A Doctor's Bittersweet Homecoming

At the Koo Foundation Sun Yat-Sen Cancer Center (SYSCC) in Kuantu in Taipei's Peitou District, a quilt hangs on the wall of neurologist Lai Chi-wan's office. It is a memento stitched together for him as a gift by children who participated in the summer camp he organized for epileptic children seven years ago, before he returned to Taiwan from the University of Kansas School of Medicine.

After returning to Taiwan in 1998, Lai served first as vice president and then president of Hualien's Tzu Chi Buddhist Medical College. Four years ago, he moved to Taipei. In addition to his position as neurologist at SYSCC, he is president of the Taiwan Epilepsy Society, and established the Yang-sen Sunshine Summer Camp for children in Taiwan with epilepsy.

For children with epilepsy in both the US and Taiwan, Lai made the dream of going to summer camp-an activity from which they had been excluded in the past-come true. But has his own dream-of making a contribution to his own homeland-been realized?

For Lai Chi-wan, a doctor for over 20 years, this quilt of thanks provides warmth even in the coldest winter. (courtesy of Lai Chi-wan)

Fame no guarantee of quality

Having returned to Taiwan after practicing medicine in the US for 23 years and serving as professor of neurology at the University of Kansas, Lai is critical of the medical establishment in Taiwan.

Historian Daniel Boorstin has said that in society today, there are many heroes who are overshadowed by celebrities. "Celebrities are people who make news, but heroes are people who make history." Lai points out that in Taiwan today there is a plethora of famous doctors. However, such doctors do not necessarily excel at their profession, and this is a point worthy of everyone's attention.

The result of a misplaced belief in the superior abilities of celebrity doctors has led to their practices being overrun by patients.

Lai points out that 30 to 50 minutes are spent examining a patient abroad, while in Taiwan a paltry three to five minutes is given to the examination. "During the SARS outbreak, the number of patients seen at hospital outpatient clinics declined greatly, but the death rate did not increase. Likewise, when doctors in Israel went on strike, the death rate did not increase. We can see from these situations that many clinic visits are unnecessary."

When a doctor consults a patient, he must first ask in detail about the patient's medical history, and only if the cause of the present ailment cannot be determined is an examination warranted. However, many doctors these days perform many examinations, spending little time on the initial consultation in order to do more business. In neurology for example, CAT and MRI scans are overused. "It may be hard for you to imagine, but in some British cities, this sort of expensive equipment is completely lacking," says Lai.

Not convinced that doctor-patient relations are beyond repair, Lai Chi-wan reminds doctors that there are some things they must do, and others they must not.

Educating patients

After spending time with patients in Taiwan, Lai's perspective changed, and he no longer placed all the blame on his fellow medical practitioners.

"In the doctor-patient relationship, one can't simply blame one side or the other. Just as in a failing marriage, the fault is never one-sided," says Lai reflectively.

The way people in Taiwan think about medication needs to be changed, he adds. "Everyone seems to believe that the more medication a doctor prescribes, the better it is. They don't care at all about the side effects of the medications or their interaction."

Lai says that on one occasion when he served as a volunteer physician for Tzu Chi in its program to provide medical consultations to residents of mountain villages, a patient complained to him of a dry mouth, insomnia, and a sense of disorientation. Upon inquiring further, Lai discovered he was a hypochondriac, and was taking six types of medication every day. The symptoms just described were side effects of those medications. He patiently explained the situation to the patient, telling him that he need only gradually stop use of these medications, and the symptoms would disappear. The patient nodded his head in agreement, but in the end, asked, "So what medication do you prescribe?"

Lai points out that when people in Taiwan see three doctors for the same ailment, they are not motivated by a desire to obtain a second opinion, as is encouraged in other countries. Instead, when Taiwanese patients go to a second and third doctor, they do not inform the doctor of who saw them earlier. Thus there is no consultation among the doctors, to say nothing of sharing results of examinations that have already been performed. Consequently, each doctor repeats the entire process, performing redundant examinations, and prescribing the same medication again-not only wasting health care resources, but also delaying effective treatment.

"Some patients in Taiwan have no sense of public ethics, and no notion of etiquette," says Lai. When he first began working at Buddhist Tzu Chi General Hospital, it was as a clinical instructor. He would see only six or seven patients in a morning. After obtaining the permission of a patient, he would proceed, while discussing the case with medical students.

On one occasion, a patient, annoyed at a long wait, barked out, "The doctor inside is probably incompetent, which is why he takes so long!" Unexpectedly, once it was his turn, he ignored the rights of patients still waiting outside, and after the doctor's painstaking examination and explanations, sought to extend the visit. He asked about some of his mother's and wife's problems, hoping to take advantage of the doctor to obtain medication for his entire family.

On another occasion, a patient asked Lai about a certain medication, with which Lai confessed to being unfamiliar. He took up a pharmacopoeia and looked it up. The patient did not express gratitude, but rather rudely exclaimed, "I thought you were a big-time professor with experience, and that's why I came to see you. I never thought you would have to look things up in a book!"

"At that moment, I felt deep despair, a feeling like I wanted to cry," Lai recounts. He often felt he was an outsider in his own homeland. Though he wanted to contribute something back, his efforts were instead cruelly thwarted.

Education on the essentials

Lai spends a great deal of time and effort on teaching. Although the time spent on educating students does not aid in professional advancement, and offers no monetary rewards, he delights in it nonetheless.

"A doctor has the opportunity to do good, so if he doesn't, he'll feel guilty," says Lai. He has lectured at National Cheng Kung University, National Taiwan University, and Tzu Chi University, the objective being to gain more interaction with medical students, and make an impact. "Only in this way will I feel I've done my part for Taiwan," he confides.

On Thursday afternoons, Lai provides clinical instruction to students at the SYSCC. The usual procedure is for teacher and student to first examine medical histories in a meeting room, and then see the patient in person in a clinical setting. They then return to study X-rays, and finally, discuss the case.

Lai believes clinical instruction is essential, especially at this point in time. Students can see for themselves how a doctor establishes a relationship with a patient and the patient's family, and the clinical etiquette involved in first obtaining the patient's approval and afterwards expressing thanks for the patient's assistance. This sort of hands-on teaching is superior to mere verbal instruction.

Lai recounts an occasion 30 years ago when he was an intern and was receiving clinical instruction. The professor needed to lift up the patient's leg, but before doing so, he first found a towel and placed it under the patient's buttocks. Lai was extremely moved by this small gesture. "During the entire lecture, I didn't hear anything that the professor said, because I kept thinking about that towel."

In order to provide role models for medical students, Lai created a column in Medicine Today Monthly magazine that spotlights outstanding physicians in Taiwan. For the column, students from Taiwan's 11 medical schools interview such doctors, who serve patients without fanfare in various places throughout Taiwan. The students thus gain an opportunity to see such doctors at work first-hand.

Lai has not only endured being an outsider in his own homeland, but also even being seen by some of his colleagues as a self-important malcontent-in particular because he has been able to find a work situation that allows him to remain faithful to his ideal of quality over quantity, at a time when most doctors are inundated with patients (or surgical procedures).

In fact, Lai believes that being a doctor carries obligations to do certain things and to avoid doing others, and staying true to one's own ideals means discovering an approach that balances the demands of the system. He believes in the pendulum theory-the notion that what goes around comes around. "Taiwan's health care system is already as bad as it can be, so there is no way to go but up," he says. Lai hopes that medical students will remain steadfast, and not give in to the temptation to relax their standards, but instead patiently wait until the health care system takes a turn for the better. Through collective will, the darkness can be turned back, and a new dawn for quality health care in Taiwan can quickly arrive.