My Summer Elective experience

This summer I spent one month in Northern Ontario on a medical elective. Over the month I was given considerable autonomy to practice my clinical skills and interviewing, and was granted a unique view of complexly foreign part of the country. The following patient encounter was one of the most shocking and influential events of my elective.

My preceptor for the day had assigned me one examining room and given me a third of the patients. After seeing each patient I would give her a summary, discuss a management plan, and we would then go in to see the patient together. I grabbed my first chart of the afternoon, a 16 year old female patient was presenting to the clinic with what she suspected was a Chlamydia infection.

I knocked on the door, walked in and introduced myself to a nervous looking girl who seemed far to young to be worrying about STIs. We started talking, she had a previous episode of Chlamydia 6 months ago (the reason why she was so certain it was Chlamydia again) which another doctor at the clinic had treated. She had been sexually active since 13, used the birth control pill for two months when she was 14 (she stopped because she could never remember to take the pill) and had since used no forms of contraceptives. At this point alarm bells were ringing in my head and I asked her when her last period was. The answer was informative to say the least: over 7 weeks, and it had not occurred to her that she could be pregnant. To complicate matters, the patient normally drank several drinks a day, and I was seeing her the Monday after Canada Day Weekend, where she had been drunk for most of the weekend. At this point I obtained her consent to test her for STIs and pregnancy, and then made a beeline for the doctor’s office.

I summarized the patient for my preceptor and to my surprise didn’t bat an eye – it was a fairly standard story I guess. One urine dip later and my preceptor turned to me and said, “Ever told someone that they are pregnant?” I replied with a shaky no and then injected slightly more confidence into my voice and said that I would like to be the one to tell her. So tasked with relaying this all-important news, I went next door, with my parting instructions to break the news and find out if she wanted to have the baby.

I entered the room, and said, “I have some big new. You’re pregnant.” I gave her a moment, and then asked her how she was feeling. She said she was shocked. Now the tricky part – the key would definitely be in the phrasing. I cleared my throat, collected my thoughts and blurted out something wonderfully awkward along the lines of “Do you want to carry this baby to term?” She beamed back at me – the answer was a definite yes. The rationale was certainly not to my liking: Dad was in jail, not speaking to the young girl, and she wanted the baby to remember him. But it was her choice. The clinical encounter wrapped up quickly: my preceptor came into the room, we treated her Chlamydia infection (a single dose of 1 gram of Azithroymycin given orally, for those who are curious), gave her some general prenatal recommendations, and set up a follow up appointment.

The patient left the office happy, but I was left with some serious doubts. Aside from being concerned about her prospects for the future, two nagging issues stood out to me. First, this young girl was a high risk pregnancy with significant risk to both mother and fetus (mainly Fetal Alcohol Syndrome). I was aware of it as was my preceptor, but it is unclear how adequately we relayed that message to the patient. It is possible that the patient was unaware of her risk. Should we have directly laid out the risks for the patient before asking about having an abortion? Would it still have been appropriate to discuss risks and offer alternatives after her expressed desire to have the baby? Does pregnancy count as a “medical procedure” for which complications, and alternatives must always be discussed and then offered to the patient?

I was also struck both by how preventable the situation had been and the clear signs that this patient needed help before she showed up at the clinic pregnant. After this “routine” event, there was no discussion of how to adapt or alter the practice, and I am quite positive that similar outcomes will continue to occur. I learned considerably from this encounter, and even more from my time up north, but left my elective cognizant of enormous gaps in our health care system, which unfortunately have no easy solution.

Reflections on Chinese Healthcare

When my friends ask me how medical school is, I explain to them that the human body has been written about with zeal for millennia and that I’m spending a paltry four years catching up on as many stories about the body as I can. In every scientific paper and report and publication I read, I ask myself: what did this researcher observe? How did she come to terms with what she observed? What story is she trying to tell me, and how is she wrapping her head around what she saw?

Sometimes the stories affirm one another, and other times the stories conflict. Here’s an example: in the past, Western medicine used to say that peptic ulcers were caused by stress and excessive acid production. But when Barry Marshall and Robin Warren entered the scene in 1982, they told a different story: peptic ulcers are largely caused by an organism known as Helicobacter pylori. I absolutely believe it to be true, but I also understand that the story they tell is about a small creature that few will ever have the privilege of seeing first hand and that doctors recommend their infected patients to vanquish this little beast by consuming small yellow pills.

The point here is that I take information on faith by the authority of those teaching me, which is the same way my teachers learned from their teachers and how they continue to learn from their colleagues. And so I need to make a disclaimer before I begin this article: I know precious little about medicine of the Western variety and even less of the traditional Chinese variety– only what I have been told and what I have seen.

I spent the past summer in China with four friends on a very non-systematic tour of hospitals and other care facilities in five different cities. On three or four occasions, we saw traditional Chinese medicine (TCM) being practiced. Sometimes, it was in TCM hospitals: six story complexes divided into departments with teaching faculty and nurses and the same aura of legitimacy of any hospital, but devoted to a system of medicine that I had been told lacked evidence. Other times, we visited the TCM department nestled within a larger public hospital or community care centre. These departments seemed just as busy as the outpatient departments providing Western medicine.

The presence of these well-funded and well-visited complexes was evidence with which I grappled. The first thing I conceded was that traditional Chinese medicine was doing something. At the very least, it did enough to get people to change their behavior and spend money. Some patients traveled hours by train to see a doctor. Others were following through on doctor’s recommendations to live closer to the hospital so that the doctor could provide more regular care and update their herbal regiment more closely. And every TCM patient we asked gave us a testimony of how it really worked for them: their asthma was better, their cheeks were less flushed, their hematuria lab results came back negative, their diarrhea was relieved. We had a case where a patient reported having Duchenne’s muscular dystrophy (an irreversible genetic condition) improved with TCM.

Confused, I wanted to learn more about the principles behind TCM, and the opportunity came in our last week. We were shadowing Dr. Sun in his clinic at the Shanghai Children’s Medical Centre and his students brought in some bilingual textbooks on Chinese medicine. They were a series of four books published by the Nanjing University of Traditional Chinese Medicine and translated in Shanghai and they covered the basic theory, diagnostics, science of prescription, and science of curative properties. So in between patients, we each read a little.

Two theories govern Traditional Chinese Medicine, but before I get into them, I need to expose the underlying premises in Western medicine. Western medicine is generally built on a theory of reductionism and causality: we break the body up into systems and then the systems down into organs, tissues, and cells, and we then find out what everything causes in order to predict how we can change things. I’ll give you an example: if someone comes in looking jaundiced (yellowish in colour), our explanation is based on how abnormal function of the smaller parts of the body add up to this overall appearance. Jaundice is caused by the excess build up of bilirubin in the skin, and bilirubin is cleared by the liver and produced when red blood cells are broken down, and so the problem must be with the liver or with the break down of red blood cells. It’s a remarkably systematic and rigorous approach to the body.

By contrast, the theories in Chinese medicine are primarily theories of dynamic equilibrium– that the whole body is in a state of balance that’s established by conflicting forces. That balance is thrown off if one side becomes deficient or too strong. One theory asserts that the balance is always between two forces; the second theory asserts that the balance is a complicated web between five forces. Note that these ways of thinking aren’t foreign to one another. The Western notion of water balance (homeostasis) in the body has the same philosophical underpinning– you’re not drinking enough or you’re sweating too much. Similarly, Chinese medicine does break the body down into different functional systems. But in Chinese medicine, the concept of balance comes first, and the concepts of reductionism and causality occur WITHIN the framework of these forces that need to be balanced.

And so the balance between two forces is known as the Yin-Yang theory, while the balance between five forces is known as the Five Elements theory. All disease always goes back to Yin-Yang or the Five Elements. These are abstract concepts: yin-ness is exemplified by the moon, the shade, the internal, the cold, downward directions, etc. while yang-ness is exemplified by the sun, heat, the external, upwards-ness, etc. So, if you’re too hot and feverish, it goes back to either too much yang or too little yin. And the treatment (whether herbal or pharmaceutical) is, by definition, a yin-strengthener or a yang-inhibitor. The Five Elements are also abstract concepts: fire, water, metal, wood, and earth, and they have a relationship of either strengthening or restraining another element. This is where things got strange for me.

TCM believes that the Five Elements get mapped to five systems in the body based on traditional abstraction. The Fire element is mapped to the Heart– but not just the anatomical heart. The Heart includes the blood, the vessels, and the tongue. So perhaps it is better to say that the Fire inside the body is manifested in the blood, the vessels and the tongue. Metal in the body is mapped to the Lungs: but the Lungs also include the hair, the skin, the nose, and sweat. So far so good– maybe TCM simply regroups organ systems along different categories. But I balked when the book made an assertion about the relationships between these categories. Why should Fire necessarily restrain Metal? Sure, I could interpret the sweating from a heart attack as Metal becoming overactive once Fire failed to restrain it, but it didn’t seem like a particularly rigorous or well-founded association.

I tried to put my skepticism aside as I watched Dr. Sun apply these theories to his practice. Like a primary care physician during a routine checkup, he’d ask questions about how the patient was doing and whether there have been any changes recently. But I wondered about the credibility of his diagnoses when I saw that his physical exam consisted chiefly of inspecting a patient’s tongue. The reasoning goes as follows: childhood illnesses tend to be problems of too much yang, the Heart is a yang organ, and the tongue is a window into the Heart. From there, he’d make a conclusion (many of which were lost in translation and understanding), and then he’d tailor a herbal recipe based on each herb’s yin or yang property and its elemental attribute. After that, the next patient.

So over this backdrop of a very unfamiliar medical system and cultural and language barriers, I watched as patients poured into Dr. Sun’s office and sometimes paid a little extra to get a bit more time and attention from him. I mean, what was he doing for them? Was he improving their health? Or if not their health, was he improving their wellness? Was he offering the reassurance of his white coat? And if so, was the reassurance powerful enough to make them well? I grappled with the possibility that he was a charlatan and a quack, selling them the promise of better health but being unable to deliver it.

Calling Dr. Sun a quack is a heavy criticism on both the integrity of his character and his beliefs, and there are a few things that keep me from laying down such a pronouncement on him and by extension, TCM practitioners in general:

Firstly, as squeamish as I am about the theories behind TCM, it could be a working medicine of inaccurate theory but accurate associations. There is some evidence where traditional remedies outperform placebo: Chinese herbal medicine works for irritable bowel syndrome (Bensoussan 1998), and acupuncture is indicated for chronic pain (Manheimer 2005). In this situation, it may be that certain treatments were documented to have a positive effect on certain conditions and out of a desire to create a unified system of thinking, TCM used opposing elemental categories to record which treatment was effective against which condition. And when I reflect on the history of Western medicine, I concede that oftentimes, we are also a medicine based on association rather than bulletproof theory, but still we practice.

Secondly, I found that the TCM students were just as motivated by altruism as I was, and putting myself in their shoes, I couldn’t accuse them of any insincerity or quackery. They gave the same response that I would give if I were asked why I wanted to study medicine– they want to help people. And it’s hard for me to fault them for what they believe: the same way I usually don’t question whether clarithromycin works against H. pylori so long as my professor tells me it works, I imagine they don’t question the usefulness of a herbal remedy when Dr. Sun tells them it works. My convictions regarding the efficacy of Western medicine are founded on the trust I have for my teachers. If Western medicine is superior to TCM, then isn’t the validity of my belief only the result of my privilege to be told true stories about what makes people healthy and sick?

Thirdly, TCM is neither a small nor static field of study. Dr. Sun’s students will be learning TCM for the next four years. Just as they respectfully acknowledged that their field is complementary to the massive body of knowledge that is Western medicine, I have to admit that there is so much about TCM that I don’t know and never will. The total index of herbs is in the thousands (though less than a hundred are used regularly). They pick up new techniques from other naturopathic schools. And they are starting to use Western diagnostics to quantify their practice.

So, as China continues to grow economically, it will be interesting to see how their medical system negotiates between TCM and Western medicine. If patients substantially switch over to Western medicine as the medicine of preference, perhaps it suggests that traditional medicines were a compassionate cushion for those who couldn’t afford better care. But at present, I’m more inclined to withhold passing judgment on TCM. I think it is easy to pick on alternative medicines from within a North American medical fortress, to come to a rash conclusion, and to develop a hostile us versus them mentality and in doing so, create conflicts where there are none.

Why Medicine

I remember wanting to be just like Woody and Buzz from Toy Story. I was six years old when I first watched the movie and decided just then that I would grow up to be a Space Cowboy; the best of both worlds! However, as I progressed through all the remaining developmental milestones of my childhood and hit adolescence, one thing appeared obvious – the job market was not (and is not) very receptive of aspiring space cowboys. And so, I entered high school with a broken dream.
Continue reading Why Medicine

Golden Key – An Organization Dedicated to the Education of the Visually Impaired in China

This summer, four classmates and I visited several non-governmental organizations (NGOs) during our five-week trip to China as part of the Medical Student’s Initiative in China (MSIC). These NGOs were often faced with many challenges including difficulty in securing funding, entrenched cultural attitudes, and problems faced by the sheer size of the population they wish to serve. Indeed from what we saw, it seemed NGOs as a whole in China tend to be generally less well off than those in Canada. However even among other Chinese NGOs, one NGO stood out from the rest in terms of the disproportionate need they sought to address and the resources with which they were equipped to do so. Nonetheless I was encouraged by the optimistic and passionate attitudes of its members in the face of such a challenge. I choose to write this article about Golden Key Research Center of Education for the Visually Impaired for such reasons.

Golden key focuses on education for the blind and low vision population in China. The organization was established in 1988. Their eventual aim is to have every blind or visually impaired child in China have access to education. China has a total population of 1.3 billion, 50% of which are classified as rural, and 15.9% of which earn less than $1.25USD per day. The liaison we spoke with, May, mentioned that Golden Key is the only domestic organization dedicated to promoting education for blind and low vision children in China. The headquarters in Beijing currently employs eight full-time workers, including May. To put it lightly, Golden Key has set a very ambitious goal for itself.
Indeed the state of education for blind and low vision individuals in China is lamentable. This problem is more severe in rural areas. In these areas, families of blind or low vision children are often poorly educated and do not have the knowledge or resources to handle the special needs of these children. To further exacerbate the problem, there is a wide-spread belief in many rural Chinese communities that disabled children are born as a result of the parents’ wrong-doings.

This can include wrong-doings related to directly to maternal or fetal health, or to acts which many Westerners would see as unrelated e.g. not abiding by Confucian social order. An example of the former, May reported, is when some parents try to abort a fetus by ingesting chemicals. This may be done for a variety of reasons, for example sex-selective abortions, attempting to abide by the one-child policy, born out of wedlock, and so on. The efforts of the parents may not always be successful, and can sometimes pose risks to the fetus. Thus, fearing shame and rejection from the community, parents often keep disabled children at home, and subsequently these children do not receive education.

The minority of blind and low-vision children who do manage to receive education are often faced by discrimination and stigma in the work force. For example, May brought up the example of a low sighted person who, when attempting to find employment, was consistently confronted by the belief that blind or low-vision worker would require more work on the part of the company. Part of the discrimination stems from Chinese culture, in which a large value is placed on conformity, and with a low tolerance for unorthodox or abnormal behaviour. Since blind or low vision individuals often have special needs or cannot fulfill roles in the same way that other non-disabled people can, these make them obvious outliers compared to the otherwise healthy and uniform population.

Overall, the current state of blind and low-vision support in China is one that lags behind the standards of many developed countries. However, as China’s economic progress approaches that of developed countries, there will be increased material wealth and likely increased access to education. Increased material wealth will hopefully lead to increased funding for domestic NGOs. Overall increase in access to education will hopefully make education more obtainable for the disabled, and help to soften some of the social and cultural beliefs held by the population at large, which poses such a substantial barrier to a disabled person’s education.

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“How was India?”

The answer to this seemingly simple question eluded me upon my return from a summer spent in India as part of the India Health Initiative (IHI). I struggled in vain to compress such a rich experience into a few words or sentences.

Looking back, the things that stood out most were the friendships we formed with the individuals encountered in this journey. The most precious moments were those spent playing with the children, caring for the babies, chatting with spinal cord rehabilitation patients, and being alongside families at Lifeline Express. I wish to share these heart-warming moments through a collection of photographs and the little vignettes that accompany them.

Families for Children (FFC) is an orphanage providing care and education for children, youth, and women regardless of any physical or mental handicaps. I had previously envisioned an orphanage as a sad and gloomy place, but my experience at FFC has changed that view completely. The children are all brothers and sisters in one big family, and they take care of each other. They welcomed us with their open hearts and warm smiles such that within a few days I felt like I was part of this big extended family.




There is no better way to start the day than walking to school with the boys. They told us many things about their neighbourhood: which houses have scary dogs, where the safest place to cross the busy street is, and what kind of plants are growing in the gardens and roadside.





A picture capturing one of the heart-warming moments at FFC: walking the “big babies” from kindergarten back to nursery. We spent a lot of time taking care of them: playing, feeding, and changing cloth-diapers.








“Draw a monster! Draw a monster!” I sketched a monster on a page from our notebook. The boys liked it so much that they copied the drawing onto their backpacks.




Located at the village of Ayikudy, Amar Seva Sangam (ASSA) is an NGO dedicated to the service of the disabled in rural South India. The India Health Initiative was formed by two UWO medical students who visited this organization in the summer of 2003. It was wonderful to have this long-standing relationship and to be able to see the contributions IHI teams have made over the years.




We were active participants in the children’s daily physiotherapy sessions. Many of them have physical disabilities that require treatment and we were able to integrate simple games into the therapy sessions.








Simple things such as accompanying the children to their daily physiotherapy session and having lunch with them filled my days at ASSA with joy.




We also had the opportunity to take part in village-based rehabilitation home visits; it provided personal insight as to what life in rural India was really like. We witnessed first hand how one’s economic status is not the sole determinant of one’s happiness







We were also active participants in their learning environment. This picture was taken at a school assembly.




We quickly became friends with the residents of the Spinal Cord Rehabilitation Unit at ASSA. In addition to taking part in their medical care and rehabilitation, we also shared our life stories with each other. In our free time, we played chess, card games, and frisbee (as shown in this photo).

The third NGO we visited, Lifeline Express, is a mobile train hospital with the mission of serving the underserviced population in rural India. It took us 48 hours to reach the remote Bastar district in Chhattisgarh, among the bottom five of India’s 643 districts for development and health. It was an eye-opening experience to see the staggering medical needs as well as the tireless efforts of the volunteer medical staff. In addition to learning about the various medical conditions and surgical operations, it was very touching to witness and be part of such tangible positive change.



Mother with daughter waiting for her cleft-lip repair surgery at Lifeline Express. She was elated that her daughter could receive this free treatment that would significantly improve her life.





A young girl woke up from anesthesia after her orthopedic surgery for congenital talipes equinovarus (CTEV). There was a passing train in the background through the windows.




It is my wish that these photos can convey a sense of what I experienced in a way that my words cannot. I have come to realize and experienced the fundamental basic human connections that transcend cultural and language barriers. These people we met have enriched my life by the generosity of their friendship; for that I am truly grateful. I have learned a lot from this summer elective experience and I hope to return to these places one day as a physician and a friend.

My experience with IHI (India Health Initiative)

I had heard of complete chaos, but not truly experienced it until that very instant. I stood frozen, looking upon the scene. I was in a laparoscopic tubal ligation camp at a small primary health care centre just outside of Jagdalpur, Chattisgarh, India. We, the India Health Initiative team, had spent the past four weeks learning about health care and rehabilitation medicine in different areas of South India. Nothing we had seen so far had prepared us for this. Women, maybe only a few years older than myself, clad in their gorgeous colourful saris, half-sedated, were being led to tables in a chamber the size of a small clinic room. Men, who were there as nurses or volunteers, were carrying the women out in their arms after the minor operation that would drastically affect their lives, only to place them upon rickety beds in the outer hall, for their entitled two sutures. As the men walked between the chamber and the hall, they nearly tripped over the dozens of women who were tossing and turning in discomfort, as they lay on a threadbare carpet on the floor in the hallway.

My head was spinning with questions, and a general feeling of uneasiness settled over me. Where had I come? What was happening here?

The gynaecologist was alternating between two beds with his laparoscopic instrument. Enthusiastically, he showed us how he pierced the skin near the umbilical region. He allowed us to look through the camera and see the rings surrounding the fallopian tubes, displaying the tubal ligation that would ensure the women would have no more children. “This camp, like others, is a government initiative,” he said, “And a much needed one.” He insisted that the ladies were aware of that, and had come for the procedure of their own accord. But I couldn’t help but think: had these women, lying awkwardly with their eyes half-closed and legs raised up, truly given consent for this procedure? Did they know the risks, the consequences of having this done to them? Did they even understand what was going on?

I felt helpless, enclosed, and claustrophobic. With absolutely no power in this place, was there even anything I could do? Then it came to me. I recalled a scene from earlier in our trip: we had been observing the dressing changes for a spinal cord injury patient in the post-acute rehabilitation centre at Amar Seva Sangam, Tamil Nadu. The man was in extreme pain and terrified. Even when there was seemingly nothing we could do to help him, being untrained and out of our comfort zone, one of our teammates, Julia, reached out to hold the man’s hand as he had his bedsores dressed. Though they spoke different languages, she made eye contact with him, and smiled encouragingly. I saw the gratitude in the man’s eyes. This moment stayed with me.

It struck me that I could do the same for these women, and so I did. As the next woman was lowered onto the bed, I took her hands in mine and held on to them as tightly as I could as she underwent the procedure. The nurses around me looked at me strangely, but their gaze, though scrutinizing, was not unkind. I ignored them as I felt the returning squeeze of the young woman’s hands with the sharp intake of breath that told me the local anaesthetic was not as well administered as it could have been. I held on tighter, whispering words of comfort in Hindi, hoping that she could hear me and gather some strength from my presence.

I came away from the experience with mixed feelings, unsure of what I had just experienced. It made me question many things – basic things that we sometimes take for granted here at home like hygiene and privacy, and deeper layers such as motives in health care and the ethics of consent especially in poor, young women. It is not an issue that can be explored overnight or that I can resolve on my own. Though there will definitely be resistance, I will continue to think about these issues and hope to do my part to contribute to global health and awareness, to be able to preserve the innate sanctity of the delivery of health care.

But it also taught me that even in the depths of despair, even when I was confused beyond belief, and upset by the loss of dignity of these women, I was not helpless. There was still something I could do to preserve the human spirit and trust in that situation. It was possible to reach out and connect to another human being. And it does not require a medical degree, years of training or experience. It requires only a heart that feels…a hand of care…a voice of warmth…

Life in the Truck

In the first draft I wrote up for this blog post, I tried to write a grand overview of the life and culture of paramedics, without success. I realized I was trying to do one of the things that being a paramedic had taught me to avoid: I was lumping everything together, when paramedics are actually an incredibly diverse and dynamic group of people. So I went back to the drawing board to draft a version of the only paramedic story I’m qualified to tell- my own. Continue reading Life in the Truck