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Reflections on my Trip to Taiwan

Christine D. Wang

I am in a bleak hospital waiting room, surrounded by rows and rows of chairs with dozens of people milling around, waiting, waiting... Number 84 pops up on the screen, oh that's me. As I enter the doctor's office, I see a desk with a doctor and his nurses sitting on both sides of the desk. Behind him are six students and residents, half staring, half sleeping. I take a chair and tell the doctor my complaint. After only a few brief questions, he diagnoses my problem, prescribes five medicines, and quickly ushers me out the door, all within a matter of minutes. The next patient is already in the room waiting for me to finish. No introductions, no physical exam, no instructions, only a handful of prescriptions as I leave the room.

This is my picture of a patient experience during a routine clinic visit in Taiwan. During March and April 2000, I had the opportunity to rotate through various hospitals in Taiwan. I was a fourth-year medical student at Vanderbilt University in Nashville, Tennessee and took the freedom of my fourth year to observe medical care in Taiwan, from inpatient wards to outpatient clinics to mobile clinics. First, I spent four weeks at National Cheng Kung University Hospital in Tainan, in the departments of pediatrics and dermatology. Then for one week I was in the Traditional Chinese Medicine Department at Chang Gung Memorial Hospital in Linkou. I ended my trip with three weeks at the Mennonite Christian Hospital in Hualien, doing obstetrics-gynecology, internal medicine, and rural/family medicine. In addition to my medical rotations in Taiwan, I had the opportunity to visit relatives, participate in language exchange with other Taiwanese students, and participate in the exciting presidential election process in March.

Throughout my experiences in Taiwan, I was able to see how medical care and medical education are done at several Taiwan institutions, as well as reflect on and compare with what I have seen in America during my years of medical school. In both Taiwan and America, medicine has the same purpose: caring for the patient by diagnosing and treating illnesses. Likewise, medical education has the same goal: training students to become competent and caring physicians. Differences have arisen based on how medicine has developed in the respective countries and their cultural expectations of medical care. These similarities and differences can be seen in comparing medical education, inpatient and outpatient care.

I. Medical Education

Superficially, medical education in Taiwan and the path to get into medical school are very different from that in America. Students must study extremely hard in order to do well on their national exams which determine which medical school they will attend. This is very different from the American application process, consisting of a personal statement, grades, MCAT exam, activities, letters of recommendation, and interviews. American students have more institutions from which to choose, and their futures are not based on a single test. In both countries, however, attaining entrance to medical school is very competitive and an honor to finally achieve.

In Taiwan, medical school consists of seven years of education, starting right after high school, with two years undergraduate study, two years basic sciences, two years clerkships, and one year internship. In the US, medical school is a post-graduate institution; therefore, students begin after completing four years of college. Typically, medical school consists of two years of basic sciences followed by two years of clinical experience. While internship is the seventh year of study in Taiwan, it is the first year of residency in America. The Taiwan “internship” has the responsibilities similar to an American externship or fourth-year student, while the American “intern” is the same as Taiwan’s first-year resident.

Spending time with medical students and residents was definitely the highlight of my time in Taiwan. I was amazed at their ability to learn medicine in a foreign language, English. Learning medicine is difficult already, but to have to read English textbooks and journals was impressive. What struck me most was how similar Taiwanese medical students were to American students – studying a lot, not having much time for leisure activities, but still making efforts to pursue interests outside of medicine. We were all overwhelmed by the quantity of information we needed to learn, but we also had the desire to be competent and caring physicians. They were very welcoming and helped us find our way in the hospital. I only hope that American students are this hospitable to foreign students who come to US hospitals.

II. Inpatient Medicine

I began my Taiwan experience with three weeks in inpatient pediatrics and the neonatal intensive care unit. I also participated in inpatient medicine and Ob-Gyn. For the most part, inpatient medicine was the most similar to American medicine, as compared to outpatient medicine. I saw common cases, ranging from asthma to meningitis. The work-up was basically the same and the residents were as over-worked in Taiwan as they are in America. Resident education was also very similar, with morning case conferences, plenty of patients, attending rounds, and teaching conferences. The hospital had many of the same technologies, from cardiac caths to MRI’s, with all the subspecialties represented.

The few differences I observed in inpatient medical care included some disease processes much less common in the US, such as G6PD deficiency, chronic arsenism, scrub typhus, and more widespread active tuberculosis. Other significant differences I saw were the length of hospitalization and the number of unnecessary hospitalizations. Unlike the US, where the emphasis is on getting the patients out of the hospital as soon as possible, in Taiwan many patients would stay for weeks, when they would have been discharged much earlier in the US. Because the cost of a hospital stay is not excessive, many families would choose to admit their children to the hospital even if they were not that ill. Physicians would agree to hospitalization, not for medical necessity but because the families were very concerned and would not be satisfied otherwise.

III. Outpatient Medicine

During my weeks on outpatient clinics, from dermatology to Ob-Gyn to internal medicine, I was most impressed by the differences between outpatient medicine in Taiwan compared to America. First, each physician needs to see an inordinate number of patients. For example, one OB physician with whom I worked saw over 100 patients at each three-hour clinic shift, which added up to over 600 patients a week! Some nights he even saw 200 patients. While most physicians did not see this many patients at a time, it was not uncommon for one doctor to see 40-60 patients in a morning. As described in the first paragraph, patients are rushed in and out of the doctor’s office, with little or no time for patient education or preventive medicine. While this system allows for more efficiency, it also prevents the development of the patient-doctor relationship.

Another difference was patient expectations. Because this is the way medicine has developed in Taiwan, the patients expect this type of medical care. Patients also expect to be prescribed multiple medications, even for illnesses that do not require medication, such as viral illnesses. I was told the average patient walks away from a clinic visit with 3.5 prescriptions. In one clinic I observed, elderly patients were given IV infusions of glucose water because the patients believed that only IV meds would help. I was shocked that physicians would give in to this, but otherwise, these patients would not ever seek medical help. In contrast, in America there is an impetus to prescribe fewer medications to improve patient compliance, reduce drug-drug interactions, and cut down on costs.

It was also interesting to discuss insurance problems with physicians. In both Taiwan and America, the issue of how to provide affordable medical care to all of its residents remains a huge problem with an elusive answer. In Taiwan, they have a national insurance program which has been successful in covering a large number of people. However, physicians are being reimbursed only a few dollars for each patient visit, causing them to schedule more and more patients in order to make ends meet. Furthermore, the program is losing millions of dollars a month and changes are being considered. In the US, physicians are also disgruntled with insurance and HMO’s, and a large portion of the population remains without any insurance. In both Taiwan and the US, the need to provide affordable medical care is of paramount importance but remains a large problem.

Conclusion

As I look back on my time in Taiwan and all that I have learned both inside and outside the hospitals, I am very grateful for the opportunity to have gone overseas. I mostly enjoyed getting to know the people in Taiwan, especially the medical students, residents, and attendings. I also learned a lot about Taiwanese culture and its people, and I hopefully improved my Taiwanese and Chinese as well. There is a lot to learn from other cultures and countries, and experiences such as these cause one to appreciate all the blessings we have in America and to see what we can take back to America.