Name: Desmond Ching Jin Kang

Matric No: A185589

Date: 11/8/2024

2.⁠ ⁠Your progress so far

My clinical elective posting in Kaohsiung Chang Gung Memorial Hospital ended on 9th of August 2024. Throughout my second week of clinical elective posting in Taiwan, I had truly adapted to this new environment and my relationship with the doctors and seniors had become closer than first week. This week, I continued to join ward rounds with my supervisor, Dr Chen and my seniors (houseman in Taiwan) at 6.30am everyday. Before every ward round, my supervisor would have a pre-ward round teaching session to discuss the cases with us. By doing this, we could have a better idea on the progress of the patients in the ward before we went in to see them. Not only that, I also joined my supervisor's clinic on Monday and Tuesday evening. The clinic session on Monday was very special for me and Ying Ju because it was a teaching clinic session. This was a session in which my supervisor, Dr Chen would pick an interesting case from his clinic to discuss with us. I found this beneficial because we could observe how he clerked the patient and learned the case together. On Tuesday, we also went to observe ultrasound guided pleural aspiration. Most of the patient who came in for pleural aspiration had lung cancer. From that session, I also had a chance to learn how to interpret chest X-ray with pleural effusion. On Wednesday, I was glad to observe sleeping medicine with my friends, Chen Thung and Ying Ju. I was super excited because I had never seen the procedures of carrying out sleep study. On that day, we went to the sleep medicine department at 10pm. Then, the medical assistant and nurses introduced to us how they conduct the study at midnight and how to put on the device on the patients. At around 11.30pm, all the patients involved had been put on electrodes and started to sleep. We stayed in the computer room to monitor the condition of the patients until around 1am. On Thursday, we attended a morning meeting in the auditorium. The topic of the meeting was about palliative care which is conducted by a geriatric doctor from Tainan Hospital. From the talk, I understood that palliative care and curative care can be done simultaneously to optimise care to the patient. Not only that, I managed to understand more about the journey of becoming a doctor in Taiwan from my seniors and also the healthcare system throughout that week. On Friday, I submitted a case write-up to the secretary of the Internal Medicine Department. This is a task given to all the students during the first week of posting, in which students were required to record a clinical case from the ward and discuss the case with the respective supervisor. From the case write-up, my supervisor Dr Chen explained to me the function of healthcare matrix in medicine. Healthcare matrix is an evaluation form which comprised of patient care, medical knowledge & skills, interpersonal & communication skills, professionalism and system-based practice. From this matrix, my supervisor explained to me what are the importance of each components in providing treatment and care to the patients. After submitting the case- write up report, that marks the end of my clinical elective posting in Kaohsiung Chang Gung Memorial Hospital. On Saturday (10/9/2024), Chen Thung and I checked out of the hostel and we traveled to Tainan to start our vacation. 

3.⁠ ⁠Your feelings and thoughts 

Overall, I was satisfied with the clinical elective posting in Kaohsiung Chang Gung Memorial Hospital. I was happy throughout the posting because I had a nice supervisor who was kind and willing to share his experience with me. I also had a chance to meet new friends in the hospital and they were very friendly with me. Their kindness and friendliness had really boosted my confidence and made me comfortable to learn in the hospital. It also helped me to adapt to this new environment quickly. From my case write-up, my doctor emphasizes to me about the importance of patient-centered care again. “Do not treat patients’ disease alone, treat patients as a whole” was what Dr Chen always mentioned to me and he asked me to always remember this when I become a doctor in the future. I also felt very proud and grateful to the Faculty of Medicine UKM because I could not complete this wonderful clinical elective posting without the knowledge and skills that UKM had given to me. The knowledge that I gained from 3 years of studies in UKM allowed me to have an opportunity to discuss cases with the doctors in Taiwan. I was also very thankful to our faculty for giving me a chance to conduct my elective posting in Taiwan so that I have an opportunity to experience life as a medical student in Taiwan. 

4.⁠ ⁠How did you learn and apply the skill of decision making in your EP journey?

The incident that I learned the decision making skill throughout the elective posting journey was on the first day I arrived in Taoyuan International Airport. Before we departed from Malaysia, I bought three High Speed Rail tickets online and the departure time of the train that I booked was 5.10pm. The ticket price was around RM200. On 28th of July 2024, which is the day we arrived in Taoyuan International Airport, Taiwan, we missed the train at 5.10pm because our flight was delayed and we could not reach the train station on time. Unfortunately, we had to buy another ticket which cost around RM200-300. From then on, I learned that I should think and plan things properly before I made a decision to avoid wastage of time, energy, effort  and money. Therefore, I applied the decision making skill by not buying high speed rail train ticket for my vacation first to avoid wastage of money due to unforeseen circumstances.

5.⁠ ⁠How did you manage your time throughout this EP journey? 

I would make a time table and to-do list for every day before I went to sleep. I usually will wake up at 5.45 am during the weekday because I wanted to join the ward round at 6.30pm. In order to wake up early, I made sure that I slept early and get enough rest. In my to-do list, I usually would put a few objectives to achieve in a day. For example, joining ward rounds, observing procedures, studying in the library before lunch hour and so on. Completing a to-do list daily was also a big motivation for me to become independent and hardworking while I am studying abroad. I usually returned to my room from the hospital around 2pm-3pm. During the evening, I would spend my time doing some revision and pre- reading in my room before I go for my dinner. During the night, I would spend my leisure time with friends traveling around Kaohsiung City and enjoyed the local food in Taiwan.

6.⁠ ⁠Your plan for next week (Phase 4)

For my next week (Phase 4), I will travel to Tainan, Sun Moon Lake and Taipei for vacation with my friend Chen Thung before I return back to Malaysia on 18th of August 2024. I will also take photos and documentation for my weekly update in the Padlet.

2. Your progress so far?

   I am in the last week of my attachment under the Division of Pulmonary and Critical Care Medicine in Taiwan. I attended the pre-rounds with the nurse practitioner and ward rounds with my supervisor, Dr Lie as usual where both of them would utilize any opportunities available to share their experiences dealing with different cases. I also had two teaching sessions with Dr Lie this week on the topic of Lung Carcinoma and its management which fell on Tuesday and Thursday respectively. Procedure-wise, I was scheduled for observation of thoracentesis under ultrasound guidance this week as well. On Wednesday night, I reported myself to the Sleep Medicine unit in the Rehabilitation Building for observation of polysomnography and continuous positive pressure airway therapy (CPAP) for obstructive sleep apnea patients from 10.00pm to 1.00am the subsequent day. The technician in charge also explained to me regarding the setting up of the equipment for the procedure as well as the parameters measured. Dr Lie also invited me to join him on a journal reading club conducted in the pulmonology examination unit where the PGY1 doctor (Equivalent to Malaysian houseman year 1) presented a journal paper entitled "Long COVID" to the rest of the consultant pulmonologists. Question and Answer (QnA) session was conducted afterwards. I would like to share that I was joined by a local final year medical student and a new PGY1 doctor this week for all my sessions with Dr Lie. I managed to chat with the local medical student where we discussed on the differences of medical curriculum between Malaysia and Taiwan. The department also scheduled me for another class on the topic of ECG interpretation along with the other local final year medical students in the Department of General Medicine. Prior to finishing my posting, I requested for evaluation of my performance and feedback from both the nurse practitioner and Dr Lie. The response from both of them were positive.

3. Your feelings and thoughts.

   I encountered a total of 4 deaths during my 2 weeks of posting here in the Department of Pulmonary and Critical Care medicine, which was quite shocking for me. Dealing with death and breaking bad news to the family members were undeniably difficult and heartbreaking. However, I was told by Dr Lie that most of the patients under the care of this department had poor prognosis given the severity and the nutrition status as well as the age of patients (oldest that I have seen here was 104 years old) so they have the highest mortality rate in the hospital overall. As a result, dealing with death is the "bread and butter" under this field and mastering the ways of regulating own's emotion and the method of breaking bad news are extremely important.

4. How did you learn and apply the skill of decision making in your EP journey?

   My learning around decision making skill mainly centered around arranging my learning plan. Conducting elective posting in Chang Gung Memorial Hospital was mainly a student-centered initiative as the person-in-charge would ask for a brief learning plan from the applicant. Hence, I brainstormed on what I want to learn here instead of them arranging everything for me. Apart from that, arranging my own transportation travelling around Kaohsiung as the place of my posting required me to consider the pros and cons of each method whilst not forgetting the consequences of every one of them as well as any alternatives available.

5. How did you manage your time throughout this EP journey?

   I would write down my plan for everyday the day prior, listing down what would I like to do, how long do I want to participate in the activity and save it in my phone or tablet for future reference. I would also confirm all these sessions with my supervisor to ensure there is no overlapping with his schedule.

6. Your plan for next week (week 4).

   My plan for next week would mainly be visiting around Taiwan with my batchmate, Desmond Ching where we will visit various cultural sites in Taiwan, understanding their cultures. The vacation would be 1-week long before we return to Malaysia together on the weekend for preparation of our report.

1.Name: Madhavan A/L Nagaratanan

Matric number: A189433

Date: 11 th July to 14 th July

2. Your progress so far

So the inbound week that all of us been waiting for has arrived. On the 11th is the academic day then followed by Community Service day on 12th followed by Sociocultural day on 13th and 14th is the closing ceremony. So far all the flow was very smooth since all of places and event ideas got approved by the respective departments and we are always ready to execute all the plan as well. Since the day the delegates arrived we visited them and had a mini Chit chat session. The delegates comprised of 6 person in total of 2 boys and 4 girls. They all were so excited for the event days. The first day on 11th, we first had an ice breaking session and played a kahoot quiz to know how deep they knew about of cukture,food and traditions. Then we went to the anatomy lab and Dissection hall but unfortunately we can't take pictures there as it is strictly prohibited. We then decided to roam around the campus area and hospital area. We decided to have our lunch at Zecon hotel since it's nearby and then we went straight to the Gamma knife centre. We had a good exposure of gamma knife from Prof Ramesh and he explained lots and even brought us to the treatment room and explained how the machines and equipments works. Overall it was very systematic. Finally we ended at UMBi and it was my very first time even entering there. I was amazed by how the technology there is so advanced and the research they conduct is so on point . Later that day we decided to have a walk at Taman Tasik Bandar Sri Permaisuri. The next day, it was a community service day and we went to Rumah Kasih Charity Home. We decided to entertain them by lots of songs and the session was very interactive. We even played games with the people there. It was such a heaven to see smile on their faces. The next day was Sociocultural day and we brought them to lots of places like Putra, Port Kicks on and we ended the event on 14th July by closing ceremony

3. Your feelings and thoughts

Honestly although it was tiring I was glad that I could spent a lot of time with the delegates. We shared out knowledgeable and lots of experience on skills and how their system works. On the academic day , 0rettybsure our syllabus especially are somewhat overlapping so like we had something in common to always talk about. Not only that besides studies, all of them were very extroverted to share about things they feel in Malaysia and how their cukture is different from ours haha. Can't wait to visit Taiwan and see what's different there. So far I really enjoyed everything it was a great experience with lots of understanding not only about the culture etc but also how to interact and communicate also share things and knowledge with someone who just we newly met.

4. How did you learn and apply the skill of decision making in your EP journey?

Well decision making is always tough and when you're th ehad of a committee department it all comes to us that makes the great decisions because a single mistake tables will be turned and the game is over. But I'm glad tgat my back up plans were made ahead in case if difficult circumstances do appear I can balance them out and still make the programme to tun out successfully. Guess what yes we did it and I always learnt to be patient in every situation. When we tend to get panicked, there's no way we can find a solution. Instead try to focus on the solution rather then the problem or issues that's blocking us.

5. How did you manage your time throughout this EP journey?

Well time wasn't a big deal since it's already our holidays. Time management maybe for the event day was challenging because one after the next session needs some prior heads up for example like we are gonna arrive at Gamma Knife centre, so I texted the PIC 30 mins ahead so that they're always ready.

6. Your plan for next week (Week 4)

For the final week it's tike to pack my baggage and luggage because we are flying to Taiwan for outbound week . Very excited and waiting for it yeayyyy!

Matric Number: A187931

Date: 19/8 – 23/8

1.     Your progress so far

My Monday started easy with a short introduction to the Anaesthesiology department at Taipei Veteran General Hospital (TVGH). My new supervisor, Dr. Wu Hsiang-Ling, is a specialized anaesthesiologist in the department. She welcomed me with open arms and ran me through the department's details and their work style. I was introduced to their daily duty roaster and learned they have very different working styles from surgeons. Later that day, I spent some time in a cozy café, completing my report from last week as well as doing some revision on anesthesiology.

On Tuesday (20/8), I officially started my posting in the Anaesthesiology department by joining their morning meetings. They had a case-based discussion (CBD) every morning, where they discussed relevant learning topics in the department. That morning, they talked about transversus thoracic plane (TTP) block in chest and thoracic surgeries. Then, I shadowed Dr. Wu for the rest of the day in the operating theatre (OT). It was very interesting to experience the mobility of the anaesthesiologist here. They were mainly only responsible for the induction and emergence of the patients. For the rest of the time during the surgery, the patients were under the care of their specialized anaesthetic nurses. In exchange, anaesthesiologists were always responsible for more than one room. This was why they were constantly hopping from one room to another.

Wednesday was similar to Tuesday, where I also spent most of my time in the OT. However, the new thing that day was that I was allowed to perform bag ventilation on the patients. I always knew how bagging works, but to do it on real patients for the first time was difficult. However, Dr. Wu was understanding, and she allowed me to practice several times that day. Fortunately, with practice, I got a hang of how to practically bag the patients successfully. I was satisfied by the end of the day, picking up a new hands-on skill.

On (22/8) Thursday, I spent a day at the Catheterisation (Cath) lab in the side building of the hospital. It was a new experience of anaesthesia induction in a different setting. Dr. Wu told me it was called the Non-Operative General Anaesthesia (NORA). It was a relatively challenging induction and maintenance process for anaesthesia, for the machines and medications were borrowed from the main OT instead. In the meantime, the manpower here was also a problem. For that reason, unlike in the OT, where anaesthesiologists can have breaks between surgeries, here they have to stay with the surgical team to ensure if something goes wrong, the patients are in great hands.  It was still a procedure conducted in the same hospital but in a totally different way.

On the last day of the week, I managed to experience the outpatient clinic of an anaesthesiologist. I was fascinated by the different OPD experiences in comparison with general surgery (GS). My supervisor now had to complete almost 60 consultations in one morning. Unlike in GS, where the cases for consultation were of all types, the ones here were all similar. Anyhow, it was a fruitful session to learn just from observing, as we met patients of all types, including those who came in for painless endoscopy consultations, surgery consultations, and even children for dental procedures.

2.     Your feelings and thoughts

To be honest, the week was a little challenging for me as I tried to adapt to a new environment. It was because GS was so much different from anaesthesiology. From a very hectic and compact daily experience in GS, suddenly to a less intense one in Anaesthesiology, had kept me thinking that I had not been doing enough throughout the week. It was contradicting though, for that I knew I had actually learned so much about the department for the past week.

3.     How did you learn and apply the skill of decision-making in your EP journey?

Personally, the biggest lesson learned from the past 3 weeks was to stay calm in the most critical times. In GS, I have seen Dr. Chiang overcoming too many obstacles during his surgeries. Although it was like a simple, basic quality of a surgeon, it was still mesmerizing and definitely something I am working hard to achieve. Not only in my career but also in my daily life. On Tuesday (20/8) something unexpected happened. Somehow my phone’s network hung and was not working. It was terrifying, as I was to contact my supervisor via Messenger to get to know where I should be meeting her. The worst part was I had no other way of getting in contact with my supervisor. At that moment, I forced myself to calm down. And the magic of staying calm at these times appeared. I remembered the daily department duty roasters Dr. Wu talked about the day before and decided to head there for some clues about where she would be. Then, I followed the information I got from that duty roaster, headed to the assigned rooms one after another, asking the nurses inside if they saw Dr. Wu. Fortunately, on my way to the last room where Dr. Wu was responsible, I met her on the walkway. This was not an academic problem faced, but an actual practice of staying calm. It aided me in seeing more possibilities and chances for my problem.

4.     How did you manage your time throughout this EP journey?

The past 2 weeks when I have been in GS, time was not an issue as I was well-equipped with the basic knowledge as well as the experience in a surgery posting. Revising them was easier. However, after moving on to anaesthesiology, in which I have never had a clinical practice, I constantly felt a lack of knowledge. In the beginning, I was nervous about it, as I did not have enough time to revise enough with all the traveling after class. Gladly, the work time here as an anaesthesiologist is more mobile, and I had time to do some readings during the day in the restroom of the OT. So I made it a habit to always carry my iPad along with me, diving into notes on anaesthesia whenever I have time. It was a great practice, in fact, as I was able to strengthen my memory of the knowledge and topics Dr. Wu taught when I found them in my notes.

5.     Your plan for next week (Week 4)

I am planning to try more hands-on experience in the OT next week, with the supervision of my supervisor. I am also looking forward to having a short Q&A session on the questions I had from the OPD that I did not manage to ask. In the meantime, it is my last week of placement here, and I am absolutely looking forward to picking up as much as I can, both knowledge and skills, in the upcoming week. I would also like to have simple farewell sessions with the friends I met here!

A188150

19/8/2024 - 25/8/2024

2. Your progress so far

In the third week, I’m still in the trauma department but with a different supervisor. Dr. Lai, my supervisor for this week, specializes in facial fractures. As a result, I’ve had the opportunity to observe various cases, including orthognathic surgery. It was amazing to see the results after the 5-hour-long surgery. So far, this week has been fulfilling and enjoyable!

3. Your feelings and thoughts

I felt a sense of security this week as I met a house officer who is also under the same supervisor as me. She was willing to teach me and explain the patients' conditions, including the management plans. My supervisor has also been very kind and patient, encouraging me to ask more questions. As I approach the end of my EP, I feel a bit sad, so I am becoming more appreciative of every moment I have left here.

4. How did you learn and apply the skill of decision-making in your EP journey?

I observed different supervisors and how they manage their patients, especially in emergency cases where critical decisions need to be made quickly. They also presented me with situations and asked how I would handle specific patients, providing feedback to help me improve.

5. How did you manage your time throughout this EP journey?

I joined ward rounds every morning at 8 a.m. Afterward, I either went to the clinic or the operating theater with my supervisor. Generally, I was in the hospital from 8 a.m. to 5 p.m. on weekdays. At night, I reflected on and revised the learning objectives by researching interesting or new cases I encountered that day. Occasionally, if my class ended early, I would exercise in the gym. On weekends, I explored the city to have some fun before starting the new week. Overall, I feel that I have had very fulfilling days throughout my EP.

6. Your plan for next week (Week 4)

Next week, I will be moving into microsurgery. I hope to make the most of this final week of my journey in Taiwan by learning something new. I also plan to say goodbye and thank all of my supervisors for their guidance over the past month.

Name: Tan Shi Ying 

Matric number: A189552

Date: 17/8/2024

2. Your progress so far

This week marked a significant advancement in my exposure to cardiology, with a focus on both inpatient and outpatient settings. I joined the ward rounds daily, which helped me build on my theoretical knowledge while learning on patient care. One of the more fascinating cases I encountered was Takotsubo syndrome, a condition I'd only read about before. Observing and learning the theory behind this syndrome deepened my understanding of stress-related cardiomyopathy.

I had the opportunity to attend clinical teachings in the outpatient department, where I observed new cases as well as follow-ups from last week. I focused on improving my history-taking skills and learned how to identify physical findings, such as heart murmurs. Additionally, I guided a new Japanese medical student who joined our department this week, helping him navigate the environment and practice in English. 

Throughout the week, I observed several procedures. On Tuesday, I observed an echocardiography session, and on Wednesday, I witnessed an electrophysiology study. I was excited to be allowed inside the procedure room to observe a case of typical flutter Left Bundle Branch Block, wearing lead and sterile aprons, which gave me a much closer view of the procedure than last week. 

On Thursday, I participated in a morning journal reading meeting at 7:30 a.m. Later that day, I observed a cardiac catheterization for pulmonary hypertension. Similarly, I got the chance to be inside the room, which greatly enhanced my learning. On Friday, I observed the use of continuous wave Doppler with my supervisor, and I also completed my evaluation form.

I prepared handwritten cards to express my gratitude to the doctors and a nurse who have taught and helped me throughout this elective posting, and I take pictures with them to preserve the memories.

3. Your feelings and thoughts 

This week, I felt a deepening sense of belonging in the cardiology department. Being able to interact more closely with procedures and observe cases in greater detail gave me a stronger sense of accomplishment. Guiding the Japanese medical student made me realise how much I've grown and how far I've come since starting my elective. It was a rewarding experience to share knowledge and offer support to someone new.

The earthquake I experienced this week was both terrifying and surreal. It was my first time going through something like that, and it shook me emotionally. Thankfully, everything was fine, and I’m grateful for the safety precautions in place.

I’m grateful for all the help and guidance I received throughout this elective posting journey. The handwritten cards I prepared were a personal touch to express my gratitude and create lasting memories with them.

4. How did you learn and apply the skill of decision making in your elective posting journey?

Decision-making became a more prominent aspect of my experience. During outpatient sessions, I observed how the Dr weighed different diagnostic possibilities based on patient history and clinical findings. For example, learning how to differentiate between different causes of heart murmurs and understanding which diagnostic tests to prioritise has helped me grasp the nuances of clinical decision-making. Additionally, observing complex procedures, such as electrophysiology studies and cardiac catheterizations, allowed me to witness real-time decisions during the treatment process.

5. How did you manage your time throughout this elective posting journey? 

Time management has been crucial in balancing clinical exposure and study time. Joining ward rounds daily has created a structured routine for me, but I also set aside time in the evenings to review what I learned during the day. Attending additional sessions, like the journal reading and procedural observations, has pushed me to optimise my study habits by being more focused during downtime. I would utilise the break in between classes to revise some knowledge regarding the information I had just learned. I would also set aside some weekend time to travel around the country.

6. Your plan for next week (Phase 4-conclusion)

Next week, I will conclude my elective posting by exploring Taiwan’s beauty. I plan to visit various tourist attractions across Taiwan, using the time to reflect on my journey here before returning to Malaysia. It will be a perfect opportunity to unwind and appreciate the culture and sights of this wonderful country before resuming my medical education back home.

Name: Karuna Lim Jing

Matric number: A185596

Date: 19/8/2024 - 25/8/2024

2. Your progress so far:

I’m now in my 3rd week, still in the geriatrics department, but I was assigned to another geriatrician, Dr. Yan. As usual, we have ward rounds, a teaching clinic, and teaching sessions. This week, the main focus was on interpreting lab investigations, especially urine analysis and urine culture. I learned how to calculate total protein intake to assess whether a patient is in a state of malnutrition. Besides that, I’ve become more adapt at taking patient histories—like a hypertensive patient with a new onset of headache—and I’m getting used to conducting comprehensive geriatric assessments. Initially, it took me some time to figure out how to engage patients so that they felt they were having a conversation with me, rather than just answering a questionnaire.

3. Your feelings and thoughts:

Different doctors have different teaching styles. Dr. Yan prefers open discussions on cases, where everyone in the team contributes their opinions. This level of engagement pushes me to put more effort into diagnosing. Since he started ward rounds on the same day I began following him, I’ve had the chance to learn how thoroughly he discusses patient cases and understand his reasoning behind his decisions. I’m grateful to have had the opportunity to learn from two different doctors, which has allowed me to apply a variety of approaches to my learning.

4. How did you learn and apply the skill of decision-making in your EP journey?

As part of the learning process, we conduct comprehensive geriatric assessments that include the Mini-Mental State Examination, Geriatric Depression Scale, Confusion Assessment Method, Braden Scale, and Functional Mobility Assessment Tool. We must make decisions based on the patient’s responses to determine their status and figure out what actions we can take to help them. For example, I encountered a patient at high risk of immobility. I presented the case to my doctor and suggested that the patient undergo rehabilitation to improve mobility and regain confidence.

5. How did you manage your time throughout this EP journey?

I planned my days carefully to balance learning and personal activities:

- Attending morning and afternoon teaching sessions

- Engaging in exercise sessions, such as playing basketball and swimming

- Hanging out with friends to explore Taiwan, including visiting Taipei 101 and nearby districts

6. Your plan for next week (Week 4):

- Conduct history-taking with patients

- Participate in a gathering and prepare farewell gifts

- During my last week of the exchange, I plan to:

- Reflect on the overall experience and summarize what I’ve learned

- Write thank-you notes or give small tokens of appreciation to the medical staff and fellow students

- Prepare a brief presentation or report on my exchange experience to share with my peers and mentors back home

- Make sure to spend some time enjoying the local culture and scenery before leaving

1. Your name, matric number, date

Name: Low Yu Sen

Matric Number: A190206

Date: 19 August 2024

2. Your Progress So Far

In terms of leaning experiences, I started having more practical involvement in my geriatric elective at Linkou Chang Gung Memorial Hospital as compared to my first week in the department. Some advancements that I made in the second week includes having opportunity to conduct a consult at the outpatient teaching clinic. Fortunately, language barrier wasn’t a big problem as I was able to communicate in Chinese and a little bit of Taiwanese. It was a simple case of hypertension follow-up so it wasn’t a hard clerking for me.

Besides, during these 2 weeks of my elective, I witnessed a spectrum of patients in the geriatric department. The spectrum ranged from patients who are completely bedridden and dependent on others for all aspects of their care, to fully independent uncles who can walk into the clinic, and talk and laugh with the clinic staffs. What’s more surprising is that he is more than 100 years old!

I am also involved in patient assessments and contributed to discussions. I did a comprehensive geriatric assessment (CGA) on 2 patients in the ward, and along the dialogue, I explore the patient’s need and “What matters” to the patient

Besides, I have a deeper understanding particularly in the principles of geriatric medicine like polypharmacy management and patient communication. This was reflected during ward rounds and MDTs where I understand more on why did the physician decided the management plans and medications on the patients. For example, I observed a case where the physician chose not to aggressively control a patient’s blood sugar levels despite not controlled in the targeted range, considering the risk-benefit balance. The physician was concerned about the risk of hypoglycaemia, which can be particularly dangerous in elderly patients.

Other than that, I also witnessed a few of our patients that we have been following for some time expired in the ward. However, what more important beyond that is decision making skills and communication with family members. In these cases, discussions around Do Not Resuscitate (DNR) orders were particularly significant. I observed how the medical team carefully considered the patient’s overall prognosis, quality of life, and the likely outcomes of aggressive interventions. Overall, my learning has become more practical and case-focused. I am now applying my knowledge in real-time, making clinical decisions, and considering the ethical dimensions of care, particularly in managing complex cases.

3. Your Feelings and Thoughts

Over the past two weeks, I’ve experienced a wide range of emotions and learned a lot about geriatric care. Seeing patients from all walks of life: some completely bedridden and others, like a vibrant 100-year-old man, still independent and cheerful has been eye-opening. It made me realise how diverse the aging process can be and the importance of tailoring care to each individual.

Talking about feelings, its happy when you see your patient getting better day-by-day and discharge with cheer but sometimes you have to accept the fate that every life have an end, and we have to acknowledge that. Reflecting what I saw in the wards and clinics, I realise something very important: at the end of the day, what matters is just our basic needs, and who really cares about you.

And in terms of thoughts clinical experience, I felt very grateful having the chance to approach elderly patients in Taiwan and understand the difference of medical care between Taiwan and Malaysia and able to have practical applications of clinical knowledge learnt in a foreign setting.

4. How did you learn and apply the skill of decision making in your elective posting journey?

Decision-making is an important aspect in elderly care, especially in inpatient settings. Throughout my elective posting in the geriatric department, one of the most obvious example I learnt and observed the skill of decision making is “To save or let go”. It is a heavy and challenging aspects of geriatric medicine because it involves balancing the potential benefits of medical interventions with the risks, especially in frail, elderly patients who may not tolerate aggressive treatments well.

For example, there are a lot of elderly patients in the ward who are strongly indicated for bronchoscopy and intubation. However, due to their frailty, these procedures cannot be proceeded due to physiologic and pathologic changes that occur with age, they have higher risk of morbidity and mortality.

Another example that I observed is that there were patients in the ward who suddenly went into respiratory distress, shock and having unstable vital signs. The patient had fast AF, heart rate rushed up to 200+, and inotropes were given intensively.

In a normal medical setting, intensive rescue will be started immediately however here in the geriatric ward, I witnessed how the team decided whether to continue life-sustaining treatments, such as intensive care or resuscitation, or to shift the focus to palliative care. This process involves an important aspect in geriatrics: “What matters to the patient”.

Eventually, after some short discussion with the family members, they decided to respect the patients’ will to not continue to suffer and resuscitation was not done eventually. These decisions are not made lightly; they require a deep understanding of the patient's overall health status, prognosis, and most importantly, the patient's and family's wishes. The topic of 'To save or let go' is heavy because it involves confronting the reality of mortality, both for the patients and their families, as well as for the healthcare providers. It requires not only clinical judgment but also empathy, communication skills, and an ethical approach to care.  

Hence, by real case examples, I have a deeper appreciation in the skill of decision making in my elective posting journey.

5. How did you manage your time throughout this elective posting journey? 

Time management wasn’t a big problem during my elective posting journey as I had a scheduled arrangement in the department. However, it took me some time to get used to the pace in the department as there were sessions in the early morning where I had to get prepared.

Ward rounds sometimes started as early as 9.30am, or sometimes in the afternoon. Hence, I will go to the ward early with my friend to read the charts before ward rounds to know the progress of the patients, like check on their vital signs, labs and CXR if there are any improvements.

Joining ward rounds daily has created a structured routine for me, but I also set aside time in the evenings to review what I learned during the day. I made some notes and jot down on some interesting cases and review them again before the next day.

I also attend additional sessions, like the weekly CGA case discussions and procedural observations, to maximise my exposure in my elective posting. Occasionally, I observed how the residents insert central venous catheters after the ward rounds.

During lunch breaks, some of us at Linkou CGMH will gather together and exchange stories and share our experiences in different department. By staying organised, actively participating, and reflecting on my experiences, I’ve been able to make the most of my time in the geriatric department, ensuring that I’m not only fulfilling my elective requirement but also growing and learning as a medical professional.

6. Your plan for next week (Phase 4-conclusion)

With my elective posting in the geriatric department now completed, I plan to take the upcoming week to relax and enjoy a vacation. After the intense and rewarding experiences of the past few weeks, this will be a perfect time to explore the beauty of Taiwan’s culture, attractions and food!

As I conclude my elective posting in the geriatric department at CGMH, I will begin preparing for my final reflections on this elective experience. This preparation will involve reviewing my notes, reflecting on the cases and lessons that stood out to me, and consolidating the skills and knowledge I’ve gained. Overall, next week will be a time for both exploration and thoughtful reflection as I bring this valuable chapter of my medical elective journey at CGMH to a beautiful end.

Name: Khor Shin Rou

Matric Number: A188404

Date: 24/8/2024

2. Your progress so far

This is the third week of my exchange at the 4th City Hospital in Almaty, and I have transitioned from the Orthopedic Department to the Purulent Surgery Department. On the first day, Dr. Miras, our resident, introduced us to the Purulent Surgery Department, where the focus is primarily on wound dressing for diabetic foot infections and post-surgical infections.

We observed several wound dressings for diabetic foot infections, including two cases with gangrene and Charcot foot infections. The surgeons decided to perform amputations on these patients to prevent the spread of infection and necrosis. The patients appeared desperate and sad when informed about the need for amputation to minimize necrosis. However, this was the only option to control the infection. The doctor explained the situation to the patients and their families, provided comfort, and allowed them time to come to terms with the decision.

Additionally, I had the opportunity to attend a surgery for a uterine cystic tumor, which was my first time witnessing the removal of a uterus. A 15 cm x 13 cm cystic tumor was located at the fundus of the uterus. The cyst was filled with about 8 liters of fluid. I was both surprised and excited when the surgeons incised the cyst membrane and removed the fluid. Due to the cyst's large size at the fundus, the entire uterus needed to be removed. I was fascinated to see how the surgeons carefully separated the uterus from the bladder, avoided injury to the sigmoid colon, and ultimately removed the uterus at the junction of the cervix and vagina. It was an eye-opening experience to observe a total hysterectomy and see the meticulous technique involved.

3. Your feelings and thoughts

Over the past three weeks, I have actively learned and adapted to different medical specialties, which has helped me expand my knowledge and skills. Witnessing patients facing severe medical conditions and having to make difficult decisions about amputations has clearly been an emotional experience for me.

Additionally, observing complex procedures such as the removal of a large uterine cystic tumor has been both surprising and exciting. This experience has given me a deeper understanding of surgical techniques and the intricacies of such operations. I also admire the surgeons for their concentration and precision in performing these procedures.

4. How did you learn and apply the skill of decision-making in your EP journey?

So, when we were attending the uterus cystic tumor removal surgery, I asked the permission from the surgeons to get closer and see how they removed it, and they agreed. I was quite surprised that they allowed me to get closer to the surgical bed to observe as I thought they would refuse my request. This made me feel more excited and thrilled to attend OnG surgeries. Even though the surgeons are not fluent in English, they understand my questions and they will ask the nurse to help in translate them for me. The head of Department of Obstetrics and Gynaecology was also there during the surgery, he can speak some English and he always tried to explain to me what they are going to do. I am so glad that I met surgeons and doctors who are willing to explain to me instead just asked me to observe.

One thing that I decided to step out of my comfort zone during this week is that, I asked the Head of Department for Obstetrics and Gynaecology, Dr Sergey’s permission to join their surgeries for next week. I am glad that I asked, and he was surprised that I want to participate in their surgeries. He welcomed me to join the surgeries and assisted in if there is a chance. I am so happy that I asked to join them instead of just waiting for instructions from Dr Miras, the resident of the hospital to tell us which department we should go.

5. How did you manage your time throughout this EP journey?

During this elective posting period, I enjoyed my time throughout this EP journey. We managed to achieve a good work-life balance by spending half the day in the hospital and the other half exploring the city. Although we didn’t have much time to travel to nearby cities due to their distance and the time required to reach them, we thoroughly explored Almaty. We visited museums, national parks, botanical gardens, and several lakes. They were all amazing, and I can't believe how beautiful and incredible Mother Nature’s creations can be!

6. Your plan for next week (Week 4)

My plan for next week is to ask my resident’s permission to attach to the Oncology and Gynecology departments, as I really enjoy being involved in and attending oncology surgeries. I am also planning to buy some souvenirs from the Green Bazaar, the most famous market in Almaty, as gifts for my family and friends. As my exchange program is coming to an end, I need to pack my things and prepare for my flight back to Malaysia on 31/08/2024. I am really excited to return to Malaysia and share my experiences in Kazakhstan with my friends.

5. How did you manage your time throughout this EP journey? 

   I had a TO-DO List with me during the elective posting where I listed down my daily agendas to that list to ensure I will not miss out anyone of them. Once I have completed, I will just strike it off and continue to do the remaining. Personally, I am not a procrastinator and I do not like to drag my thing until the last minute. Thus, it is not hard for me to stay discipline and nice to say that my time was being managed quite well during the elective posting. 

6. Your plan for next week (Phase 4)?

   Week 2 marks the end of my elective posting in KCGMH and my plan for the following week will be visiting around the famous tourist attractions in Kaohsiung, to visit their night market and to try out their local food. I wish to know more about the local cultures by immersing myself into the local daily lives.