Community of Reflective Practice: Clinical Education in Taiwan Yan-Di Chang Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy under the Executive Committee of the Graduate School of Arts and Sciences COLUMBIA UNIVERSITY 2017 © 2017 Yan-Di Chang All rights reserved ABSTRACT Community of Reflective Practice: Clinical Education in Taiwan Yan-Di Chang Medical practice entails lifelong learning of both the science and art of medicine. However, it is not easy to teach or observe what one has learned about the latter. Previous literature has found that learning during the clinical phase is influenced by both the macro, structural issues and micro, individual factors. This ethnographic study investigates the deliberate, systematic, and sustained effort of clinical education at a district hospital in Taiwan in order to find out how medical educators can train and retain caring and competent physicians. It focuses on the students’ experiences during their clerkship, formal and informal teachings such as ward rounds, teachings at the operating room, and fortnightly medical humanities discussions, as well as what the hospital has done to create a conducive environment for teaching and learning. Using a grounded theory approach, it uncovers the problems novices face in clinical practice and learning and effective techniques expert clinicians use in teaching. It concludes that the most effective and efficient education happens when learning is made explicit and visible, when teachers actively engage students in legitimate peripheral participation, when learners become self-directed in their endeavors, and when there is a community of reflective practitioners. TABLE OF CONTENTS Title Page List of Tables ii Acknowledgments iii Dedication v Introduction 1 Part I: The Students 34 Chapter 1: The First Day 37 Chapter 2: A Student’s Initial Clinical Experience 81 Chapter 3: Trying Not to Be a “Roadblock” 119 Part II: The Teachers 152 Chapter 4: The Ward Rounds 158 Chapter 5: The Professor Rounds 207 Chapter 6: Some “Classic” Teachings 238 Part III: The Hospital 266 Chapter 7: The Hospital and Its People 267 Chapter 8: Sharing Talk About Being a Doctor 291 Conclusion 321 References 327 i LIST OF TABLES Title Page Table 1: List of Characters in Alphabetical Order of Their Pseudonyms 33 Table 2: Orientation Schedule for Medical Students in Internal Medicine 43 Table 3: Weekly Schedule of Clerks in Internal Medicine 48 Table 4: Activities of a Medical Student during the First Two Days in Internal Medicine 82 Table 5: Comparison of Chelsea’s First and Last Case Presentations 132 Table 6: Analysis of Dr. Song’s Class on Chronic Wounds 244 ii Acknowledgments First and foremost, I have to thank my advisor, Professor Hervé Varenne, for his endless support, encouragement, guidance, and assistance. I would also like to express my gratitude to: my committee members Professors Lesley Sharp, Charles Harrington, Myron Cohen, and Ray McDermott; Dr. Gary Ardan of the Office of Doctoral Studies; Bridget Bartolini, program assistant to the Anthropology Programs, and Tony Reen for helping me with my computer and other problems. I owe my fieldwork skills to Prof. Robert Sember. I am forever grateful for the friendship of Ven. Doaseeing (Prof. Chiu-Chuan Chien), Hong-Ling Hsu, and Dr. Hsiu-Feng Tsai; their love, inspirations, and insights guided me through various crises in my life and towards the completion of this dissertation. I was very fortunate to work and learn under Dr. Chi-Wan Lai, who continues to be my mentor and whose compassion, wisdom, and humor shines like a beacon on those around him. I have to thank the National Poison Center, Taiwan for giving me a space to write my dissertation and in particular Stella Sa, Dr. Jou-Fang Deng, Dr. Chen-Chang Yang, Wan-Ling Ong, Jia-Fang Wu, Wei-Lan Chu, and Hui-Mao Chen for their assistance, support, and encouragement. Numerous others have helped and sustained me through these long years of study. This dissertation would not be possible without the kindness and assistance extended to me by the administrators and my co-participants at SOTH, to all of whom I would love to express my gratitude individually but whom I cannot openly acknowledge. I am indebted to them and I hope I have done the hospital justice in my analysis. Any faults or mistakes in this dissertation are mine. iii My education was financially supported by the following organizations or programs at various stages and I am very grateful to them: the Ministry of Education of Taiwan, the Foundation for Poison Control (Taiwan), the Fulbright Scholar Program, P.E.O. International (U.S.A.), the Tokyo Foundation and the Sasakawa Young Leaders Fellowship Fund (Japan), Columbia University’s Weatherhead East Asian Institute and Institute for African Studies, and the HIV Research Trust Training Scholarship (U.K.). Last but not least, I wish to thank my family for their unconditional and unwavering support throughout all these years: my parents Yung-Chan and Yu-Lan, my brothers Cheng-Hsian and Cheng-Yu, sister in-law Jiafang, and my husband Jen-yen Chen. iv Dedication To my parents and my beloved “kanqiu” v Introduction 十年樹木，百年樹人 It takes ten years to grow trees [but] a hundred years to cultivate people – Chinese idiom1 Between 2008 and 2010, I was in charge of a program by the Ministry of Education (MOE) of Taiwan to promote and improve the teaching of medical humanities in all the medical schools in the country. We involved school administrators, faculty from various fields, including clinical medicine, basic sciences, social sciences, arts and humanities, and other disciplines such as nursing and social work, as well as students. Our ultimate goal was to produce “good” doctors who are not only competent in their medical knowledge and skills but also caring toward their patients.2 The local word for patient (病人) is made up of the character for illness or disease (病) combined with that for a human being (人) — in other words, a sick person — and we wanted our physicians to not only treat diseases but also to heal the individual. We were pleased that the mandate from the MOE allowed us to focus on the latter aspect so that we could make our medical education program more comprehensive and holistic. However, we often encountered 1 The saying originates from a sentence by Guan Zhong (管仲, circa 720–645 B.C.E., a politician and philosopher of the Spring and Autumn Period) which appears in his book, Guanzi (Writings of Master Guan). 2 We based this aim upon the local concept that a doctor should ideally possess know-how (醫術, literally, medical skills but also including knowledge) as well as virtuous conduct (醫德, or code of ethics). Incidentally, our view was similar to that of our counterparts in the United States as noted by M. Good (1995). 1 doubts about whether the art of medicine could be inculcated and even among those who believed that it could, the question remained how it could be taught effectively. As a clinical practitioner, medical educator, and applied anthropologist, my interest lies in finding out how we can produce, i.e. educate and train, and retain good doctors. There is urgency in addressing this issue because the health care profession in Taiwan is in great trouble. In March 2015, the local Global Views Monthly magazine published a feature entitled “A Critical Report on Health Care in Taiwan” in conjunction with the twentieth anniversary of the implementation of the National Health Insurance (NHI), our universal health care program (Peng and Lin 2015). The report was based on the results of an online survey the magazine conducted which received nearly nine thousand responses.3 It found that 92 percent of health care professionals were pessimistic about the future development of medicine in Taiwan (among physicians, it was as high as 97 percent: with 37 percent replying “very pessimistic” and 60 percent “somewhat pessimistic”) and that more than three quarters of the respondents admitted that they were dissatisfied with the general medical environment. Some time ago, observers began to notice that fewer physicians were specializing in the major fields, especially surgery and obstetrics. The phenomenon was labeled as “the emptiness of the big four”, referring 3 The survey was conducted between December 12, 2014 and January 9, 2015. Invitations to fill out the online questionnaire were sent through associations and societies of various health professions (excluding dentistry and traditional Chinese medicine) and hospitals, and a total of 8,733 effective samples were collected from doctors (20%), nurses (53%), pharmacists (16%), and others, e.g. laboratory technicians and hospital administrators. 2 to the four major specialties of medicine: internal medicine, surgery, obstetrics and gynecology (ob/gyn), and pediatrics, and was borrowed from a Buddhist saying.4 The 2013 statistics from the Taiwan Medical Association (TMA)5 showed that while it is true that more physicians were going into certain fields thought to be easier and more lucrative, such as plastic surgery and dermatology,6 and that many specialists were leaving their own fields,7 the problem is also about the uneven distribution of the health workforce between cities and rural areas. Within this country with a total area of thirty-six thousand square kilometers (almost fourteen thousand square miles) and a population density of 644 persons per square kilometer, nearly thirteen thousand people do not have access to a physician and more than three hundred thousand people receive inadequate health care.8 4 The phrase in Mandarin is 四大皆空, meaning that all four elements of which the world is constituted — earth, water, fire, and air — are void, i.e. completely indifferent to all worldly temptations.