First day on the job.

This morning I woke up early to take the bus to the hospital and then find and eat breakfast there, then take another bus to the Hospice Ward. I met with Dr. T who is a resident in Family Medicine. He showed me around and we saw a couple of patients, whose charts he gave me to study. We had a long discussion about the differences between Taiwan's Universal Health care program and the U.S. health care system.

It seems that in Taiwan, because things are relatively cheap for the patients, they tend to "doctor shop" and hop around from one doc to the next for 2nd, 3rd, 4th opinions and more medications. Often patients here will get medications for their other family members while they are at the doctor's. The patients here seem to have a lot of power; if they are unhappy, they will either sue or complain to the goverment health care system.

Dr. T did not seem to optimistic about the position of doctors in Taiwan: the cost of practicing is getting higher and higher, while the compensation is getting lower. He printed off several articles from Taiwan newspapers for me about different "frivilous" lawsuits in which the doctors got blamed for a patient's death even when their actions did not cause the death. Interesting conversation, but I'll be sure to have more before I figure out what I really think on the subject.

We had lunch with the nurses and Dr. T bought me lunch. I was quite embarrassed, for I had my money ready but he beat me to it. So far I have met two residents (Dr. T and Dr. H), both of whom are in their early 30s and are married with little children. This seems to be the typical age progression here as men still have to serve in the Taiwanese army for 2 years after graduation.

That afternoon, the attending doctor, Dr. S, came and we did rounds on the Hospice Ward patients. They are all terminal patients who are there for palliative care only. Most of them had several family members around to talk to the doctor and take care of their loved ones. It was quite touching.

I saw an elderly woman with hepatic encephalopathy (there are many cases of hepatocellular carinoma here) and her husband and daughter were holding her and stroking her arms and legs and speaking softly to her to calm her because she didn't really know where she was.

I saw a late-middle aged man with liver cancer who was bright yellow from jaundice. He had 6 family members there to talk to the doctor and take care of him. His older sister was there and she just stroked his hand and struggled to hold back the tears pouring down her cheeks while he clutched her hand anxiously. I was close to tears myself, though I suppose it's because I was paying more attention to what they were doing than what the doctor was saying because it was in Taiwanese (the doctors here use Mandarin with some English words between themselves but almost always use Taiwanese with the patients).

Making patient care decisions here is very much a family affair. As a physician, you must discuss with the family in detail before any decision is made. Another complicating factor is that it is considered bad luck and bad manners to tell a patient that they are dying directly. To get admission to the Hospice Ward, you have to meet certain criteria and be DNR (Do Not Resuscitate), but sometimes due to this delicacy in explanation, the patients who end up in the Hospice Ward may not necessarily know why they are there or what exactly the DNR means.

Also, there is a large problem with getting people to leave the hospital. Since it is relatively cheap to the patients to be there, they often prefer to stay rather than paying for in-home care or a nursing home. Many families are also reticient to take their loved ones home because they feel that the care the doctors and nurses give is better than what they could give themselves. Mostly, this involves teaching a family member how to give the medication appropriately, but it can be daunting.

Tomorrow, I am meeting the team to head off into the community for Hospice Home Care. It is very important for many Taiwanese that their family members die at home, in peace. Therefore, much is done so that this can happen. Often, if a terminal patient techinically expires in the hospital, they will be resuscitated and driven home, then taken off of respiration there.