Today was the 2nd day at hem/onc with Dr Chen and we were doing mostly outpatient visits this morning with some follow up patient rounding at the end. We saw many patients with breast cancer (w/ mastectomy), patient with myeloproliferative disorders, primary peritoneal carcinoma, TCC with invasion of the renal pelvis and WBC disorders such as CLL. Most patients were at the clinic for follow up and discussed with Dr Chen on side effects of the chemotherapy. It is sad to note that although there are clinical trials to support some of the chemo drugs, many of the "ideal"/"best" options are not available at the Taipei Hospital so Dr Chen would have to recommend other therapies instead. From what I have seen so far, I realized that many patients will initially reject the idea of chemo until they start to present with systemic symptoms. Often times then the physician will have to suggest much aggressive treatment and patient may not respond to the standard therapy. Of course there are always exceptions. Dr Chen mentioned that generally in Taiwan hospitals, oncologist will have to see at least 50-60 patients during each clinic section (up to 100 patients for IM doctors). This is due to the fact that doctors are paid on average 100NT/patient/visit and therefore in order to make a reasonable income, doctors will have to see as many patient as possible. He said that basically quality patient care is pretty much impossible under the infrastructure of Taiwan health system. Physicians in Taipei Hospital are under a salary system so doctors don't have to sacrifice as much of the patient-doctor facetime as working elsewhere.
Although the patient population at the Taipei hospital is relatively small, there were 2 unique cases that I have observed this morning:
Case 1 68y/o male with Multiple Myeloma, anemia was the only presenting symptom.
Currently there is no cure for multiple myeloma. 1st line standard treatment is usually bone marrow transplant with chemo but the drugs are not available at the hospital. Although the patient has chronic MM, he does not present with any bone destruction and his condition has been stable. However, his recent blood panel has shown escalated IgG and he had infection of the epididymis couple months ago with unknown etiology. Patient will restart on chemo with a combination of cyclophosphamide and steroid. I asked Dr Chen on why steroid seems to be pretty commonly included in chemo therapy. He stated that capillary leakage is relatively common for patients who are on chemotherapy and steroids are used as a prophylactic drugs to prevent such condition.
Some patients that are taking steroid as a prophylactic are also diabetic patient with dyslipidemia. Normally in a family medicine/IM clinic we would want to have the patient's glucose level controlled ideally at <100 mg/dl. However, steroids will usually cause a spike in the serum glucose level, so when a patient in on chemo, the glucose control is relatively more flexible (~200mg/dl is acceptable).
Case 2 Male, initial presentation was aspiration pneumonia and jaundice. Dr Chen as the consulting doctor confirmed that the patient has consolidation in RLL in CT. CT also showed lymphadenopathy and enlargement of the trachea. He explained that aspiration pneumonia is unlikely since the consolidation showed no air-bronchogram. Signs of lung metastasis was also shown in the CT scan. He ordered a panendoscopy and confirmed finding of upper 1/3 esophageal cancer. He said that he is not sure if it is a double cancer or if the patient has SCC with metastasis, but smoking contributes hugely to the condition and it induces colonization effect. Treatment for this patient depends mainly on whether the tumors can be completely resected, and unless surgical resection is successful, patient's prognosis is very poor since the success rate of chemo for SCC is <40%.
Immediately after we greeted the patient, he asked to be discharged from the hospital. He repeatedly mentioned that he doesn't demand much, and he has no close family and thinks that his condition is hopeless. Dr Chen told us afterwards that in this sort of situation, the most important thing is to tell patient the facts and lay out all the possible outcomes and options, and let the patients themselves make the decision. He explained to the patient calmly that his esophageal tumor is so big that it is almost blocking the whole esophagus. Although patient has already stated that he doesn't want to receive any treatment, Dr Chen continued with explaining the progression of the disease and treatment options. It is the physicians responsibility to provide all necessary information. The patient will eventually develop lateral chest pain, rapid weight loss and hemoptysis, and the chemo will not cure the cancer but at least can slow the progression of the disease. It was really difficult to witness the patient's decision on not receiving any treatment so quickly.
What I have also learnt from today is that although we do see a good amount of foreign caregivers at the hospital, the application process and regulations of the approval of such aid is relatively complicated. Patient usually have to be at least 80y/o, or have h/o CVA. Additionally, many of these caregivers come to Taiwan through an agency, and the agency will usually keep their 1st month's salary, then 1/3 of their salary each month after the 1st month. I guess all systems have their own advantage and disadvantages, and I wish the healthcare system is not this complicated, then physicians can really do what they are supposed to do - patient care.
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