Dermatology - Week 3 - Day 15-19

Day 15
June 15, 2008

First day of the Dermatology rotation. I am very excited about this because I have an extensive history in Derm as a patient. As a wrestler I experienced many skin problems, and have also been treated for psoriasis for 10 years.

In the morning all three of us sat in on Dr. Kuan’s clinic. He is an older physician, and has a resident type on the computer for him while he still uses the ‘old school’ paper. I was very eager to learn and asked a lot of questions.

The resident would take some time to explain some concepts to us.

At one point, Dr. Kuan said ‘In Taiwan you must have studied dermatology before being allowed in the clinic. I think I was being too aggressive with my questioning. So I held back with him after that. I decided it would be a good idea to purchase a dermatology hand book. This way I can also look at the computer screen, which is generally written in English.

In the afternoon, all three of us shadowed Dr. Hu. This woman had incredible energy. She came from Hong Kong. I wonder if it is her Hong Kong traits or her unique personality that exudes this feeling. She reminded me of a late teen in her youthful happy energy. She was very excited about showing us her Cosmetic center. She gave us her contact information and wanted to read our blog and take pictures with us. She said the best thing about being a dermatologist is using the treatment on herself! She was fun. She also was open to us asking questions. There was a stark contrast between this session and our morning session. Many of her patients came with cosmetic cases. I find myself enjoying the beauty of cosmetic medicine. I think my Mom is disappointed for me to say this. I think she feels that it would be shallow for me to go into cosmetic medicine. I believe that people can heal from the outside-in just as people can heal from the inside-out.

Day 16
June 16, 2008

Today I have been organizing plans for the present and future. Sometimes it is difficult to balance time with friends, family, and solitude. I am trying my best.

The Taiwan medical system is so efficient. The doctor stays in one room at the clinic while the patients come in one after another. In 3 hours the doctor saw more than 60 patients. There is less time for building of rapport as the patient just starts talking about the problem as soon as they walk in. The previous patient is still in the room with the next patient looming over their shoulder. I love it how each patient has a national insurance card where all their medical history is accessible as soon as it is inserted in the magical computer slot.

Due to this high volume of cases my dermatological learning has been thru repetition. Now that I have a handbook of dermatological disease I can read about the disease as the doctor is talking to the patient. This way I won’t have to bug the Doc with too many questions. I tend to ask a lot. Eczema, dermatitis, psoriasis, hair loss, scar reduction, hyperpigmintation, vitiligo. These are very common. The doctor I shadowed today specializes in hair transplantation and a procedure in which he forms a double eyelid. Many Asians want this feature. I asked if I could watch his operation tomorrow and he agreed .

Laundry time then dinner.

I am making some time every day for Board studying. I guess I am hard core. That is what Tammy said. I think it’s just that I love medicine.

Day 17
June 17, 2009

I was able to catch up on sleep today after having to be up at 5 am to go to Taipei for a morning pathological meeting the day before.

We went on rounds in the ward at 10 am. We were then sent to the treatment room. I saw a case of actinic keratosis and I also saw a biopsy taken with a differential of T cell lymphoma lesions or eczema.

I was granted permission to visit Dr. Huang and watch him perform the blepharoplasty (double eyelid surgery) in the afternoon. I feel that Dr. Huang is a gifted doctor and really cares for his patients. I am waiting for the surgery to begin while I wait in Taipei. While waiting I have been walking around Taipei, drinking tea and visiting Banks and business offices eavesdropping on conversations. There are a few English speaking Caucasians around. I am now less of a novelty.

Apparently plastic surgeons, dermatologists and opthamologists can do this cosmetic surgery in Taiwan. Interesting overlap.

I was able to see a second blepharoplasty of the lower eyelid to improve puffiness under the eye. The patient seems to experience pain. During these procedures only local anesthesia is administered. I believe this is probably a stark contrast from the United States.

I also witnessed a hair transplant. Dr. Huang specializes in this procedure. Hair from the posterior side of the scalp were removed follicle by follicle and inserted into the excisions made at the anterior scalp. A time consuming process, but the doctor explained that re-growth is about 90 percent.

The highlight of the day for me was to watch the upper eyelid blepharoplasty. This doctor does about 200 procedures a year, and he uses a technique he learned in Japan. Many Asians do not have a ligament attached to the orbicularis muscle of the eye. This will not allow a crease on the eyelid. Many Asians find the double eyelid more beautiful as it opens the eye. I find it fascinating how different cultures vary in their standards of beauty. Myself, aesthetically I prefer the look of an asian eye without the double eyelid. Many people want what they can’t have I guess. The procedure took 40 minutes and had a very noticeable effect. Only complications are swelling for a few days.

After the surgery I went by myself to the religious relic/herbal medicine area of Taipei. I was on a mission to find some herbs to try. I walked in and they asked me what was wrong. We stumbled through English with random Chinese words thrown in that I used to try to be a little less of an outsider. It would make them giggle. I told them nothing was wrong, but I wanted something to make me feel good. They ground up a mixture. I know there was Ginseng as part of the mixture. The woman that sold me the herbs flexed her muscle and pointed to her head indicating that the tincture would make me feel strong and smart. Later I asked a resident in acupuncture and he said the concoction would enhance my Qi and blood flow. Cool! It seems as if they don’t regulate who sells these herbs. No prescription needed. Interesting.

Day 18
June 18, 2009

This morning Tammy, Bill, and I were lucky enough to shadow a doctor who really spent a lot of time with us, explaining differential diagnoses and having us interact with patients.

I felt comfortable asking questions, and he would pull out books to show us images and concepts. He will be attending UC-Davis in the fall to study Law. I offered to show him around a bit. It will be a great opportunity to show him about Touro and Osteopathy! He seemed incredibly excited.

He walked around fast and had a big toothy grin. His excitement for teaching us showed me that he really loved to learn. I admire him for that. He is certified in Pediatrics and Dermatology! And now he will study law. When you love what you are learning you will be great to your patients I believe. From my brief interaction I feel he is one of the best doctors I have been around. He took us out to lunch and let his enthusiasm seep into us.

In the afternoon we shadowed Dr. Kuan, the same doctor from the first day. We were able to see many lasers as he treated patients for warts, pitting scars, nevi, dark circles under eyes, and hyperpigmentation. I did not realize how many various forms of laser are used.

When warts are removed we were told it is important to wear a tight mask to prevent wart growth in our trachea. That gave me a horrible scare!

Many people ask us to dinner here. Our dermatologist preceptor did. Regrettfully I had to say no because I wanted to take care of some personal chores and exercise. I am realizing I can’t say yes to everything in life.

Day 19
June 19, 2009

We shadowed a female dermatologist. She was cycling through patients very quickly, and it was difficult to ask her questions. Still, we were learning through repetition. I flip through my Dermatology handbook while she works with the patient and the computer screen written in English.

This doctor asked us questions at the beginning about our impression of the patient’s pathology. Generally, this was beyond my knowledge base, but I could reason. I think she assumed we had already completed our dermatology coursework.

Taidong - Jack's father's birthplace Day 19

Day 19

June 19, 2009

In the evening our group went to board a plane to Tai Dong. I probably butcher the spelling of these names. My phonetic intuition leads me to this spelling. Jack’s father is from this seashore town. We had a true local experience! We saw Mr. Tseng’s childhood house and sat around and ate Mangos. Probably the best mango I’ve ever had! We saw a beautiful local temple. His father took us to a Hot Spring. Hot Springs are resort areas here. Each pool of water has a different temperature so we can listen to our bodies wishes. After Jack and his father showed enough courage to immerse themselves in the nearly scalding water I along with Sean and Paul followed suit. After heat that extreme the cool water felt like heaven. My skin was beautiful for the next

while.

Visiting an old friend in Kaohsiung

Day 20

June 19, 2009

We woke up very early. I have a dear old friend in Taiwan ( I met him while we both lived in France) that I have been wanting to visit for years. This is one of the major reason I came here this summer. The rest of the group stayed to go to Green Island but I took a train to Kaohsiung to visit. He is a risk taker, after coming to Taiwan on a whim to teach english. He is still here after 5 years, speaks Mandarin and owns a business. When I am around him I tend to let go of my professionalism, which is quite nice.

It all came back, and we went out to PARTY! ………..

He is part of a foreigner scene. Local Taiwanese also like this scene and we met people that liked hangin’ round the foreigners.

Also had fun riding on the back of his moped. Taiwanese love scooting around on these things.

Day 21
June 21, 2009

After adventure, we took it easy. Ate a casual lunch.

Caught in a rainstorm the tire went flat while we were riding a car with a guy named Chen. Tom was determined to take a risk. He wanted to change it. It started pouring down. We were soaked as we watched Tom fumble with the poor tools. Chen wanted to call professionals. Tom was about to lose hope. The jack almost was tilted and almost fell as Tom slaved. Danger lurked. He couldn’t get the jack high enough to get the spare on, the other tire was already off. The jack unstable, could fall any minute. Chen said he learned he couldn’t trust anything Tom said. Finally he got it. Relief. Adventure. Risk. The life of Tom. Chen was the voice of reason, Tom the crazy one, and I the giggler, amazed.

Still soaked we drove in our repaired car to the Mall to watch a movie. Packed, Taiwanese love to shop! We watched the American movie, “The Hangover” Nice to feel American. The movie was hilarious. Awesome!

Afterwards, Time to go home. Home is now Linkou, Taiwan. Truly feel comfortable there. I took the high speed rail. This rail will take you from southern to northern Taiwan in a couple of hours. Studied the USMLE first aid book on the ride, even though exhausted. I have been trying to study most days. I should practice more OMM, but these days are pretty packed it seems.

Ready to be back in Linkou and around medicine.

Metabolism and Endocrinology Wk 4

Day 22

June 22, 2009

Last week. Metabolism and Endocrinology . These cases prove to be complicated. Paul and I are partners. When we walked in the preceptor Dr. Chen seemed to be very pleased that we had come. He sat us down and knew a lot about us. Apparently he had studied our Curriculum Vitae. I felt like we needed to live up to our paper selves. We talked a bit about why we were interested in Taiwanese medicine and told him about Osteopathy.

There were two interns and a resident present as well. After an intern took a lengthy history from a patient, Dr. Chen asked me to do a physical exam. I took a deep breath and proceeded. Even though there was a language barrier with the patient I managed with the help of translating interns to cover most bases. I knew there was probably a problem with her thyroid or adrenal gland so I made sure to palpate her thyroid for thyromegaly just like Touro has taught us. I also completed an abdominal exam and musculo-skeletal and reflex exam. It turned out that these were important in discerning the disease process. It turns out that the complete general physical exam I learned at Touro has paid off as I was able to be efficient and thorough, surprising myself! This was my first physical exam I have performed on a real patient!

We only saw 3 patients the whole morning so we were able to ask lots of questions and dig deep into the knowledge bank of his mind. He asked us ‘pimp’ questions. We responded and analyzed. Americans are creative with their answers. Some people call it ‘creativity’ and some people call it ‘bs’ Or maybe we just talk more than our Taiwanese student counterparts.
During lunch we had a Doctor lecture about new diabetes management methods directly to us. This week it’s like we are enrolled directly in a course. Learning a lot.

In the afternoon we went to pathology conference. I asked a question at the round table to a bunch of senior doctors. Nerve racking, but good for me. I asked if Hashimotos Thyroiditis is connected to carcinoma. This question actually began a discussion amongst the doctors.
At the end of the day Dr. Chen gave us an introduction to thyroid issues, pathology, and diagnosis. This laid a nice base. He also gave us a tour of the research laboratory that he uses. We looked at some cell lines.
Catching up on sleep at night.

Day 23

June 23, 2009

At the hospital ward we joined a team of about 5 others for treatment of diabetic patients. Many patients have a ‘diabetic foot’ that needed amputation or other major procedures due to lack of blood flow. The attending physician on the team was kind enough to brief us about each case in English before going on rounds. We were given the opportunity to ask many questions. I think the Endrocrinology and Metabolism department looks at this as opportunity to help teach their staff and students English and the importance of international medicine. This department seems very excited about us being there and dedicated to teach us as much as possible. Also, they may hope to give their hospital a good name in the Americas. Regardless of the reason, it is a great learning experience.

In the afternoon, we went to the thyroid ultrasound examination room. When we first arrived the thyroid sonography appeared as a foreign language. After Paul and I examined each other’s thyroid with ultrasound and used the instrument on actual patients I know what a nodule and cyst look like on a thyroid ultrasound, and I can even maneuver the equipment. We also saw the doctor do many fine needle aspirations. He was a believer in hands-on training, but it’s probably a good thing we didn’t aspirate each other’s thyroid with big needles.

The preceptor was soft spoken but very patient, thorough, and organized with the method in which he taught us. He had a plan, and by the end I feel fairly confident with thyroid ultrasound diagnosis.

We went to Taipei to see a movie in the evening. Bonding time with the crew! I was in a giggly mood this night.

Last Day- Day 24 6/24/2009

Day 24

June 24, 2009

At the ward again we joined the diabetic foot team. These foot infections and deteriorations thru gangrene, cellulitis, and osteomyletis are visually disturbing as well as difficult to treat. The patients stay in the hospital for a long time in comparison to the U.S. because the insurance covers hospital stay. The doctor’s say this presents a problem and that many patients could care for the wound at home when they choose to stay. Overcrowding of hospitals. Learned a lot once again.

Came home and checked my email. A family friend sent an email advising me to call my family ASAP. Called and reached my mother. She told me that my dad had died this morning while they were riding on their tandem bicycle.

Intense shock followed by sadness.

My Dad is an incredible man. He died doing what he loves with the one he loves, my mother. They have the best relationship of any couple I’ve ever known. They love bicycles. They have ridden from coast to coast across America together. He lived for the love of life. A genuine, kind, and happy man. I am lucky to have had him as my father. He had a thirst for knowledge and loved to laugh. I will try my best to live up to his example.

It is time to go home to be with my family to mourn and celebrate life.

I had to leave 2 days early. I am on the plane now. I will arrive to Indiana in about 22 hours or so.

Day 1: 6/1/09 Traveling and Arrival to Taiwan

Day 1
Monday, June 1, 2009:
Traveling quite a long way makes a man in his mid 20’s a bit tired, but luckily I had a good travel companion in Tammy. I also got to watch 2.3 movies on the plane. I usually do not make time to watch movies so this was a special treat. Watching “Gran Torino” set the stage for observing how cultures can collide and even mesh. As I arrived, not speaking the language was difficult. Luckily, I thrive feeling lost in translation. One of my roommates is a senior resident in Plastic Surgery named Yi. He’s a quiet fellow with a gentle demeanor. My other roommate is a kind and overly excited gentleman from Canada. He has a girlfriend who is also doing rotations with him here in the ER.

The Modern Toilet (Restaurant)

For more pics click here! click here!