A visit to Nagi Family Clinic.

During the final week of August 2008, I had an opportunity to stay with Dr. Akira Matsushita, the family medicine physician at Nagi Family Clinic, one of Nagi town's only two medical facilities. A larger hospital in nearby Tsuyama, which is a 40-minute drive, is the only in the region offering tertiary medical care.

Nagi is a small town in Okayama, situated in the partly mountainous region of this rural prefecture in the southwestern part of Honshu, Japan. A 15-minute drive will take you to the border with Tottori prefecture. Sarcastically nicknamed 'the Ginza of Nagi' by some, the central part of the town is not bustling at all, with only two supermarkets (closing at 7PM), one convenient store, a tiny locally-owned bookshop, an elementary school, one pharmacy, the town office, and the clinic. Home to 6,690, Nagi's population has been decreasing year after year, just like many other rural towns and villages where younger generations have decided to move to not-too-distant urbanized areas such as Okayama city, Kobe, or Osaka, in search for better jobs, a wider choice in academics for their children, or simply a more convenient lifestyle.

So, why did I visit the clinic? Well, after seeing various types of community-based health care in the U.S., Thailand, Scotland, and Tokyo, I wanted to have a glimpse of what rural health care is like in a place far from the country's capital or any other big city. The closest to Nagi is Okayama city, which is more than a two-hour drive. Dr. Matsushita, well-known among general practitioners in Japan for family-oriented primary medical care and medical education in family medicine, happened to be the former attending of a doctor at my university's general medicine department who I am very fond of, Dr. Hiroyuki Saito.

Now what's so special about this clinic? Well, to put it in a single sentence, Nagi Family Clinic knows its patients very well, and that is very, very well. The doctors take a considerable amount of time in listening to the patients, some of whom make visiting the clinic part of their weekly schedule just to have someone to talk with. You may think that is wasting time, but if that is helping the patient stay happy and actually healthy by means of making the patient think and recall what happened in the past week, that is not necessarily correct. All the medical records have been digitalized and are online on the clinic's server, and that has enabled them to create the 'electronic family tree', where when you look at a patient's medical records, you can also see the family members and their medical records at the same time, which is a handy tool that helps to make medical care more family-oriented. The doctor can interact with the patient with all that background of the patient in mind. Another special feature I noticed is that, every single staff, including the paramedical workers, know so much about the patients. Their medical issues, their character, their habits, and so forth.

So, my week at the clinic and town enabled me to get a glimpse of who and what kind of people live here, the social issues that underlie, and how health care is done in this small rural town, from different perspectives, as Dr. Matsushita kindly made it possible for me to spend time not only with the clinic staff but also with the social worker at the nearby town office and staff at the local non-profit organization (NPO) called Kazamakura, which offers services for the elderly including home-visiting nursing care and driving them to health care facilities. A low-fare local town loop bus was introduced recently, but for the elderly, bus-stops are often still too far from the home to walk to, and you don't have the option of a taxi in this rural part of the prefecture. Like in many other rural areas of the country, the over-65-years-old population is growing there too, now exceeding 25%.

The Japanese Self Defense Force (JSDF) base and training grounds play a large role in supporting the local economy (the JSDF even pays a certain amount to the town for each and every single bullet fired) in a town where apart from one construction company's factory are only small local businesses and agriculture. And that factory is currently amid a dispute with the people living nearby, who are complaining of the exhaust that comes from the factory chimneys causing respiratory problems, though company officials claim they are meeting all environmental standards. It is a bittersweet situation for the local government, which finally succeeded in inviting this first company to make a factory in town but that is now having conflicts with the locals.

Every week, a 'community care meeting' is organized at the family clinic, which is a gathering attended by staff from the homes for the aged in the town, the local town office, Kazamakura, the local pharmacy, and the clinic, to discuss the latest health matters and try to solve them through cooperation and close coordination. For example, they would talk about s 90-year-old lady living in the southern part of town who's dementia has recently deteriorated and needs more frequent home-helper visits, or how to make efficient and sustainable safety nets for the elderly living alone and far from the center of the town. This town, being small, means human resources are limited, but on the other hand it could also be an advantage, as it makes it easier for them to communicate with each other, coordinate closely, and make decisions fast. And including the aforementioned clinic staff, everyone knows the town people very well. Truly a form of community-based holistic care.

People of Nagi are bright. I don't know, but every time I visit countrysides, I can't help myself from getting the impression that people in rural areas generally seem to be happier than those living in the busy mega cities. And the elderly in Nagi, yes, some are surely vulnerable to illnesses, but there are still many 80-year-olds and even 90-year-olds working in the fields from sunrise to sunset. One old man told me, "yes, I'm way past 65 (retirement age), but working in the fields is what I enjoy and that is my living".

Good communication and cooperation is there with the health care staff and happiness and livelihood are not yet lost with the people. Yes, many small villages and towns have chosen to merge with their neighbors due to financial uncertainties, and no doubt there will be challenges ahead for Nagi as well, but with all the strengths plus a touch of creative thinking, I believe they could well be poised to become a good example of rural community holistic care. :-)

How should we save more lives from cardiac arrests?

During the second week of September, I was in the Department of Emergency Medicine as part of my clinical rotations. Our university hospital focuses primarily on tertiary emergency medicine, therefore, only the most severe patients are carried into the ER here, such as cardio-pulmonary arrests (CPAs). However, there are exceptions, including cases where the ambulance had been refused by other hospitals, which is unfortunately, not rare at all. Through my four days here, there were some things I felt and thought I would like to share.

In emergency medicine, a CPA patient is defined as one who is unconscious, whose breathing cannot be seen, heard, nor felt, and pulse cannot be felt at the common carotid artery. When this patient is carried in, we basically follow either the Immediate Cardiac Life Support (ICLS) or Advanced Cardiac Life Support (ACLS) guidelines and attempt cardio-pulmonary resuscitation (CPR). However, through the days I was there, out of a total of seven CPA patients carried in, none recovered from coma and one reached recirculation but did not regain consciousness. The hospital admits 350 to 400 CPA cases per year, and circulation returns in approximately 50 of them, and total recovery is 10% of that, and that means a single digit number.

When one falls into CPA, which part of the human is most quickly damaged? The brain. Not only is it a damage, but an irreversible one. It is said that if recirculation could not be achieved within five minutes of CPA, chances of full recovery declines to 50%, and after 10 minutes, that plummets to somewhere extremely close to zero. With this considered, in the U.S., some local authorities have begun to adopt the termination of resuscitation (ToR) guideline. It supports termination in the out-of-hospital setting subsequent to failed basic life support (BLS) resuscitation by emergency medical services (EMS) personnel if all of the following are true: (1) no return of spontaneous circulation prior to transport; (2) no shock given prior to transport; and (3) arrest not witnessed by EMS personnel.

Our university hospital concentrates on tertiary emergency medical care, so in other words, patients carried in are those whose chances of full recovery are close to none. But no matter how the situation is, ER personnel will do whatever they can do to resuscitate. In Japan, the average time it takes for an ambulance to reach the site after the 119 call is seven minutes, and it takes 30 minutes from the time of arrival at the site to reach a hospital. It doesn't take a rocket scientist to see that that is well beyond the 5 minute 50-50 tipping point.

Without doubt, knowing the ICLS or ACLS procedure is a must for all health care providers. However, chances of a CPA patient being saved is extremely low, unless someone at the site knows BLS and carries it out. What I would like to clarify here is that yes, knowing the ICLS or ACLS guidelines and being able to perform it is important, however, teaching people the basics of emergency medicine and making sure they can perform BLS promptly and appropriately is the way to significantly cut the number of lives lost from CPA. The good news is, BLS seminars are becoming more common, and organizations from corporations to governments are placing automated external defibrillators (AEDs) here and there. Now, we also need to focus on how to help people keep up with their BLS skills. :-)

A visit to The Royal Infirmary of Edinburgh.

My first visit to Scotland, and Great Britain. It was months ago when I decided to participate in the three-week 'English for Medicine' course offered at the University of Edinburgh's (pronounced 'yeh-dinbra') Institute for Applied Language Studies (IALS), and what made me do so was that I wanted to see the Division of Community Health Sciences and meet a professor named Dr. Raj Bhopal there to seek some advice about how I should pursue my area(s) of interest. Having interest in family medicine and public health with a clinical taste, I also wanted to take a look at how general practitioners (GPs) work and get a general idea of the health care system there.

As in other countries as well, the U.K. has both public and private hospitals, the former of which is run by the National Health Service (NHS), a non-profit organization funded by the government but independent from, paper-wise. Now, in Japan, patients have the freedom to choose the hospital or clinic they wish to visit. Whether it's your local clinic or a university hospital or the cancer center, it is basically up to you to decide where to go, however, this is not the case in Great Britain. If you become ill and wish to see a physician, unless you have a contract with a private health insurance company, which will allow you to have access to a private hospital, there are only two ways you can see a physician: see your GP or end up in the accident and emergency department (A&E). GPs are allotted a certain population in an area, meaning from the patient's point of view, you are automatically determined who your local health care provider is depending on where you live. Only when your health problem cannot be solved at the GP or A&E clinic that you first have the chance to see a specialist, in the form of referrals written by your GP.

A GP has two major roles: an expert in general medicine providing primary medical care, and a gatekeeper of resources. The former role includes not only the clinical part (inside the clinic and also visiting homes), which includes pediatrics, maternal health, referring patients to specialist hospitals, and follow-up of patients with chronic illnesses, but also a variety of other tasks for community health, such as prevention and health promotion, and sex education and family planning. But in reality, most of the GPs in populated areas only have time to do the clinical part, which can be understood from the fact that patients are made to wait an average one week from when you make your phone call to the point of your appointment. No wonder an increasing number of patients, who can afford, are choosing private hospitals. If you're referred to a specialist, it will likely add more weeks or even months to that.

The GPs' latter task, as a gatekeeper of resources, is in two perspectives. A GP has to prevent inappropriate use of treatments and 'control' the patients' demands, thereby saving financial resources, and also guide the patient to the right care they need, as in referring to the appropriate specialist, thereby saving human resources. However, because of this, there are many GPs who face a dilemma, as they are also the closest health care personnel for the patients, and speaking out for them is the basis of a GP's job.

So, when I had an opportunity to follow Dr. William MacNee, a consultant physician and professor of respiratory and environmental medicine at the Royal Infirmary of Edinburgh (RIE), I wanted to focus on not only how he interacts with the patients but also how he communicates, or exchanges information with the patients' GP, system-wise, as good communication is vital between the specialist and the GP as well in a health care system like the U.K. Oh, how do I know him? Well, Dr. Patrick Barron, the passionate professor in charge of the International Medical Communications Center (IMCC) at my university, kindly introduced me to him.

In a typical medical consultation here, the physician only jots down notes, instead of scribbling on the official medical records, which makes reading them a decipherment for others. After the patient leaves the room, the physician will read aloud and record on a tape what he wants written in the official records. The tape will then be duplicated, with one copy going to the patient's GP and the other to the physician's (or the department's) secretary for transcription on to the electronic medical records. The one going to the GP is labeled urgent (red) or not (blue). This system saves a considerable amount of time for the physician, though that means more work and some medical knowledge needed for the secretary.

The RIE is a specialist hospital, so there are no GPs, except for those in the A&E. Tracing its roots back to 1729 as the oldest voluntary hospital in Scotland, it was incorporated into the NHS scheme in 1948, and the current facility, located south-east of the city, was completed in 2003 for 190 million British pounds and boasts 900 beds. Due to its location, it also serves Midlothian and East Lothian. Adjacent to the hospital is the medical school of the University of Edinburgh, which the hospital has maintained close ties with for years. Some noteworthy features of the facility include a 24-hour A&E unit, the Simpson Centre for Reproductive Health, giving birth to 6,000 babies each year (largest in Scotland), and the Scottish Liver Transplant Unit. In the hospital's main hall are banks, eateries, a general store, a bookshop, a barber, and the patients' information center. Brochures and pamphlets covering a variety of topics, from information of diseases to informed consent, or self-help guides, such as how to deal with stress, can be found here and the good thing is all are free for the patient to take home. Very useful and interesting.

Finally, I would like to share some phrases and expressions I heard in the patient-physician interactions, especially from Dr. Gourab Choudhury, who is Dr. MacNee's registrar. I spent the morning following him on the day I was at the RIE. When a patient kept on complaining over and over about how her dyspnea was so severe, he used the phrase "Oh dear." several times. It's sometimes not easy to think about how to react when your patient keeps on complaining, and I thought this was a nice and simple way to express sympathy. Another phrase is "Let's take it on from there.", which he often used when he was finishing up the medical consultation. I often find it difficult to find an appropriate phrase to end the conversation with a patient, but here it is, a simple, convenient expression with a positive-thinking meaning and a touch of sympathy. :-)

A visit to Hinohara Village Clinic.

Hinohara Village is part of Tokyo, located in the northwestern corner of the huge city. The place neither looks like Shinjuku with the jungle of 50-story buildings nor Azabu with all the four-star restaurants and residences of the affluent, but more like a gathering of homes in a mountainous countryside. From central Tokyo, it takes two and a half hours by train to reach the nearest station and a bus ride from there that takes a further 40 minutes.

I had an opportunity to visit the village clinic here on the 25th of February. Two doctors work here, one of whom I know from a primary medical care seminar that took place last September, Dr. Aizawa, and when I asked him whether I could visit to see what health care in a remote area is like, he kindly gave me a nod. So on this morning I got up at 5:00am (still a bit dark around this time of the year), hopped on the train, and headed for Musashi-Itsukashi, the station nearest to the village. And since there are only six bus round-trips between the station and the village, Dr. Aizawa was kind enough to pick me up on the way from his home to the clinic.

The road winds between the mountains along a river, and I realized a lot of snow still remains. There are so many cedar trees on these mountains, many so close to each other, and Dr. Aizawa tells that these were planted in the 1940s for war, but have been left as they are ever since they became unnecessary soon after. The population of the village is now around a little over 2,850 people, with an amazing decreasing rate of 4-5% per year in recent years, with last year's number being 3,000, and the year before a little under 3,200. People over 65 account for 41% and families of the young generation continue to move to urban areas, no wonder there's no high school and the number of students in the village's sole middle and elementary school stand at 30 and 90, respectively.

This day was a relatively easy day for the clinic staff, which is comprised of one office personnel, one medical technologist, three nurses, and two doctors, as they only had about 30 outpatients. The clinic has a small inpatient ward that can accommodate two, but is usually only used in emergencies since a general hospital is about a 40-minute drive from here. Unlike the big hospitals in the urban areas, patients who come here complain of a variety of disorders, from common problems such as simple chest pain caused by falling down, or common colds, to major diseases such as diabetes and other lifestyle-related disorders or pneumonia.

In the afternoon, I had an opportunity to see what is called an "Oushin", which is a house call where a doctor goes and sees the patient at his or her home. I saw a similar activity at Ukima Clinic. (See post 2007/11/20) But unlike in the urban areas of Tokyo, the houses are so far apart, Dr. Aizawa says it could take well over 30 minutes to reach the home. Fortunately today, the house that gave us the call was close enough. It was a big 2-story house with an old couple living together, their children having already moved out to the urban areas with their families, leaving many rooms unused. The husband could not walk anymore, so his wife was taking care of him. Dr. Aizawa adds that many homes are too large, and since only a few live in them, many are cold even inside the house. There are sometimes severe cases, such as when they found a handicapped elderly living alone in a large house on top of the mountains with malnutrition.

Although the current state of health care here could not be said convenient, Dr. Aizawa says that it's much better than that of villages in other prefectures. Local governments in Tokyo are eligible to receive a considerable amount of financial assistance from the metropolitan government, partly due to the fact that they have made it a rule to place at least one doctor for each and every single local government, including small villages with a few hundred people. Meanwhile, not far from Hinohara Village is the countryside of Yamanashi Prefecture, where he says health care is in a "much worse condition". He added that you can even notice the difference in the quality of the road pavement when crossing the border.

There's much more he talked about this day, especially about his early years as a doctor in the remote islands of Tokyo floating in the Pacific. But for now, I'll stop here. Through this visit, I was able to get a general idea of what health care in a remote area is like, at least in Tokyo. I should visit other prefectures too. I would like to thank the kind staff at the clinic for making this visit possible. :-)

Looking back at 2007.

Time flies.

Oh boy, I wonder how many times I've said this phrase on this blog. But well, it's true. But it's also true that this year was full of meeting new friends and discovering my interests... and myself.

In spring, I participated in VIA's (a non-profit based in San Francisco and on the Stanford University campus) Exploring Health Care program to learn about health care in the USA and in the Bay Area in general. Along with medical students and undergraduates thinking of going that way, we hopped around the area to see hospitals, clinics (both private and free), homeless shelters, shadow doctors' rounds, participate in class to get a taste of what medical education is like there, and much much more over a period of 2 weeks.

The gay clinic called the Magnet, located in the heart of Castro, the gay mecca of the country, is what sparked me into community-based health care, or in other words health care that involves the entire community. What's amazing is that it's not merely a clinic but has the potential to act as a catalyst to bring a people together and empower them as a whole. I'll talk about this much more in detail another time...

And this summer, I found myself in a 11-day primary health care (PHC) training program at Mahidol University's ASEAN Institute for Health Development (AIHD) in Thailand. Along with nursing school students from that country, we followed a highly-concentrated course to see health care in the urban areas of Bangkok (including the slums), go up 4 hours by bus to the rural areas in Uthai Thani Province and stay in a village to do some epidemiology field work 'for beginners', and do a presentation at the end with our groups.

The rural area home-stay and the interviews and other interactions with the villagers totally changed how I think, and this is where PHC and community-based health care got on me. Again, I have to save another time to tell this in detail...

And last but not least, DOCS (acronym for Development of Clinical Skills), which we formed with the former participants of the Exploring Health Care program in our university to get a head start and practice clinical skills, played an important role in my life this year. We found energetic, passionate, student-caring doctors who were willing to teach us, in a university where we once felt finding those kind of mentors was devastating. Moreover, the activities led me to knowing general medicine, family medicine, and primary medical care, which then led me to Ukima Clinic, a community-based clinic up in northern Tokyo. (See post 2007/11/20.)

The more I look back at this year, the more the activities I was involved in get connected in one straight line. Compared to a year ago, I couldn't have imagined myself where I am now. This year helped me discover what my true interests are in (at least for now), and now I can much better describe the bigger picture of the doctor I have in mind for my future.

Wishing everyone a happy holiday season and another great year! :-)

A visit to Ukima Clinic.

When I contacted Dr. Fujinuma to ask whether I could see Ukima Clinic, a community-based clinic operated by the Tokyo Hokuto Health Co-operative, he happily nodded. So, on November 6th, I had the chance to visit the clinic I had been wanting to visit since spring.

I invited three friends who also participated in the Exploring Health Care program this March at Stanford University and University of California San Francisco (UCSF) and now belonging to a clinical skills practice group called DOCS (acronym for Development of Clinical Skills), which we formed after knowing how much clinical experience the medical students on the other side of the 'big pond' are exposed to.

So that morning, the day there started out in the outpatient clinic. Of course, it was our first ever time shadowing a doctor, so there was so much to learn, both in terms of knowledge and the way the doctor interacts with the patient. However, what I felt here most strongly is that health care is truly patient-oriented, in other words, even if patient A and patient B have the same health issues, the medical treatment or the approach taken by the physician may not necessarily be identical.

For example, there's not much hope in persuading an alcoholic or a heavy smoker to quit or reduce the amount if he insists he earns money to drink or smoke, respectively, and if that is the ultimate joy for his life. However, a different approach may be taken towards a person who is more willing to care more for his own health. A woman who smokes five cigarettes a day to refresh herself during break at her work says she is aware that it's not good and she's thinking of cutting the amount, but just couldn't make the move. So, then the physician would actually show her some other ways of refreshing, for example drinking tea or coffee or having a light snack, and chatting with her fellow workers. Naturally, there are exceptions, but in general, the doctor does what makes the patient most happy.

In the afternoon, we participated in what is called an 'Oushin', which is a house call where a doctor goes and sees the patient at his or her home. This is a very interesting form of health care, since you really have the chance to see the environment the patient is in, including the lifestyle and the socio-economic background. There are households with various status, from seriously poor ones to rather wealthy ones. In this afternoon we visited seven.

There was a family where the only person in the house was a 90-year-old lady lying all day in the bed, having only one grandson living with her to look after her when he doesn't have work. Other members of the once big family have either died or are literally 'missing'. The house looked as if it's going to crumble with a couple more earthquakes (yes, common in Japan), and the physician, now used to visiting this home, told us the places in the room where the floor had become too weak to support us. There was also a relatively wealthy-looking family, living in a mansion. Nicely dressed ladies (apparently sisters) had gathered to look after their mother who had become ill. This was a first-time visit for this patient, so the doctor goes through the explaining and all the communication with the patient's family thoroughly and carefully with detail. After the visit, she added that it's essential to build a favorable first impression, since that leads to trust and will ultimately have a substantial effect on the future relationship with the family.

So the day ended roughly eight hours after we arrived at the clinic in the morning, though the physicians still had some paperwork left including reviewing the patients' medical records. It was a day where I had the chance to truly understand that there actually are various kinds of people with various backgrounds. I mean, I knew that by words, but this experience enabled me to put those words in my own context. It is often said that the socio-economic disparities have widened in Japan, but still not to the extent of those seen in the U.S., Europe, or developing nations, however, disparities do exist and those are not minute. It is all the more important to understand the true needs of the patient, considering the background and the environment of the patient, and think about what happiness means for each of the patients, and tailor health care to help them become happier.

At the end, Dr. Fujinuma summarized the day by giving us a small lecture about what primary health care (PHC) is, and what strategies the clinic is taking to make the community more happy as a whole. Through this talk, three key words got connected in one straight line in my mind: primary health care (PHC), public health, and community building and empowerment. There's a whole another story to this, so I'll stop here for now. :-)

Patient assessment workshop by young doctors.

What would I do if a person walking in front of me suddenly collapses? He's holding his stomach and seems to be suffering from some kind of severe pain...

Much has been talked about basic life support (BLS), but that algorithm basically only applies to cases where the patient's heart has stopped. Well, then what do we do if a person's heart still seems to be working but he's unconscious and seems to be hurt in some way, is the question here. This is called advanced medical life support (AMLS) or international trauma life support (ITLS), and it's about assessing the condition of the patient in an emergency.

The algorithm consists of three major steps, and the first is called "Scene Size-Up", where the checklist assesses five points: body substance isolation (BSI), scene safety, number of patients, nature of the illness or the mechanism of the injury, and the resources that you have at that moment. The main purposes of this step is to provide safety not only for the patient but also for yourself, and collect information that can be gathered in a glance.

"Initial Assessment" is the second step, which is also the most important of the three. We assess five things here too: general impression of the patient, mental status, airway, breathing, and circulation. Does the patient seem severe? What's the level of consciousness? (AVPU - Alert, reacting to Verbal stimulation, reacting to Pain stimulation, or Unconscious?) Is there anything obstructing the airway? Is the patient breathing? What's the heart rate and condition of the peripheral circulation? Is the patient bleeding? Appropriate assessment in this step is vital, as the third step depends on the condition of the patient.

If the heart is not moving, we move on to BLS or advanced cardiac life support (ACLS). But if that's not the case, we first evaluate whether it's a trauma case or not. If it is, then we see if it's a single trauma or multiple. If it's single, we do a focused rapid examination of the injured area and ask the patient SAMPLE (Sign/symptom, Allergy, Medication, Past medical history, Event prior to the symptom) questions, while if it's multiple, we need to do a rapid thorough trauma survey of the entire body before asking the same set of questions. All of this is done before handing the patient over to the hospital.

Now, if the case is not a trauma, then we first see whether the patient is responsive or unresponsive. In the latter case, we must go through a rapid medical assessment of the entire body and check the vital signs (circulation and blood data). Gathering the medical history of the patient comes last, since one cannot speak at this moment. If the patient can respond to you, you gather this information first and then move on to rapid medical assessment and checking vital signs. Again, this is done outside or in the ambulance, before it reaches a hospital.

Of course, there's more detail and thinking to this, but the important thing about this type of learning right now is for us to do simulations with our fellow peers over and over to memorize the algorithm with your body, instead of the just the brain. Then we can move on to the details and the thinking of case-by-case scenarios. What's amazing about this workshop was that it was planned and carried out by a group of only first and second-year doctors and students. It really motivates you. :-)

Thanks for reminding me.

The other day I was talking about doctor-patient relationships with one of my friends who goes to nursing school, and it helped me remind myself of the image of the doctor I want to become.

Clinical rotations and training have started for her, and right now she's rotating through general hospitals to local clinics and health centers, while also shadowing nurses who are involved in various kinds of health care. And that day, she was complaining that some doctors really only look at the disorders the patients have and not the patients. In other words, these doctors are more focused on diagnosing and treating the disease, not the patient.

Then I thought... do I want to be that kind of doctor?
Well, I don't think so, but not to mean any offense to those doctors.

After all, I believe the doctors who immerse themselves in facing the diseases rather than the patients are the ones who bring new breakthrough technologies and advances in medicine. I also feel that many surgeons belong to that category too, as they're more like artisans or craftsmen, spending a significant portion of their life just to build up skills, sometimes just to treat only a couple of diseases. But that's still necessary, no question.

But the picture of the doctor I have in mind is more like a general practitioner, and probably more general and broader than the term actually means. I'm not attracted to craftsman-type doctors, and this just comes from my tastes, you either like it or not. I want to be able to serve people with various backgrounds. Not sure why, but I guess it has something to do with the fascinating discoveries and thoughts I've had in the past through meeting many people, many of which have helped me shape what I am now. Through examining the medical problem of the patient, I want to interact and understand more about the patient, including one's socio-economic background. If this is done at a certain community-based level, I have a feeling it would enable you to see the strengths of the community, as well as the social issues that are underlying.

Well, in conclusion, whether the doctor focuses on the disease or the patient, I don't think it matters much as long as it makes the patient happier than before. And as long as the patient is happy, what form or type of approach the doctor follows is up to the doctor's personal preference. The doctor should be happy and comfortable too, about not only what he does, but also how he does it. Anyway, there will always be a need for both types of doctors.

I've always been interested in combining the characteristics of general medicine and public health in a clinical manner. You know how you want to face your profession, but there are times when that picture gets blurred, and this recent talk with my friend helped me see it clearly again. Many thanks to her. :-)