By Yu-Chien Kuo, MD

Whittier Presbyterian Hospital, California, USA

    The hospital is what I expected for a teaching hospital-large and busy. It is akin to our LA County Hospital in many respects. There are many residency programs under one roof, and thus there will be turf battles and bickering of responsibility. However, medicine is still practiced there, patients are treated, and residents trained and graduated. My own hospital in Whittier is a community-based hospital, and only supports one residency program, the Family Practice. Family Practice crosses the lines into other fields, and sees a wide variety of patients. Thus, being the only program in the hospital, our Family Practice has fewer battles for patients and procedures. There are no limits to our experiences. It only depends on our own efforts.

    My first week here in the Family Practice was very interesting. I could not believe the volume of patients that are seen in the clinic. A doctor can see 50-60 patients in a morning. If I see 10-12 in a morning, I am seeing a lot. These volumes are a product of the people, society, and government. Patients in Taiwan can choose to see any physician they choose. Medical care is cheap so volume is needed to make up the difference if a physician is to make a living. Patients can see many physicians in one day, even for the same problem. Thus to keep the patients returning, a physician must keep the patients happy. This translates into not making them wait, drawing blood for tests, and giving medication. The trouble of this type of practice is improper diagnosis, unnecessary blood tests, and polypharmacy. There seems to lack a stepwise approach to medical treatment, and no thought as to the differential diagnosis, because that would take too long.

    Patient expectations further drive this type of medical practice. A patient can still be telling the physician of symptoms with the family members standing behind him but are driven out of the room, ending the visit. Patients and families do not expect to speak to the physician for long periods of time. They expect quick results, often to their disadvantage. I find that Taiwanese patients are also not very receptive to patient education about disease states and processes. This is probably a product of their past experience of the medical process. Patients are generally older, and they grew up with quick visits and a fist full of medications. Their perceptions are difficult to change, and unfortunately are being passed to the next generation.

    The expectation of speed needs to be modified. It is difficult to show compassion and concern in 2 minutes. The emphasis should be on correct diagnosis and patient education. Patients need to understand that it took them days to get sick, so it will take at least that long to get well too. Perhaps the younger generation is a place to start. However, with so many patients waiting, the physician is also reluctant to spend the time. There is hardly time even for a physical examination. It is quicker to just give them what they want so they will leave, so the physician can attend to the next patient.

    I am somewhat dismayed at the relative lack of procedures among the family practice residents. My understanding of family practice is an all accompanying field, a jack-of-all-trades. We are not experts in a specific field, but we are experts in the common disease processes. We can do many procedures just as well as the specialists. I was shocked to see that very few residents have done a Pap smear. This is one of the most basic and frequent procedures for a family physician. When I look for a job next year, my employer will be very interested in what procedures I can do. Again, maybe it is the medical environment family practice finds itself in that restricts its scope of practice. I hope that this will change in the future.

    Every visit with a patient is an opportunity to bring them back for health screening, even if it is just a cold. Every one of my female patients is asked if their Pap smear or mammogram is up to date. If not, that is an opportunity for another visit, and further patient education. I also ask parents of the health of their children, if they have had their annual exam or if their immunizations are up to date. Every visit is an opportunity to expand your practice.

    The prevalence of hepatoma is much higher here in Taiwan. To have a case in the States is not commonplace. Thus training in abdominal ultrasound is essential for screening and follow up for residents in Taiwan. I am not trained in ultrasound in my program due to relative lack of necessity. I agree that it is a very useful tool, and wish I could be thus trained. Due to the large numbers of hepatitis B and C infections here, Taiwan has much more experience in the treatment and follow up for these disease processes. The world could learn from this volume of data. This is an ideal setting for hepatologists to train.

    My second week was on the internal medical wards. The wards are, as expected, a scene of controlled chaos. Residents are attending to patients and attendings breezing in for bedside rounds. I find that junior residents are relatively unsupervised while on the wards. That is okay, until something happens. My greatest difficulty as a junior resident is knowing when I needed help in managing a patient. I did not always recognize the warning signs. When I did finally realize it, it was a little late, and the patient suffered the effects of my oversight.

    We have a policy at my hospital in Whittier that all resident procedures must be supervised. The attending must at least know you are doing the procedure, even if they are not physically present. If I am uncomfortable, I will ask for supervision, even if it is just moral support. To learn the procedure correctly the first time will make the second easier to accomplish. The “see one, do one, teach one” saying has merits. After all, if there are complication, it is the attending that is ultimately faulted for improper supervision.

    In reviewing the charts of many patients, it seems to me that there are always too many medications. The practice of renewing orders is a good one, as it forces you to reevaluate how you are treating the patient. Most residents probably see it as just more busy work. However, I do not know if residents are actually reviewing the orders, or just copying from the previous order sheet. I doubt if patients know what medications they are taking, or why they are taking it.

    There is a lot of paperwork to be done on the wards, wasting a lot of time. Each laboratory order has its own order sheets to be filled out. This is akin to County hospital. At Whittier, the laboratory orders are written and then entered into the computer. This cuts down on all the clutter.

I find that physicians here address the family members more frequently than the patient himself. This is due to cultural differences. The family is the more important unit here. Many families do not wish the patient to know the disease or the prognosis. I find this unfair to the patient, but this is the accepted practice here.

    A more concerning issue to me is the daily use of FFP and Lasix in treating ascities. I realize that FFP is cheaper than albumin, so it is the preferred agent. I also understand that albumin is not the first line treatment for ascities. First line is volume restriction and salt restriction. If needed, do a paracentesis. There are times when a volume expanding agent will be needed to mobilize the third spaced fluid, but daily use of 4 units of FFP? FFP is not a benign product. It is a blood product, and thus carries the risks of all blood transfusions. I doubt if patients know of the risks. FFP is also a limited resource. I do not understand where this practice eminated from. In searching textbooks, I could not find evidence for such treatment. I would like to see the evidence-based literature on this matter.

    There still exists here the aura of the attending physician as “all knowing, infallable”, as in the Japanese culture. I would caution residents from this attitude or practice. Medicine so vast and it is continually changing. What is correct today may not be correct tomorrow. It is difficult to always be on the cutting edge. There must exist a dialogue between physicians of all levels and specialties to freely exchange knowledge. There is no shame in making a mistake. The job of a medical student is to learn how to treat a patient. The job of a resident is to question why we treat patients so, and search for better ways. The job of an attending is to teach, but also to learn. This is all for a common goal, the well being of the patient. To be a physician is to accept that you will always be a student, always learning.

    My final days were spent in the Emergency Department. Its look and operation, again reminded me a lot of LA County hospital. Lots of patients on gurneys lining the walls, waiting. The hospital Emergency Room (ER) , unfortunately becomes a medical ward in itself due to lack of beds and the ongoing bickering of the departments in accepting patients. It is not unusual for patients to spend days in the ER undergoing treatment, and then being discharged from there.

    Residents who rotate in ER are actually just doing another internal medicine ward rotation rather than learning emergency room medicine. If this is the case, there is no need for an Emergency Department. There only needs to be a triage area, and an urgent medical care area. Everyone else goes to the general holding area until a bed is available, or the patient gets tired of waiting. There needs to be more cooperation between the departments to smoothly transition patients onto the wards. Again, the patients themselves are a big factor. It they expect to be hospitalized, it is difficult to get them to go home. Thus they will wait for a bed until they get tired of waiting.

    The conflict of the departments is difficult to resolve. Every department head is territorial and proptective. They want to be able to dictate what they will do, and what they will not. I find this most true of the surgical departments. If all they want to do is to operate, then they are more interested in the technical procedure, and not in being a physicians. Anyone can learn to do a technical procedure without a medical education. Care of the patient extends from pre-op evaluation, to the procedure, to the recovery period. I find this lack of patient care unbecoming of a proper physician.

    There is a lack of infection control in the ER. This is one of the reasons why TB is so prevalent here. Transmittable diseases are not well contained. I feel that I need to get myself tested for TB when I return to the States. I would not be surprised if I test positive now. It seems unlikely that the ER would close if an environmental hazard walked in the door, unlike US ER’s. There is a need for decontamination for the safety of all patients and staff. I understand this is an ongoing topic of discussion in the Emergency Department.

    My visit here to the Tertiary Referral Hospital has been very informative. The differences in the people, society and government influence how medicine is practiced here. There is no right or wrong way. Sick patients get better in Taiwan just as they do in the US. Medicine is continually changing, and we as physicians will change with it. The patient attitude will slowly change as the governmental policies regarding health care changes. I suspect that there will be stop gap measures implemented in the future to prevent the tremendous waste that occurs under the current policy. The current policy is bound to fail, and will have to be reevaluated sooner or later. Both patients and physicians will feel uncomfortable with the change, but overall, it will be a better policy.

    I’d like to thank several doctors for their time and effort in supervising and arranging my rotation here at the Tertiary Referral Hospital. Without them, my time here would not have been possible.