Anny Xiao Week 2 Nephrology Rotation Day 2

So far this week I've been really impressed with the nephrology department at Taipei Hospital and especially with Director Chen. Although he's the director, he spends almost all of his time seeing patients, either rounding on them in the hemodialysis center, on the inpatient service or in the outpatient clinics. For a specialist, he is surprisingly focused on seeing the patient as a whole person rather than an isolated organ system. He emphasized to me today that although many nephrology patients present with the same symptoms, they all have different etiologies, risk factors, comorbidities, complications and abnormalities. It takes careful investigation and close following of their clinical status in order to distinguish those who are at higher risk and to provide every patient with the best care. This is a different approach than what I've seen from shadowing some specialities in the US, where the emphasis is often on the specific organ system and not the patient as a whole.

There are so many cultural differences here that change way healthcare is provided, compared to the US. Patient privacy is virtually nonexistent, with patients overlapping in exam rooms in order to increase the efficiency of the physician's busy schedule. In the outpatient clinic, there are doors connecting each exam room and they are often left open (for better ventilation perhaps?) and conversations between neighboring physicians & patients can be heard. Patients will often sit down next to the doctor while he still has the previous patient's chart open and some patients enter the room while the previous patient is still getting dressed. Despite this, none of the patients seem to mind and each visit is concluded with patients profusely thanking the physician. The patients view seeing a doctor as a privilege, and although doctors will often see upwards of 30 patients in 1 afternoon, they still manage to fulfill the needs of all their patients. Instead of having a nurse or MA take vitals, there is an automatic machine that patients can use while they wait for their appointment and they then bring the recorded vitals into the exam room where the physician can enter it into their EMR.

The most interesting case we saw today was a 20yo male patient who had severe proteinuria of 3427.9 (normal is <150), hematuria and HTN found incidentally on a health screening exam to determine his military eligibility. Dr. Chen informed the patient that his lab results are actually quite concerning, given his young age and the severity of his proteinuria. The patient was not ill-appearing and did not have any recent infections, so Dr. Chen said it was unlikely to be acute glomerulonephritis, and he suspected chronic GN instead. He ordered a slew of tests, including anti-GBM, c-ANCA & p-ANCA, ANA to rule out causes of secondary immune-mediated GN and instructed the patient to return to the lab tomorrow. The treatment plan was to start the patient on an ARB for to control his BP. Depending on his lab results tomorrow, Dr. Chen may order a renal biopsy to determine the pathology behind his suspected chronic GN and start the patient on steroids & cytotoxics (but only after the lab results are available). This case was extremely relevant to the 3rd block of our 2nd semester classes in school and I felt fortunate to be able to see this patient with Dr. Chen.