Only in Taiwan

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.


Gender equality

is hard to come by. With an emphasis on “equality”, which I would define as being equal, or the same. In the literal sense, of course male and female cannot be the same, nor is it desirable for male and female to be the same. Gynecomastia, virilization, hirsutism, etc. are symptoms for men and women whose hormone balances tip towards the opposite sex.

Ok, enough tongue-in-cheek. No one means “equality” in its literal sense when they discuss the topic of gender equality. So, what do they really mean?

There is no specialty for which the gender ratio is 50:50. There are more male orthopods, and there are more female ob/gyns. There are more female medical students and general practitioners today, which is a shift from the previous era. Is that inequality? Is it unfair that, under the current admission standard, more female medical students are selected over male ones? Should it be tweaked so that we have a 50:50 split every year?

It turns out that equality is a very difficult notion to define. Perhaps it means that men and women are given equal opportunities, responsibilities, reward, and respect. That is all fine in words but complicated in practice, because men and women are biologically and therefore fundamentally different. The average men have higher water and lean mass content than the average women (actually the medical literature defines “typical men” as white males in their 25-35s or something like that but it works for our argument). The average men have higher testosterone than the average woman. This biological difference results in some phenotypical differences that are fundamental to each gender and therefore difficult to change. Such things include: greater physical strength and higher rate of aggression in the average male, and greater social skills and higher rates of depression in the average female. Note that I have deliberately used the “average” male and female because there are of course variability in each population, and we need to focus our discussion on the populations to avoid “but there are some women who are twice as strong as your skinny ass” type of rebuttal. 

But the fundamental difference between the genders end pretty quickly after basic biology and perhaps some psychology. Beyond that, as we move further away from the XX vs XY end of the divide and closer towards the Office vs Kitchen stereotypes, biology plays a smaller and smaller role. If the average women spend more time in the kitchen than the average men, I’d argue that has to do more with society than with biology. And I’d further argue that since society change as people change, there is no reason why the average women have to spend more time in the kitchen than men. Same goes to earning money. Becoming good doctors. And winning presidential elections.

In other words, I think that differences between men and women are due to two factors: biology and society/environment. (Good old multifactorial, nature vs nurture explanation.) Some differences between genders are more due to biology than society, and some the other way around.

So the issue becomes, what kind of societal pressures is in place to keep men and women live life differently? And which of these pressures are desirable and which are not? For one clear case of societal pressure as example: the guy usually buys the diamond ring and proposes to the girl. Is it a desirable societally-pressured inequality? Should we strive for equality and start a movement where girls propose to guys (with awesome computer gadgets, perhaps)? Another societal and historically based inequality: the baby usually takes on the dad’s last name. Does it have to be that way? Should we make the “family name” the mom’s name or the dad’s name based on a coin toss?

Nah probably not. Either proposal would be kinda weird. But any shifting of paradigm in society would be kinda weird at first, so it being weird doesn’t mean we shouldn’t do it. On a societal level, what gender inequalities should be kept and which ones should be fought needs to be dealt with on a case-by-case basis as our culture evolves.

On an individual basis, though, the above argument does not apply. As I mentioned, people are different and probably follow a normal distribution for aggressiveness, emotionality, assertiveness, chivalry, etc. This means there are probably many women more aggressive than many men, many men more emotional than many women, and so on. How a couple could work out the balance will be unique to that couple, and it may very well carry a wide range of normal.

So when someone say: “men should get their balls back and be manly” or “women should be nicer and more girly” in a relationship, I would say: depends on who you are talking about, what their relationship is like, and on what circumstances you are basing your critique. If you are critiquing on the society as a whole, then I would say: good on ya, trying to shape our culture one facebook comment at a time!

Why I am writing again

Blogging has been a pretty big part of my life for a long time, up until some 3-4 years ago. Then for some reason, the blogging me really slowed down. Perhaps it’s because I got into medical school. Not because I become too busy (I did manage to get into Starcraft II and throw tons of hours into the epic interspecies galaxial war), but I think I couldn’t figure out how to fit blogging into my new identity as a doctor-to-be.

You see, I have more than once wrote something that genuinely pissed people off. Not that I was being mean or vulgar; some topics that I was passionate about were just too controversial to not cause a debate. But somehow being a doctor-to-be has caused me to really think twice before posting my opinion on debated topics such as religion, politics, abortion, etc. I guess I felt that since I am training to become a professional, I need to learn to be impartial and unbiased. Or maybe since I will become a searchable figure in a few years after I start practicing, I shouldn’t risk writing things that may alienate significant fraction of my potential patients.

And for the same reason of becoming a searchable name, I expect that it would be very challenging to separate my private life from my public one, so I hesitate to pour my day to day thoughts and feelings onto the pages for the world to see.

But every once and again, I miss the feeling of thinking out loud and hearing my thoughts become sound, watching my voice become words, and knowing my ideas will reach dozens or hundreds of pairs of eyes.

I am getting close to the next phase of my journey: residency. The application process is arguably less daunting than applying to med school, with fewer headaches (no MCAT) and a much better chance for success (overwhelming majority ((like 95% or something))get into a residency program). But more is on the line as well; at this stage of the game, many med students are married or in a serious relationship, and it would be very difficult to go out of province for 2 to 5 years of residency training.

So like how I used this blog to prepare for MCAT and med school interviews, I am going to use it to prepare for residency applications. I’ve been told by many upper year students that one way to prepare is to reflect on my experiences during med school that interviewers are bound to ask. Like dealing with difficult situations, breaking bad news, handling conflicts with colleagues, etc. I was really good at that for my application to med school 3 years ago because I’ve been blogging and reflecting day in day out for years. Now I think it’s time to pick that up again.

So, I will borrow what I said 3 years ago: here comes another page in zeroratio history!