Megan Lung Pulmonology W3D3

Today we shadowed a respiratory therapist named Eva. She gave a brief summary of what she does in the ICU unit and the Respiratory Care Ward. Eva also gave us an excellent historical, economical, and social perspective to Taiwanese healthcare.

First she began with a powerpoint that explained the basic concepts of mechanical ventilation. While the US has 60 years of respiratory therapy history, the field is exceptionally young in Taiwan; only 25 years old. In Korea and Japan, about 50% of the doctors also do the job of respiratory therapists. Respiratory therapists manage patients who depend on BiPAP, tracheostomies, or intubation. They also try to get the patient better and "wean" them off of respiratory machines by going through exercises to strengthen their diaphragm and chest wall.

Eva then gave us more information about the majority of patients who come to Taipei hospitals. Patients that come to this hospital are often elderly, poor, and have many comorbidities. These three identifiers affect each other and cause a vicious cycle of poverty that leads to many complications and illnesses. Many patients present with pneumonia and COPD and often spiral into sepsis and multi-organ failure. Furthermore, many of the patients are either uneducated about healthy choices, or cannot afford healthy food. Xin Zhuang, the place that the hospital is located, is considered a small part of "New Taipei" (all the colored areas). New Taipei is poorer than Taipei city. Unlike the U.S., the rich and educated live in Taipei while the poor live on the outskirts. However with the metro, transportation has made traveling to better hospitals easier for those living far away from Taipei. I thought that this was an interesting aspect that has a huge influence on healthcare. Still inequalities exist between northern and souther Taiwan, as well as those who live farther away from Taipei. Hopefully with the ever expanding metro, quality health care access will cease to be an issue.

Eva also showed us the Respiratory Care Ward. Most of these patients have chronic lung problems and are in there for long term care. Some have loss of consciousness and two patients we saw had ALS, which made them unable to move any part of their body except their eyes. It was truly a sad experience to see so many RCW patients who have been there for so long, some for multiple years. Eva told us that she often visits these patients to cheer them up and wishes there was better palliative care for these folks. She suggested music, art, or even some spiritual guidance. This kind of thinking is pretty common in the states already and it is a pity to see that Taiwan is still lacking in end of life care. Traditional Chinese philosophy here is to avoid any invasive procedure yet at the same time to keep their family member alive at the expense of quality of life. Here "face" is very important. How much you care about your parents is linked to how aggressive you try to keep them alive; letting them go peacefully can be a sign of disrespect and lack of filial piety. Interestingly, invasive procedures such as a tracheostomy are adamantly opposed because there is a background of Daoism that is a big part of Chinese culture that promotes 'naturalness' and 'wholeness'. There is still a clash between culture and modern medicine and it leads to patients who are in the RCW for years on end.

Eva gave us some perspectives to consider when we begin to practice medicine. She told us that she was aggressive with her treatment when she first began as a RT. Gradually she became 'soft' and said that when you push treatments on patients you have to ask yourself why. Is it for the patient or is it to prove that you are smart and capable? We have to constantly ask ourselves these questions and put aside our egos to be good health care practitioners.

Dr. Huang also gave me and Heidi his perspective of healthcare in Taiwan. Due to universal healthcare, patients often go "hospital shopping". Not every hospital has standardized their medications, so a doctor in this hospital cannot see the information from another hospital that the patient may have gone to earlier. This allows for a lot of medication waste. Patients go from hospital to hospital and amass medication. There are no limitations to how many times you see the doctor, and doctors are often overloaded with patients. Furthermore they are afraid to order extra tests because if they are audited and found to have ordered superfluous tests not directly related to treatment, they will be severely fined. It seems like the doctors here are over burdened and trapped between patients and the insurance company. Eva suggested that perhaps a limit to how many times someone could see a doctor could help the problem. But due to the large waste that the system allows, insurance companies cut down on other areas of the hospital that are sorely needed.

I feel like the intricacies of healthcare expand beyond the interaction between doctor and patient. Location, history, culture, and economics are all important factors that determine the course of a patient's illness. I hope to gain more perspective in the days to come.