Week 1 Cardiology rotation Day 5

Brief follow-up to my last blog post: it turns out that the 93 yo patient we saw in the ER had an acute cerebellar stroke, which was diagnosed after she underwent an MRA-DWI (magnetic resonance angiography with diffusion weighted imaging), an MRI technique with enhanced ability to detect cerebral infarct early by generating images that reflect the microscopic random motion of water molecules. The technique is based on the fact that intracellular water molecules are more restricted in their movement than extracellular water molecules due to their collision with the cell membrane. During stroke, osmosis of free water into dying cells causes an increased ratio of intracellular to extracellular water in ischemic areas, which appears brighter on DWI. Dr. Wang showed us the MRA-DWI which displayed multiple small regions of cerebellar infarction and compared it to the head CT the patient received upon admission that did not detect the regions of ischemia.

On Friday we had some time to pick Dr. Chen's brain about Taiwan's National Health Insurance. He explained that in Taiwan, all the cardiologists are paid the same exam fee, regardless of whether they are a highly trained experienced physician or a new physician less than a year out of training. Since Taipei hospital is a public hospital, the government controls all physician payments and physicians salaries are relatively much lower than in the US. However, he said that there has been a long-standing tradition where virtually all of the highest scoring students go into medicine. Unlike other countries where qualified students may choose business, law or banking over medicine, qualified Taiwanese students almost always choose medicine, despite the fact that the salaries are limited by the government. He explained that the physicians in Taiwan don't choose this field for the money but for the benefit of the Taiwanese people and as a result physicians distinctively share many similar characteristics and values.
Dr. Chen also explained that medications in Taiwan are very inexpensive since the government controls the prices and establishes contracts with the drug companies. Certain medical devices like pacemakers are also regulated by the government, and he said that prior to the NHI reform in 2011, only single-chamber pacemakers were covered by government insurance, but the Taiwan Society of Cardiology provided lawmakers with evidence of the indication for dual chamber pacemakers in many Taiwanese patients so starting in 2011 the NHI began paying for dual chamber pacemakers when indicated.
Some cons of the NHI are that many patients abuse the ER since they don't have to pay. Patients will commonly go to the ER for URTIs, indigestion and mild diarrhea, and even intoxication. Interestingly, the ER is less busy during the day but extremely busy at night. He told us that many homeless and often drunk people will come to the ER, where they know they can have a bed, air conditioning and receive IV saline.

In the afternoon we saw patients in the outpatient department with Dr. Wang, and the most interesting case was a patient in his 40s with HTN, DM, ESRD and triple vessel coronary disease. He arrived in a wheelchair accompanied by his father because of some pain he was having in his knee. He was referred to the cardiologist after presenting to the ER 3 times in the past 4 days (!) with chest pain. The patient had been lost to follow up after receiving 6 stents in his coronary arteries. He stated that he stopped taking his aspirin about a year ago after he began experiencing hemorrhaging in his left eye. It appeared that he had proliferative diabetic retinopathy and diminished vision in his left eye but apparently the patient did not go see an opthalmologist and just decided to discontinue his aspirin. His chest pain was quite severe and the patient appeared uncomfortable and short of breath.  Dr. Wang diagnosed unstable angina and asked the patient if he would agree to being admitted to the ICU for an angiogram since he was at high risk for a cardiovascular event due to his medication noncompliance. The patient agreed and was asked to wait in the waiting room while Dr. Wang requested an ICU bed for him. About 20 minutes later, the patient's father entered the exam room and asked for help, as the patient was experiencing chest discomfort in the waiting room, so the nurse gave the patient nitroglycerin. Another 10 minutes later, the father entered the room again, this time more panicked, explaining that his son really needed help so Dr. Wang went to see the patient, who was clutching his chest and gasping for air as his eyes began rolling back in his head. Dr. Wang then called the ICU to see if the bed was ready and ordered the nurses to bring the patient to the ICU immediately. Three nurses and the patient's father then proceeded to run down the hallway with the patient in a wheelchair towards the ICU.

Dr. Wang explained that the nitroglycerin did not appear to help the patient's condition since his unstable angina was so severe. He remarked that the ER physicians should have admitted the patient when he presented with chest pain during the past few days, especially since the patient was agreeable when he suggested it today. I thought of what Dr. Chen told us and wondered if the ER staff is just so used to seeing patients return frequently for trivial symptoms that they might overlook some of the more serious cases. In the US, an ER visit costs patients an average of $2200 so this is another interesting difference in the Taiwanese healthcare system.