Paul - Oncology Day 1 and 2

aaaaaa We walked toward the pathology building anticipatorily, Viet, Tammy and I, through the 1^st floor hallways of Chang Gung Memorial Hospital, some of which were lined with occupied hospital beds for patient overflow. Taiwanese families and patients moved impatiently across the airport-style check-in at the hospital’s main entrance, with their smart-cards in hand. Away from the paths of busy students, employees, and patients we steered, each one of whom wondering why we were here. Some chuckled, some stared, others didn’t even care, but a welcoming feeling filled the air.

We are the first formal American foreign exchange students at CGMH, and for this, we are truly fortunate. After our culture shock walk, we stopped. Up the elevator our trio rides, feeling butterflies inside, ready to be stripped of much of our pride. And we waited.

Viet and Tammy were quickly stolen away as I wait for my preceptor, whose Fellow approached me with some news.

“Dr. Chang is very busy this morning. He has OPD clinic, so he must see 60 patients from now until twelve-thirty, when we can all have lunch,” he informs me.

Waaaaaaaiiiiitttt a minute, back up!!! It’s currently nine o’clock and…..

”How many patients did you say?” I ask confusedly. His thick accent, though good English diction, lead me to believe that, by “60”, he meant “16” maybe?

“60 patients,” he repeated confidently. “For now, I can show you CT’s, X-rays, and profiles of Dr. Chang’s current patients so you are briefed on the cases you will see this afternoon.”

Three and a half minutes per patient????? Not to mention how hard it must be for a physician to stay focused for that long! This was my introduction to the Taiwanese healthcare system, and it made me realize how much easier it would be for us as future physicians in the United States.

From there on, it was constant pimping. I was allowed access to the patient database and would have to read about each of the oncology patients Dr. Chang would see that afternoon. Here is one of the twelve patients under Dr. Chang’s continuous care:

Patient #1:

59 yr old female farm worker

Dx: Metastatic Melanoma with primary lesion on the feet between toes

Melanoma has little to do with sun exposure in Taiwan, compared to the US.

Most common among female farm workers

Suspected Etiology: Exposure to carcinogenic pesticides and chemicals

Dr. Chang takes me through his thought process for a metastatic melanoma case:

1) Surgery – not affective for Melanoma

2) Radiotherapy – usually not effective for melanoma

a. Some palliative properties, like surgery.

b. New research says it might be effective if intermittent big doses are given (400-600 centigrade 1x/wk) rather than regular small ones (150 centigrade 3x/week)

3) Chemotherapy (including immunotherapy and hormone therapy)

a. Immunotherapy could be an effective option:

High Dose IL-2 – Extremely effective but in 70% of patients, it causes severe capillary leaking à loss of orientation, severe nephropathy, severe memory loss (Dr. Chang has seen patients forget that their loved ones have been in the hospital to see them every day during their illness), and many skin lesions. This can only be used for people in perfect health otherwise.

GP100 – Effective because it is a cell-based (as opposed to 2ndary messenger-based) immunotherapy that activates NK cells to target the tumor cells. This is his choice for treatment.

4) CAM (Chinese Acupuntural Medicine)

a. In many cases, doctors in Taiwan encounter patients who refuse all treatments. This is when Dr. Chang recommends CAM for its palliative and sometimes curative properties.

Dr. Chang also decided to do a test for occult blood and PET scan to rule out or confirm gastric metastasis.