美國2018 RUTGERS姐妹校實習心得（102001097 醫學六 盧立修）

交換日期：2018/10/08-11/02

見習科別：內科／家庭醫學科

Internal medicine

It is my first 2 weeks in Robert Wood Johnson Hospital, and everything seems intriguing to me. I took part in the grand run of family medicine, Mortalities & Morbidities of internal medicine, 3 clinic sessions (Dr. Wang and Dr. Ambrossa) in endocrinology department, and a speech of strauma ovarii (teratoma predominantly composed of mature thyroid tissue).

The clinic sessions were the most impressive to me. In Taiwan, in average, there are almost 40 patients in a session. The doctors have to try their best to finish it in 4 hours. Medical students can’t approach the patients on their own because the doctors are in a rush and have no time explaining to student. Therefore, “教學門診” was created. With at most 5 patients come to one clinic session, students are allowed to ask and do physical examination to 1 patient.

However, in RWJ hospital, third- or final-year medical students can approach 3-4 patients independently in a session. I met a student, Allison, on Friday. Seeing how she taking the patient’s history, I know students here manipulate the skills for asking question. Besides attending doctors are willing to listen to her opinion and discuss with her before seeing the patients.

Patients’ privacies are well protected. Every patient has his/her own room seeing the doctor, mostly without presence of nurse. That is totally different in Taiwan. A doctor, nurses, medical students or even other patient would be in the same room.

On Friday morning, after the performer finished his presentation about strauma ovarii, the audience asked questions very actively. It is almost impossible in Taiwan, even if we don’t understand completely. I also asked a question why some patients with nodules need FNA and some need only observation. He said it was according to how the nodule looks under the ultrasound. FNA is not recommended if it is low suspicion of malignancy.

I appreciate doctors and students I met this week. They treat me as if I am one of their teams. Hopefully, I can learn a lot in this four-week rotation.

Family medicine

These 2 weeks, I worked with Dr. Yu in family medicine in Eric B. Chandler Hospital on George St and Church St. I am so fortunate to shadow Dr. Yu.

To my surprise, Hispanic people are one of the main groups in this area. More than half of the patients coming to hospital speak only Spanish, so interpreters or phone-interpreters are important. Therefore, it takes at least 20 minutes in order to communicate with a patient. I met a student, Zac, this week. He told me he really wishes he could speak Spanish, so that he can talk to those patients directly. Besides it is said that interpreters cost a lot on insurance.

Instead of Medicare, patients here mostly use Medicaid as the primary insurance, and some even don’t have medical insurance. If a patient goes to a specialist or emergency department directly, he/she can barely afford the costs. As the results, a primary care doctor is responsible for curing patient with uncomplicated disease and making referral based on the patient’s condition. Since the primary care system is well proposed in the United States, less medical resources are wasted.

I don’t think Taiwanese government do a good job in classifying primary and secondary medicine. One of the reasons is that “全民健保” brings about the low price seeing a doctor. Patients visit a specialist or emergency room as they want. Moreover, medical centers are so common in Taiwan that it takes short time going to doctors in general hospital. People rather spend more money going to a famous doctor than wait for the referral by a family physician.

Patients over visit hospital and the workload of doctors increase consequently. Hopefully, the situation in Taiwan will improve gradually.

Healthy Aging Symposium – A multispecialty conference

The lifespan of human beings increases abruptly in decades. The case of geriatric diseases, therefore, becomes more common. More and more people dedicate themselves in studies about aging and diseases.

In this conference, lots of moderators and specialists share the results of their research to the audience. Although I couldn’t get every point due to the language issues and the difficulty of those studies, I learned a lot in that day. The section of Neuroscience and Aging was the most interesting to me.

The topics include the pathogenesis of Parkinson’s disease, emotional regulation and aging-related cognitive decline. Besides from the pathologic change in the brain, one of the speakers mentioned that cortisol, one of the endocrine affected by the emotion, makes significant influence on our memory and cognitive function. Therefore, it is important to stay in a good mood. Recalling positive experiences play a role in emotion regulation, and it is also very helpful by finding positive meaning in the negative past.

It doesn’t matter that we become in a bad mood due to unpleased experience or failure. There must always be a positive meaning in these events. It not only help us stay in a good mood, but also maintain our function of the brain.

What should I have prepared if I had known before working in RWJ Hospital

Read articles or introduction to medical insurance systems in the United States, esp. in New Jersey.

何謂Medicaid？

Medicaid（醫療救助保險）是聯邦政府與州政府合辦的健康險計畫，救助對象主要為無法負擔商業健康險的低收入者，雖然一開始是由政府設立，但各州的組織如今各異，且由州與地方政府依聯邦準則各自經營。醫療費用由聯邦、州與地方稅收基金支付，有時也需病患自負部分負擔。二○○一年美國Medicaid提供的健康險與長期看護保障受惠對象約有四千二百萬人，而該計畫對控管照護的依賴程度也日漸加深。

Medicare是什麼？

Medicare（醫療照護保險）成立於一九六五年，屬聯邦健康險計畫，在美國健康險制度中扮演著重要角色，計畫內容放諸全國皆同。其費用由被保人醵金的信託基金支出，只要符合條件，不論收入狀況、病史甚或同時享有Medicaid與Medicare，皆可獲得給付。但此計畫提供的是基本保障，要獲得更周全的保障，則必須加保其他商業健康險業者提供的計畫。然而已有健康險業者表示這種計畫是赤字經營，並已退出與Medicare配對銷售的市場。Medicare被保人約有四千萬人，且有七十六％的受益人年齡介於六十五至八十四歲之間。

Why family medicine is so important in the United States?

美國醫療體系之所以大力推動家庭醫師制度，在於保險公司希望透過醫師對病患先做有效評估與處置，便可減少支付高額急診與轉診費用。藉由熟悉的家庭醫師明白指數身體狀況，透過個人完整病歷與家族史，讓專科醫師更能深入掌握診察方向，減少掛錯科、亂做檢查所浪費的時間與金錢。