwanese, so a nurse actually offered to translate for us. This patient had ovarian cancer prior to the colon cancer. She said that she did not think life was worth living, too much suffering, and therefore delayed seeking care for 2.5 years. She even had a hunch that it was colon cancer for 2.5 years. This alerted me to how important it is to support patients' psychological well-being. Perhaps she did not go to the doctor at all in the past 2.5 years. But if she did see a doctor, who noticed and addressed her depression, perhaps she would have sought medical care for her persistent bloody stool earlier.

When we returned to the pathology department, Dr Hsieh said that we are welcome to read the slides from the colon tumor tomorrow. She also advised that we put together a case presentation, including interdisciplinary angles from oncology, epidemiology, pathology, and clinical course and treatment. She even contacted the attending doctor and ABD surgeon so that we could read the pt's chart and follow the resident for case information/interview. I am beyond words with all the help we are getting for OUR learning!

On the last note, we also had our orientation and TIHTC treated us to the most amazing traditional 12-course Chinese lunch!! We also received packets of keychain, business card holder, tourist guides, a T-shirt and other goodies. They are the most hospitable host one could imagine. We also just got a call from Yu-Yu, relaying a message from the internal medicine department—they want us to translate LOUDER at the case presentation tomorrow so that they can learn how we present in English. It sure feels good to reciprocate, even if in small ways, to those who have been so generous with their time and resources towards us.

neurology

The last few of days in neurology has only shown me how much I still have to learn. Nicole and I have learned so many things in the last 2 days. We learned the cardinal signs of Parkinson's disease: tremor, rigidity and bradykinesia. We have also learned about the examination and diagnostic tests used in neurology. The technicians in the EMG and EEG labs have been very helpful in showing us how the tests are done. We watched a 2 year old have an EEG done, which was a little difficult to watch as he was not happy at all to have electrodes in his hair. The second patient was an adult and was much easier to watch. The EEG is a test to look at the conductance in the brain to see if there is any sort of seizure-like activity. The EMG is a test to that looks at the status of the nerves of muscles. The patients often have some sort of spinal injury and this test shows which specific nerve is damaged. We watched 2 EMGs done on 2 young men. The first one was rather painful to watch. A needle probe is put into the belly of the muscle and the patient is asked to contract that muscle to test for the neurological stimulus that is being sent by the brain. A polyphasic wave suggests that there is a problem in the innervation of that muscle. The first patient we saw was in quite a bit of pain as he contracted the muscles with the needle. His test was done on his calf muscles and lower back. The second patient that we saw had his test done on his arms and didn't seem to be in any sort of pain. He must be a stoic. I can only imagine how much pain there would be if I had to contract my muscle with a needle stuck through it. It was quite difficult for me to watch the first patient as he lay in pain. The last test that we were able to watch was an EP (evoked potentials). The patient's brain is monitored with electrodes as they play sounds in each ear. This tests the auditory pathway in the brain stem and the acoustic nerve. It seems like a very easy and non-invasive way to test the sensory pathways to the brain. The patient just lays down on a table and listens to sounds. Much easier to watch than the EMG.

While we were waiting to see the EMG we were able to tour the physical therapy department and see the different modalities they use to rehabilitate patients. It was quite interesting to see the different machines and tools they had for the patients. It is also interesting to note that patients can continue physical therapy as long as they want. All they have to do is pay $60 (Taiwan) per visit to use the facility. The therapists said that many patients take advantage of this and use the facility far more than is necessary for their condition. Even though the facility remain quite busy all the time, it seems nice that the national insurance program allows patients to use the facility for their condition.

Going to the wards showed the realities of patients with serious neurological problems. The doctor is prepped by a nurse who sees all of his patients. She also follows him during the rounds to understand what the doctor is ordering for the patients. We saw several patients that had gone through a stroke and were recovering. One of the patients was in the ICU and the doctor was monitoring her closely because brain edema could occur in the next couple of days. She also had congestive heart failure and hypertension which also required close monitoring to keep her condition stable. Using the things that we studied last year, we were able to discuss her condition and understand the fine balance in fluid intake/outtake that the staff was trying to achieve. We learned about the coma scale and the tests that are done to determine the consciousness of a patient. The neurological workings of the body are quite intricate and interesting; I am privileged to get this sneak peak into the things that we will be studying this fall. I have so much to learn not only in neurology but in patient care in general. It makes me nervous about our year to come in school but this rotation will definitely give me a head start.

Neurology - Day 2

I spent the afternoon in the clinic. Dr. Yu did consultations in the clinic. Here in Taiwan, the patients come into the clinic room. Dr. Yu knew most of the patients and their conditions really well. The pace was really fast.

Many of the patients had Parkinson disease. Cardinal signs of Parkinson's: rigidity, resting tremor, bradykinesia.

I also learned about:

Tinel sign: performed by tapping over the nerve to elicit a sensation of tingling/pins or needles. It is used to detect irritated nerves. (e.g. test median nerve for Carpal Tunnel Syndrome)

Romberg sign: to test drunken drivers and neurological disorder. if +, suggests poor propioception

Phalen test: used to diagnose Carpal Tunnel Syndrome.

Later in the afternoon, EEG lab:

Indications: altered consciousness; seizure disorders; tumors; head trauma; headaches; brain absess; mtabolic encephalopathy; behavioral changes; adolescent disorders; intermitten explosive disorder; OCD; anxiety & panic disorder; bi-polar; RLS; Shaken baby syndrome; ETOH (from telemedx.com)

The use of hypoventilation in EEG lab is to wash out CO2 --> vasoconstriction of vessels in brain --> enhance abnormality

The use of light in EEG lab is to stimulate alpha wave

Ask patient to close eyes --> alpha waves should be present. Open eyes --> alpha waves should go away

Epileptic discharge --> see spiky alpha waves

Dr. Yu told me, at our level, it is important to know when to order EEG. The interpretation part of EEG takes a "life time."

I asked Dr. Yu on Day 1 which I forgot to blog what differences he noticed btw US Health care and Taiwan Health care system (since he's been to the US). He told me that most people have the government insurance, which is fairly cheap, so a lot of patients come to see doctors more often. Health care is very accessible in Taiwan, and some patients take advantage of this and come in to see doctors more often than they should, which is not good sometime. He also said that in the US, we have stricter requirements about ordering tests (order necessary tests with appropriate reasons).

I noticed that everything at TIHTC is very fast paced, while as Dr. Yu mentioned there are many procedures or "layers" to US health care system.

6/8/2011-TCM General Outpatient -Jessica

Today we begun our day with yet another new preceptor: Dr. Chen (陳建安醫師). Dr. Chen's specialty was oncology and the use of acupuncture to help alleviate the adverse effects of cancer treatment and also for recovery for stroke patients. Since it is a relatively slow morning, we spent much time talking to Dr. Chen, asking many of the questions that was raised from our observation of Dr. Ho yesterday. For example, we were curious about how the TCM doctors resolve the issue of simultaneous treatment by both western and Chinese medicine. Unfortunately, Dr. Chen does not think there is a well researched consensus among TCM doctors either on this issue. Some say at least 4 hours in between and some say 1 to 1.5 hour. We also asked about why we do not see any Tui-Na or traumatology in the clinics. To our surprise, Dr. Chen answered that Tui-Na is no longer practiced by the TCM doctors, instead, they are practiced mainly by chiropractors/massage therapists due to its low pay (problem with the national health insurance in Taiwan)  and its taxing nature on the practitioner's hands and physical energy. Although I was surprised that it is no longer practiced, I was not surprised that it pays little, since I think most manual medicine will probably face similar problem with the insurance agencies, nor was I surprised that it was also because it is too tiring for the practitioners, since that is also a problem with OMT for the DO doctors too.

 After asking our questions, Dr. Chen also gave us a short presentation covering many more commonly know acupuncture points, such as 合谷, 陽陵泉, 足三里...etc. I was pleasantly surprised that I actually know few of them just from observing Dr. Hsieh yesterday, which makes me even more excited for the afternoon session with Dr. Chen, since he would not be as busy as yesterday and will probably have more time to teach us and answer the questions we have for TCM.

TCM Rotation Day 2 General Clinic 8-June-2011

Jessica did a great job describing the obesity acupuncture points yesterday so I will start off the day with the acupuncture point protocol drawing that Dr. Hsieh (Dr. 謝) drew for Jessica and I yesterday below in case anyone wants to see a visual.

Jessica and I started the day in the TCM department with a new preceptor in the morning with Dr. Chen Chien-An (Dr. 陳建安) who is trained in both TCM and western medicine (radiation oncology). It was a rather slow day and only a few appointments were scheduled so we had time to converse about TCM with Dr. Chen. Topics included the inter-reliability problems in TCM much like OMM. As TCM is much of a clinical model, based off clinical experiences, he believes that the future of TCM is to have lab results and diagnostic exams correlated to treatments. He was very interested when I told him about how one of my TCM practitioners had used spinal X-rays to assess rotation and side-bending in my spine after initial treatment to target his Tui Na work. In addition to more rigorous research he was concerned with proper sanitary protocols to be used in TCM. He stated that while proper protocols like hand washing and proper preparation before acupuncture after every patient encounter needed to become more consistent.
In the afternoon we headed back to Dr. Ho’s clinic. It was a very exciting day as Dr. Ho spent time teaching us where and what he was feeling during his TART exam after we explained to him more about Osteopathic Medicine. He let us check for TART using our own method (Stiles screening) before and after treatment then showed us his how to use his own screening diagnostic method. From what I understand his contact appears to be more on the myofascial layer and he is able to find points of hypertonicity and restriction by assessing fascial drag. I was amazed at some of the restrictions that Dr. Ho was able to find with his hands. We also obtained permission to record some of the techniques that he used, so I will be editing the videos. He also seemed very interested in seeing some video of OMM done by one of our professors so we may work on getting something together after we clear it with the departments.
Any case off to more video editing.

Neurology - Day 1

We started off the day with a case study. That was pretty interesting. It totally reminded me of our pathology labs in which we had to discuss cases with our TBL group. I always found myself learning a lot from case studies.

So, at 9am I went on rounds with Dr. Yu.

Case 1: 65 yo female found unresponsive at home for 2 days. H/o DM which is under control with diet and medication. General weakness (3/5) upon admission. Stable after 2 days at the hospital. On Furosemide to help with pitting edema. Was given ASA but had GI bleed so stopped ASA. Give 1st generation Cephalosporin because of lower UTI.

Case 2: 56 yo male with h/o HTN and DM. Present with right hemiplagia. He has cerebromuscular disease. Severe hematuria present in urine but is getting better. Continuous flushing blood clots with intravesicular water

Case 3: 80 yo male present with behavioral dysfunction after stroke. Came to hospital in May because of 2nd stroke. Has central nystagmus, suspect central lesion of brainstem. Dysmetria. Brain CT: no hemorrhage (we need to know the differences btw ischemic vs. hemorrhage stroke). An ischemic stroke usually takes 24 hrs to show on CAT, so do MRI (diffusion MRI very sensitive) which is more sensitive to early sign of ischemia. MED: Persantin which enhances ASA effect, Diphenidol for stroke, Colchicine for Gout. Entrococcus spp. found in culture

What I learned on the rounds:

1. How to perform Babinski reflex

2. A. Fib --> blood stasis and blood deposits in dead spaces in atrium--> heart pumps out emboli --> to brain --> can occur major arteries or small vessels

3. Clinical presentations are very important to diagnosis. They guide reasons to order appropriate tests

In the Doppler lab, I got to see how technician performs the study. RI = resistance index. Increase RI if stenosis of arteries.

Indications for Doppler study:

1. Syncope

2. Suspect of atherosclerosis of arteries supplying brain in high-risk patients

3. others (I need to look these up)

What I learned from Doppler lab:

1. Know the circle of Willis anatomy

2. Toast classification of ischemic stroke: a. thrombosis or emboli due to artherosclerosis. b. embolism of cardiac origin. c. occlusion of small vessels. d. other determined or undetermined causes

3. Know hemodynamic criteria for ICA stenosis

At Botox clinic:

1. Indications: dystonia, local pain, cosmetic reasons, writer's cramp, etc.

2. Effects of botox on facial muscle spasm take about 1 week. Do not wash face with hot H2O because that will speed up the effects of botox which last about 3 months (The government only allows 3 tx/yr so most patients come in with full on signs of dystonia)

What I learned at the clinic:

1. Know the muscles of face and neck (very important)

2. #1 sign of dystonia = excessive blinking

3. Meige's syndrome = a type of dystonia, usu. a combination of blepharospasm and OMD

Oncology rotation Day 1&2 (June 7-8, 2011)

June 07, 2011

We started our first day of summer clerkship with the case presentation held in internal medicine department. The case is a 36 years old alcoholic male with chief complaint of hematemesis. The attending physician Dr. Wu asked the residents one by one about possible differential diagnosis for each sign or syndrome of this patient (e.g. Mallory Weiss syndrome or severe GI bleeding can cause hematemesis.) The residents were also asked to describe why they choose the differential diagnosis and give the list of tests that can support their differential diagnosis. This is a valuable experience for me since it gave an idea what I will face in my future as a resident physician.

After the case discussion, Amanda, Karen, Sandy and I met Dr. Chun-Yi Chen, the head of oncology department. We shadowed him throughout his outpatient hours. This morning he had about 20 patients visiting him. Most of these patients had breast cancer. Dr. Chen told us the situation of each patient during and after the patient visit. Since he got some many breast cancer patients in the clinic, we learned a lot about breast cancer in Taiwan. For example, in the U.S. breast cancer is usually diagnosed after age 55, but in Taiwan it is at age 45. He also pointed out the close association between diabetes and breast cancer he observed as a long-time oncologist. He mentioned that about 20 percent of DM patients also have breast cancer. He suggested us to find out if we have similar findings in the U.S. and suspected the insulin growth factor as the possible cause.

Sitting behind Dr. Chen gave us an opportunity to observe his interactions with the patients. Every patient walked into the room acted like his long-time friend. He made jokes to almost every patient, and many of them had smiles on their face all the time during the visit. Some patients told us that Dr. Chen is the best because he is so friendly and caring for them. And I guess his humor is another reason they like him because his jokes made them laugh, feel better, and have more positive thinking. Actually patients love and respect him so much that some of them said they will follow him to another hospital no matter which hospital he will go to. For me, Dr. Chen is the ideal model of physician I want to be.

Besides observing the interactions between patients and Dr. Chen, we also got the opportunity to interview three patients. One patient we interviewed had invasive thyoma. She told us how the tumor was found in her annual physical exam and had the tumor removed by surgery. Four months after surgery, her CT scan showed a small mass on pleura, and that was diagnosed as pleural lipoma. But later CT and that mass got enlarged over three months, so it was identified as malignancy and removed by surgery. Thyoma is a rare cancer and usually benign. But in her case, pleural metastasis was found and that’s why it’s called invasive thyoma.

After the lunch break, Dr. Chen took us on rounds and gave us a tour of negative pressure room where they prepare chemotherapy drugs and cell cultures. Then he gave us a wonderful presentation about lung cancer. We learned that most lung cancer in Asia is adenocarcinoma and 70% of Asian patients with adenocarcinoma have EGFR mutation. In other word, EGFR is an important factor for treating lung cancer among Asian population. He introduced two ways to block EGFR pathway: monoclonal antibodies against EGFR and TKI that can go inside the cell and bind to ATP binding site of tyrosine kinase. Since EGFR can mutate in lung cancer, TKI work better than monoclonal antibodies. And TKI should be used to treat any lung cancer with EGFR mutation regardless pathological finding (the exception is the presence of K-ras mutation). We also learned some general rules about cancer treatment. For example, dual block usually works better and patients responding well to targeted therapy also respond well to chemotherapy. The two-hour long presentation provided us a lot of information about staging and treating lung cancer. And what I learned from that will be very useful if I have Asian lung cancer patients in the future.

June 08, 2011

We met at Dr. Chen’s office at 9 am and he gave us another presentation about cancer. Today the topic is colorectal cancer. Colorectal cancer is the most prevalent cancer in Taiwan and it’s increasing in Asia at rate of 5% per year. He started his presentation with case history of one of his colorectal cancer patient. The patient has enlarged Virchow’s node, which is the left supraclavicular lymph node. Lymphadenopathy of Virchow’s node usually suggests the presence of GI malignancy because it takes its supply from lymph vessels in the abdominal cavity (through thoracic duct). He also introduced chemotherapy drugs used in treating colorectal cancer. FOLFOX (5-FU + Leucovorin +Oxaliplatin) and FOLFIRI (5-FU + Leucovorin + Irinotecan) are two of the most effective chemotherapy. Cetuximab (mAB against EGFR) and bevacizumab (mAB against VEGF) are other treatments used in colorectal cancer. Dr. Chen also pointed out the synergistic effect when using FOLFIRI combined with cetuximab. Cetuximab can block cancer cells’ repair mechanism toward the DNA damage caused by irinotecan, a topoisomerase I inhibitor. Exposure to chemotherapy can stimulate upregulation of EGFR pathway in cancer cells, and that provides more targets cetuximab can work on. According to Dr. Chen, cetuximab is a very interesting drug. It’s not only because of its side effect on skin (e.g. acne-like rash, pruritus, dry skin, etc) but also because of its characteristic that the stronger skin reaction are more effective the therapy will be. And right after Dr. Chen’s presentation about cetuximab, one of his patients who are currently using cetuximab walked into the office, so we got the opportunity to see real patient with cetuximab-induced skin reaction like fissura, dry and fragile skin and abnormally long eyelashes (trichomegaly).

After the lunch break, we shadowed Dr. Chen in his outpatient clinic. Today he had 16 patients visiting him. One female name on the patient list caught my attention right away. That’s because she came to visit alone yesterday in a very sad mood and wanted to stop her IV chemotherapy for six months because of the pain from frequent injection. But Dr. Chen said he can stop chemotherapy temporarily but firmly insisted her to meet him again in two week. Today she changed her mind about stopping chemotherapy and came to visit with her daughter. Dr. Chen arranged her to get a CT scan in the morning and viewed the image when meeting her in the clinic. The CT scan showed the bad news. There are metastasis to pleura and lung, which is unusual in breast cancer patient. The worst is that the cancer also invaded right bronchus and that should be quickly dealt with otherwise it will influence her ability to breath. So Dr. Chen tried to arrange a radiation therapy for her as soon as possible. Since this hospital cannot provide radiation therapy, she needs to be referred to another hospital. The closest hospital with radiation therapy facility has no bed available, which will be a problem since the patient is receiving IV chemotherapy. He can manage to get a bed in the second closest hospital, but it’s not convenient for patient since she doesn’t have car. Dr. Chen tried hard but could not figure out the best place for her to receive radiation therapy. So he asked a TCM physician who has been radiation oncologist come to his clinic. They went through the CT scan and discussed about the appropriate target area of radiation therapy in detail. Dr. Chen also asked him which of the two hospitals is better for the patient. That TCM physician provided him a very good solution --- referring the patient to the closest hospital and giving her oral chemotherapy instead of IV one.

From this whole process, I learned three important criteria a good physician should have. One is that a good physician will not easily let his/her patient give up receiving treatment. In this case, the patient wanted to give up because of pain, but Dr. Chen insisted extra two weeks for patient to reconsider her decision instead of just following her request. Another thing I learned is that a good physician should be considerate. For example, Dr. Chen allowed temporarily stop of IV chemotherapy so that she can get a break from the pain caused by repeated needle punctures. And he puts the convenience to the patient in his consideration when choosing hospital for radiation therapy. The last thing is that a good physician should be able to work with other health care providers to make what is the best for the patient. In this case, Dr. Chen worked with the TCM physician who is expert in radiation oncology to design the best radiation therapy for treatment. And without the cooperation between these two physicians, there will not be that good solution that not only avoids pain from frequent injections but also makes receiving radiation therapy easier for the patient.

outpatient clinic

Having seen two days of outpatient clinic (in neurology and oncology) has shown me the differences between Taiwanese and US styles of patient care. The Taiwanese clinic seems to be more efficient because the doctor is able to see 10-20 patients per hour. The doctor here sits in his office/exam room with 2 nurses and patients come in and out to speak with him. The patients are all numbered and, like the DMV in the US, are called in by number outside of the door. The doctor spends about 5-10 minutes with the patient, answering any questions and doing any quick exam that is necessary. If the patient needs lab tests, the patient is sent directly to the lab and the results are sent back to the doctor fairly quickly to be discussed with the patient. The insurance system is electronic and the doctor does the billing while speaking with the patient. The charting is also done simultaneously and is printed out for the nurses to paste into the patients chart. And this all occurs in the short time that the patient sees the physician. The doctors that I have shadowed also seem to make time to explain small things to me in English, which is quite impressive considering the speed at which they are working. Comparing this to the US, where the doctor probably sees four patients in one hour, and has to do his charting and billing separately, this seems to be very efficient. I have really enjoyed seeing this difference and appreciate the fact that the US should possibly learn from other countries to make the system more efficient.

Oncology Day 2/4 - Sandy

Today in the morning, Dr. Chen gave us (Bor-Han, Amanda and I) an informal presentation on colon cancer and in the afternoon, we observed him seeing patients in the outpatient clinic.

Colorectal cancer is the most common cancer in Taiwan – it occurs most frequently in the rectum, followed by sigmoid and ascending colon. Dr. Chen told us a case about a patient with colon cancer metastasized to the liver, and the conversion therapy available that can change this originally unresectable, advanced-staged liver metastasis to being resectable after chemotherapy. The patient would take a combination of drugs with different mechanisms, including 5 FU, leucovorin, irinotecan and oxaliplatin. Although the success rate is humble, about 20-30% of the trials are successful, the result is still promising. And from this data, Dr. Chen reminded us that a tumor is heterogenous, and we must always keep in mind about the possibility of drug resistance when treating our patients in the future.

We talked about how many cycles of chemotherapy are required to control a tumor, and Dr. Chen explained to us in-depth of how an average of 4-6 cycles of chemotherapy for a cancer patient came about. One cm of tumor is approximately 10^9 cells and our goal is to shrink a tumor to be less than 10^4 cells, as that is when our immune system would have control over it. Ever cycle of chemo kills about 90% of 1 log of cells, so it would take about 5 cycles of cells to shrink the tumor down to manageable size. To be confident that the tumor has shrunk, 6 cycles of chemotherapy are typically performed. Dr. Chen’s insightful explanation was excellent, and it is this kind of in-depth analysis of oncology that fascinates me as my mind begs for more.

Ironically, Dr. Chen reminded us not to be so focus to learn about learning the details and focus on the big picture instead. He said that the most important thing to learn about is to observe his bedside manner, learn the clinical symptoms, and we will have the rest of our lives to learn about the nitty-gritty, unending details of medicine. I really admire Dr. Chen’s attitude, as he employs an easy going personality and a broad perspective on medicine. His expertise in both science and clinical medicine earns him the affection of many patients – they showered him with gift certificates to restaurant and coffees for his staff. He generously gave the three of us all the coffees to bring home and we thanked him. In the back of my mind, I hope to be as respected as he is of a physician, someday.