I decided to do a 4-week internal medicine term and a 2-week radiology term at the National Taiwan University Hospital, since this is one of the most prestigious universities in Taiwan and many Taiwanese students from UNSW who went to NTUH for their electives gave positive feedbacks.

After several turbulences on the plane which made me feel like throwing up, we landed safely in Taoyuan airport. On the first day of my elective, I reported to my accommodation, the Jing-Fu Alumini Hall. Considering its “golden” location, close to the Taipei Train Station, it is not expensive (NT12,000/month). I had easy access to delicious food and shopping. My room was not much different from a motel room. There was a cable TV, fridge, my own bathroom, and two beds. I also had free internet access in the room.

Internal medicine

On the first day, I reported to the Office of School of Medicine. Gabrielle, the friendly young lady in charge of exchange student affairs, took me to the department of internal medicine. Initially I wanted to do four weeks of gastroenterology/liver disease because the hepatocellular disease unit in NTUH is recognized worldwide. However a local medical student advised me against spending such a long time in the unit since the unit is very specialized, with 2/3 of the patients having hepatocellular carcinoma. Therefore I decided to do two weeks of gastroenterology/liver diseases (Ward 13A) and two weeks of nephrology (Ward 13D) instead.

Gastroenterology/liver diseases

On my first day, I met with my GI/liver diseases team. My team includes a VS, Dr. Lee (the equivalent of a consultant), a R1 (first year resident), an intern (a 7^th year medical student), and two senior clerks (equivalent to 6^th year medical students). There is a chief resident (equivalent of a senior registrar or fellow) in the ward with his own office. He overlooks all the three GI/liver diseases teams. He also performs the procedural stuff like abdominal ultrasounds and liver biopsies. He gives us tutorials as well. Our weekly routine is as follows:

Monday

Tuesday

Wednesday

Thursday

Friday

7.30 Morning meeting

11.00 my VS’s ward round

5.00 GI conference

7.30 Morning meeting

11.00 my VS’s ward round

12.30-1.30 Fellow teaching

1.00 Case discussion

8.00-9.00 Grandround

9.00-10.00 VS teaching session

11.00 my VS’s ward round

5.00 Upper GI series

7.30 Morning meeting

11 my VS’s ward round

12.30-1.30 Fellow teaching

4.30 Prof H (Head of department) round

5.30 GI-GS combined conference

8.00-9.00 Grandround

12.30-1.30 Fellow Teaching

2.00 Prof S teaching session

4.00-5.00 Ward round

Most of the patients I saw were HCC patients. There were also patients with other hepatic tumors, hepatic failure, pancreatic abscess, pancreatitis, esophageal cancer, colon cancer, and even a TB patient! Those with tumor rupture had really poor prognosis. The elderly lady on our team with HCC rupture passed away two weeks after admission. A man in his 30s came in with a strange hepatic tumor which did not seem to fit into the description of the more common hepatic tumors. The tumor looked like a cyst on ultrasound and biopsy, but looked like a tumor on CT scan and had been growing extremely rapidly, leading to hepatic failure and gross ascites. On the 6^th day of his admission he needed CPR because the tumor ruptured and he was then sent to ICU.

Nephrology

My team included a VS, Dr. Tze-Wah Kao (高茈華), an R2, an intern, and two senior clerks and one junior clerk (equivalent to 5^th year medical students). I really enjoyed being attached to her team as she is very sincere to everyone and truly cares for her patients. She teaches a lot and gives students some tasks and assignments. Our weekly routine was as follows:

Monday

Tuesday

Wednesday

Thursday

Friday

7.30 Morning meeting

2.00-3.00 Nephrology conference

3.00 my VS’s ward round

7.30 Morning meeting

10.30-12.00 Teaching round

2.00 my VS’s ward round

8.00-9.00 Grandround

2.00 my VS’s ward round

7.30 Morning meeting

10.30-12.00 Head of department round

2.00 my VS’s ward round

8.00-9.00 Grandround

2.00 my VS’s ward round

The patients I saw on the nephrology team were more varied. Some examples were:

A lady with psoas muscle abscess and lumbar spine osteomyelitis who has been in hospital for nearly two months because her fever would not come down with medical treatments.
A poor elderly lady with diabetes mellitus, chronic renal failure and an amputated foot, who kept mumbling “ar ar ar ar ar”.
A 68 year old man with a recent stroke as well as end stage renal disease. It was really encouraging to see him making progress: Initially his arms were really floppy and he could not move them at all. We could not understand his speech either. He was unable to open his eyes fully either. By the time he was discharged, he was able to move his arms against gravity. We could understand his speech. I also realized he actually had very big eyes!
A young lady with SLE and lupus nephritis.
An 86 year old man with acute renal failure who complained he was “in hell” (he said that in English, which was rather unexpected)!
A man with a ruptured renal artery aneurysm.
A 20 year old man with a ventricular septal defect, infective endocarditis, and rapidly progressive renal failure
A very jaundiced man (I’ve never seen someone so yellow!) who refused to listen to the doctors. He kept eating and bringing in his beer friends when he was repeatedly told not to.

Radiology

I then spent two weeks in Radiology. I knew I would see a lot of films during my stay because investigations are ordered excessively in Taiwan. I met my friendly supervisor, Dr Hsu. He gave me the doctors’ schedule told me I could do whatever I wanted. Therefore, I decided to spend the first week with the 5^th year medical students, and the second week touring around the department alone.

I saw the common procedures: Angios, CTs, MRs and plain film studies in the fields of neurology, orthopedics, body, chest and pediatric radiology. More specialized studies I saw included: breast sonography, mammogram, CT guided biopsies, BMD, upper and lower GI studies, Videofluoroscopic Swallow Study (VFSS), pyelography, hysterosalpingogram.

I also listened to various VS doing radiology reports. The VS were generally very nice and teach quite a lot while they are reporting.

Taiwan versus Australia

Medical school

	Taiwan	Australia
Course structure	7 year undergraduate course, interns= 7^th year. Interns do not earn money.	6 year undergraduate course, interns= 1^st year postgraduate
Clinical years	First clinical year starting in 5^th year at NTU, but can be 6^th year in other universities. They are called Clerks, and are generally introduced to patients as “more junior doctors / learning doctors”.	Small amount of exposure in 2^nd and 3^rd year, then fully clinical from 4^th year onwards
Responsibility	The whole team stays in ward all the time instead of going around the whole hospital. Clerks attached to a ward are given one patient whom they provide “primary care” for. Another words, they have to do everything for the patient - writing up the admission notes, order forms, daily progress notes, weekly summaries, consult forms, and organize investigations, with more senior doctors supervising them and countersigning. They have to write all of the above in English. Interestingly the admission notes have to be typed on the computer and printed. They’re constantly looking at “The Washington Manual of Therapeutics”. I “primary cared” several patients during my attachment.	The team goes to various different wards during the ward round, which can be very tiring. Students generally tag along for ward rounds and are free to go around and see the interesting patients. They’re not responsible for any patients.
Teaching in the wards	Generally the resident doctors are really keen to teach and are very patient with the clerks. I have not seen any rude doctors during my stay. Some consultants teach a lot, some do not teach much, but they are generally very friendly. There’s a large tutorial room (fits around 20 people) in each ward for students to place their bag and study in. So generally time is not “wasted”, and the resident doctors come to the room to call you over whenever something’s up so there’s absolutely no need for a pager.	Very doctor dependent. Some doctors can be very nice while some can be quite rude. Sometimes students feel time is “wasted” during the long ward rounds. The students do not have the luxury of having a tutorial room in the ward where they can place their bags in. When something’s up, not that many doctors actually page the students either.
Student characteristics	Studious: I noticed that whenever the clerks are not caring for their patient, they are flipping through their textbooks / PDAs. I guess it is harder for them since they have to study English textbooks when their English levels are not that great. Interestingly, when they have a tutorial, they are also allowed to flip through their textbooks when the doctor asks them a question.	Students are expected to read up topics at home and be able to think through things logically. They can get frowned upon if they keep flipping through textbooks during ward rounds or tutorials.
	Exams: the students have exams very frequently. They’re quite used to it and do not look that stressed a week before their exams. In fact, they still continue to stay in their ward on the days of their exams. They have a national licensing exam in their 7^th year and a lot of medical students actually go to cram schools for that!	We do not get examined as frequently but the examinations are much larger. Students seem very stressed a week before exams and most hide at home to study.
	A mixture of medical students from different medical schools: Students from various medical students are allowed to go to hospitals affiliated with other medical schools during their clinical years. They also accept international students into their medical program, eg. I met a Taiwanese-Japanese intern and a Taiwanese-Korean medical student. I also met 5^th year NTU medical student who is almost 60 years old! His son is already a resident doctor at NTUH!	All the medical students of a university spend their clinical years in hospitals affiliated with their medical schools.
	Male to female ratio: only 1/4 of the students are females… or maybe even less!	60% female!
Exchange	NTU has ties with various medical schools: Harvard, Ohio State University, Northwestern University, University of Southern California, Duke University and University of Rochester. Students can apply for exchange programs without having to pay application fees but the quota is very limited.	We have to arrange electives ourselves. If we wanted to go the US, we have to pay a large sum of application fee.
	Sometimes they get visiting professors from other countries to give talks during grand rounds. For example, they had a visiting professor from OSU who gave us a very interesting talk and an excellent bedside tutorial.	We don’t get visiting professors from other countries as often.

Hospital

	Taiwan	Australia
English	The hospital notes and investigation results are all written in English (full of grammar mistakes).	Everything is in English.
Efficiency and Computerisation	Most things are computerized. The admission notes are typed on the computer and printed. The investigations are ordered on the computer and the results are also viewed on the computer. All the doctors and medical students have wireless internet accounts in the hospital so they can bring their own notebooks to do stuff. Things are generally more efficient than Australia.	Most things are handwritten. A lot of time is wasted on calling people up and chasing up results.
Wards	The teams tend to stay at one ward only. All the hepatology patients stay in 13A and all the nephrology patients stay in 13D, therefore the teams just stay in the same ward during ward rounds. They do not even have to go to the ER – they admit the patient when he/she comes up to the ward. There’s a nice homely feeling in the ward since they stay at one ward. It’s actually quite comfortable to stay in the ward since there is a spacious tutorial room for you to put your bags/study/eat in. Each ward also has an “on call” room with four beds and a bathroom – students can even go in there during lunchtime for a nap!	Lots of walking around during ward rounds, to cover all the patients in the hospital. The doctors’ rooms are tiny and crammed.
Residency program/ specialist training	In the middle of their internship year, they decide what they want to specialize in and apply for it. Once they get it, they start their specialist training during R1. They frequently have foreign doctors coming here for short term training, eg. a Mongolian doctor in nephrology and a Vietnamese doctor in radiology.	People start applying when they are residents or later.
Investigations	They order investigations excessively. eg. one hepatology patient may get liver ultrasound, CT, angiography, MRI, and liver biopsy all done.	We decide on the basis of whether an investigation will influence management.
Masks	Interestingly, most doctors and medical students have a habit of wearing masks whenever they see patients. They feel by doing this, they are protecting both the patients and themselves.	I have not seen anyone wearing masks when seeing patients so far.

Tips

You are basically thrown in with the team/students without any pamphlets or instructions. Therefore, it is essential that you grab a medical student to orientate yourself; otherwise you will be very lost. Depending on your luck, the medical students may be starting a new attachment too and be as lost as you are (that is good), or it may be towards the end of their attachment and they’re too busy preparing for exams to help you out. Many students don’t talk to you automatically so you have to start the conversation first. I was very lucky: everything was in pretty good timing and I met some very nice students.
The medical students also get extra tutorials and lectures and you can ask them about it.
The chief residents are very busy and tend to forget about you. Therefore, if you want to provide “primary care” to a patient or see some procedural stuff, you must approach the chief resident yourself
You can follow the intern “on call” for the day to take bloods, place NG tubes etc.
Given the luxury of a nice tutorial room, you should stay there until 5pm. The doctors will not be too happy if they cannot find you in the ward.
You get more out of the term if you’re fluent in Mandarin and Taiwanese (or Hokkien).
There is a gym close by called “California Fitness Center”. You can join a two-week trial membership for free and keep fit. Otherwise, you can ask the NTU students about the student gym at NTU.
Whenever you wear your ID badge, you get 10% discount in most shops in the hospital. The food in the staff cafeteria is very cheap, at NT40.
Due to the overabundance of cows in the zoology department at NTU, you can buy NTU dairy products: they are very good.

Overall, I learnt a lot from the terms and recommend them to future students going to NTUH for their electives.