have I seen the following senario so widely accepted to be the norm:
My grandma, who is a happy and pretty healthy 82 year-old, recently had a cough. She has been afebrile, and maintained good hydration and appetite. She has no constitutional symptoms like malaise and weight loss either. Her cough is productive of some yellow phlegm, and it’s been going on for about a week, so she was prescribed some antibiotics and some antitussives, and was asked to follow up in the clinic in 3 days.
Bread and butter primary care, right?
Except she went to a pediatrician‘s office.
And the thing is, I would not have thought twice about this situation a few years ago, because that is really normal in Taiwan where I grew up. There are virtually no family docs (and no patient knows what family docs do even if they see one) on the streets where medical clinics tend to cluster and where patients go see doctors. There is no concept of longitudinal care either; if the doctor in this clinic isn’t helping, patients will go to the next one down the street. (And if all else fails, or if the patients decide the problem is serious enough, they will present to the best tertiary hospital they can get to.)
So that’s what my grandma did after seeing two different pediatricians and still had the cough. She went to an ENT surgeon’s clinic.
Yes. Ear, nose, and throat surgeons who went through years and years of extra surgical training to operate on some of the most vital (airway) and aesthetically important (face) areas of the body are common go-to doctors for mild URTI in Taiwan.
Imagine the hilarity if that happened in Canada. If a 82 year old woman is referred to a pediatrician for a case of mild URTI or bronchitis? Or, heaven forbid, an ENT surgeon? The primary doctor who made the referral would not even be taken seriously enough to be yelled at. The pediatrician’s or ENT’s secretary (or medical office assistant) would probably politely talk to the primary doc’s secretary and ask him or her to check the correct addressee.
Now, this is not a criticism of the patients or the doctors in Taiwan. Both parties are doing what everyone is doing, in a way how everything has been done. In other words, this is the current medical culture of Taiwan, and no one can be faulted for doing things in the most culturally accepted way.
But just because something has always been like that in the past doesn’t mean it should alway be the same in the future. Think about the downside of having streets of medical clinics run by specialists, advertised to be the former attending doctors or even heads of departments of prestigious tertiary hospitals and academic centers, to whom hundreds of ill patients and their worried families present any condition under the sun. The patients have only their understanding of the specialty title to base their self-referral on. “ENT? Sounds like a good doctor for coughing which is kinda in the throat.” “Stomachache? Probably like the ones I had when I was a kid. Let’s see the nice pediatrician who saw little Johnny last week.”
Well, for starters, the specialists would either go mad and burn out (“WHY AM I SEEING 30 CASES OF VIRAL DIARRHEA A DAY AS A COLORECTAL SURGEON!?”) or become content with being a GP. There goes years of intense, valuable specialty training. Also, the patients are probably getting suboptimal care because of their inappropriate self-referral. They can decide that an internist is the best for their child who is vomiting, but the internist may very well not know the complete list of differential diagnoses of pediatric vomiting by heart.
I can probably go on with the problems with the current medical model in Taiwan, but I think you get the idea. The bottom line is, this model probably poses a serious drain on the health care dollar, creates unnecessary confusion and suboptimal care for the patients, and leads to much headaches and burnouts for the doctors.
The big question is, how do we change it?
That, my friend, is a good question. If you can answer it well, you should consider becoming Taiwan’s health minister.
As for me, I just ordered some delish Chinese take out and will be too distracted after the break 
Yum yum yum yum.
GOTCHA!!!”
