Medical School

The Purpura Plot: My Mother’s Patient Story

One morning in 1990, twenty-four-year-old Jing woke up with a peculiar sensation in her legs. She peeled back the bedsheets, timorously peered under her pyjama-pants, and gasped. Her legs were covered with small, purple blots, making them look like canvases onto which an artist had splashed ink all over. Her husband of a year rushed her to the local hospital in Beijing.

When my mother recounted the incident more than two decades later, she remembered being unusually calm. “We didn’t know what it was,” she recalled. “So I didn’t feel much fear.”

“We didn’t know what it was,” agreed my father. “So I was pretty scared.”

Jing’s doctor told her that she had thrombocytopenic purpura. Purpura, the Latin word for “purple,” described her symptoms caused by bleeding underneath the skin. A blood test revealed the reason: Jing’s platelet levels were dangerously low (hence “thrombocytopenic”). On a subsequent visit, it dropped even further. Her doctor suspected that the cause was immune-mediated and wanted to draw Jing’s bone marrow for further assessment. There is a possibility, he suggested, that she would need a bone marrow transplant.

Since around the 1900s, China had become more or less receptive towards Western medicine. Suspicion of Western influence, exacerbated by the Opium War with the British in the previous century, and of practices such as surgery, which admittedly must have seemed horrifying to the uninitiated, had started to give way to a grudging admittance to the efficacy of Western therapies. By the end of the century, Western medicine and Chinese folk medicine were often practiced in tandem, sometimes within the same institution.

But the culture of medical practice in China remained Chinese. The doctor’s position of power and as wielder of knowledge was to be respected and not questioned. The very idea of empowering the patient must have seemed laughable. Jing’s doctor simply told her that her disease was caused by problems in blood production, which may be fatal.

“He made it sound very scary,” said my mother, twirling her hair uneasily. “There was no comfort at all.”

“And you didn’t expect it from him?”

“He’s the doctor.”

The doctor’s attitude was officious and apathetic. Yet the interactions between Jing and her physician typified the strained relationship between doctors and patients in China even today. Physician remuneration is tied to drug sales, so patients often do not trust their prescription-pad-happy caregivers. During my visit this past summer, I discovered that several of my friends and relatives were routinely prescribed antibiotics as a way to “control inflammation,” without their knowledge of what caused inflammation and how antibiotics should be taken. In this medical climate, visiting a doctor is often seen as a last resort when one is sick.

Jing did not want her bone marrow taken from her (“I found the idea invasive,” she said). Her doctor gave her “some steroids” to take to “boost her immune system” and sent her home. Jing spent the next two weeks in bed as she awaited her fate. Her husband would rush home after work every day. “Still alive?” he would ask. He was only half joking.

What surprised me was that neither of my parents sought further explanation for my mother’s disease. That they did not seek a scientific explanation was expected: education in China at that time did not cover much biology, and neither of them had majored in the natural sciences in college. But neither did they attempt to explain her disease using the traditional Chinese medicine paradigm, which was popular then and now. Nor did they claim a spiritual explanation, which would have been common in my grandparents’ times.

“Why didn’t you find out more about your condition?” I asked.

She shrugged. “We were young. We didn’t know much. The doctor said to take the drugs, so I took the drugs.”

Blissful ignorance shielded my mother from much stress. She was also lucky. A brief search on Medscape revealed that her doctor had treated her for immune thrombocytopenic purpura (ITP), which turned out to be what she had. If she had had the similarly symptomatic thrombotic thrombocytopenic purpura (TTP), which has a mortality rate of up to 90% if untreated, the outcome might have been very different.

Jing began taking the drugs. It made her plump, which, in a picture of her next to my scrawny father, made her seem disproportionately bloated.

“Didn’t that affect your self-image? Your outlook on life?” I asked.

“I think it was a combination of youth and ignorance,” said my mother. “I grew up in a rural factory town and had just moved into the city. I was full of hope for the future. Even the doctor’s insensitive words could not touch that. I just had a feeling, at the time, that I would recover.”

“Did you tell your parents? Your friends?”

“I didn’t want them to worry. I did everything as usual. I did feel tired sometimes, but the possibility of dying, which the doctor had suggested, never crossed my mind.”

She showed signs of recovery. The purple blotches soon faded and her platelet count began to rise. She grew even plumper from the steroids. Her parents, unaware of their daughter’s condition, thought she was just getting fat.

“I am their eldest daughter. I was in the city and they were back home in rural Shanxi. I’d always carried a lot of the responsibilities in my family, so naturally I expected myself to brave this alone.”

For the next three years, the purple blotches occasionally reappeared, but less frequently and severely each time. Finally, when she became pregnant three years later, thrombocytopenic purpura left her for good.

 

 

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Personal Stories, Philosophy, Simple Explanations

Enter the Tao: A novice’s exploration of Taichi, Taoism, and Traditional Chinese Medicine

The train weaved through the landscape. Buildings turned into farmlands, then into hills, then finally, after a twenty-hour journey from Beijing, I arrived at Wudang Mountain Train Station in Hubei, China. My summer begins here.

Taoists believe that everything in the universe belongs to one of five elements: Fire, Water, Wood, Earth, and Metal. Mt. Wudang is of the Fire element, perhaps owed to the fact that its many peaks lean towards the tallest, giving it the appearance of a flame. Or perhaps it is because Wudang burned at thirty-eight degrees Celsius in the summer months, a feature I’d soon learn to appreciate.

Mt. Wudang is tucked away in an eastern landlocked corner of China. It is not a particularly convenient location. It is not near any major cities or landmarks. It is not very tall, sitting at about sixteen hundred metres in height. But Mt. Wudang is remarkable for a reason: it is one of the centres of origin of Taoism, which, along with Buddhism and Confucianism, form the de facto official religion of China. Out of Taoism came the theory of Ying-Yang, Chinese medicine, and Taichi. In fact, it was in these very mountains that the Taoist monk Zhang San Feng attained enlightenment and created the Wudang martial arts some six hundred years ago. “All Taichi originates from Wudang,” goes a familiar Chinese saying.

Taoist Wuji Kungfu Academy, run by Master Chen Li Sheng, fifteenth-generation disciple of the Xuanwu clan of the Wudang sect, sits quietly at the waist of the leviathan. There are only a few rules to become a student: You must be disciplined. (That’s fine.) You do not have to be a Taoist. (Good.) You must not hold cultish beliefs. (That one sounds a bit odd…)

Despite my slight apprehension, at three o’clock that day I arrived at the school and introduced myself.


Side-note: there are over a hundred martial arts teachers in Mt. Wudang, and not all are created equal.

I heard of a guy, a foreigner, who also trained here.

“Sifu,” he said one day, for that is what we call our Master in Chinese. “Out of everything in the world, what do you wish for most?”

His Sifu  thought about this question. He lowered his eyes and furrowed his wizened brow. His disciples gathered around him. A minute later, he raised his head. His disciples tightened.

“A Porsche,” he said finally.

The guy quit the next day.

I hope the story wasn’t true.


Round, was my first thought when I met Master Chen.

He had a round face, complete with round eyes and a round nose, on top of which sat a
black square hat. He had a round belly, giving him the appearance of a walking cauldron wrapped in white kungfu attire. His full, round lips clasped into a smile as he greeted me.

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With Master Chen Li Sheng, fifteenth-generation disciple of the Wudang Xuanwu clan

“This is Wu,” he said, motioning to a lad of about fifteen. “He’ll take you to your room.”

Wu was a lanky teenager with slit-like eyes that made you think he was constantly on the verge of a dirty joke. He and Wen were two of Master Chen’s official disciples. “There’s Wen,” Wu pointed to a short, chubby, bespectacled fifteen-year-old who looked about twelve. Wen wore an expression that made you think he’d just heard a dirty joke and was bursting at the seams.

“Wu means warrior in Chinese. Wen means culture. Here’s your room.”

I was surprised by its cleanliness. Besides a few leaky pipes, everything resembled an honest attempt at creating a hotel atmosphere. I changed into my newly acquired kungfu garbs. I looked into the mirror; a thin, young man in white looked back. “Here we go,” I said to myself.

The Tao in Movement

Bagua, Xingyi, Taichi. These form the pillars of Chinese internal martial arts. They differ from external martial arts, such as Shaolin, in that they emphasize utilizing strength from within to channel to without. Bagua, also known as Eight-Trigrams, uses circular footwork and deceptive movements to confuse the enemy. Xingyi is the most aggressive of the three and was favoured by Yue Fei, a renowned warrior-general from the Song dynasty. Taichi is perhaps the most well-known in the West. Its name consists of two characers: Tai, which means “too much”, and Ji (Anglicized into Chi, not to be confused with Qi), which means “extreme.”

“Most people think of Taichi as a gentle exercise, practiced by the elderly in parks on Saturday mornings,” said Master Chen. “But they forget that it is primarily a martial art and can be used for combat.”

“Taichi moves look gentle. But it hides strength under frailty, toughness under softness. It is like water,” he said, and pushed.

A surging force landed on the Red Beast’s shoulder and uprooted his body. He flew out a few metres and landed on his feet. The crowd clapped enthusiastically. Earlier that evening, a frigate of a man, a tourist, challenged Master Chen. He was tall, a head taller than Sifu, very muscular, and wore a red shirt, hence my appellation. A crowd had gathered during their duel.

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Sifu versus the Red Beast

“Try to move me,” said Sifu, taking a stance.

The Red Beast heaved. He lifted. He pulled then pushed. Master Chen would not budge.

“In Taichi, the body exerts force in all directions at once. No matter which direction an attack comes from, the aggressor faces an opposition of equal magnitude.”

Very Newtonian.

“When it comes to attacking, a strike is not just an isolated strike. The hand is connected to the arm, which is connected to the back, which is connected to the legs. The opponent feels the force of your entire body,” he said, then pushed again.

The Beast, presently over-invested in trying to tug Sifu from equanimity, immediately lost his balance and fell backwards into the crowd, which immediately parted like the Red Sea, leaving the Beast on its and his bottom, his face flushed into the colour of his shirt.

“Good skill, good skill,” he said, getting up and clasping his hands into a kungfu sign of respect.

“Cool,” I said.

“We start with the basics,” said Master Chen. “The stance.”

The Wuji Stance (literally meaning “no extremes”), also known as Standing Position or Circular Stance, is sometimes called Standing Meditation. I find this a misnomer. We stand in a quarter-squat with arms in front, as though the entire body is hugging a ball. Within this ball, the head, hips and extremities expand outwards, to be resisted by the tendons and bones. The body is a metal balloon, a series of opposing parts making one consistent whole.

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The Wuji stance

My first time holding this position was neither relaxing nor meditative. Five minutes into it, my arms and knees began to ache. Swearing can help one withstand pain, so I began patiently listing expletives in alphabetical order, only to realize how top-heavy the lexicon of rude words is. I got up to “F” before stopping. Ten minutes, I noted pathetically. The other students could stand for an hour.

Over the month, my days would begin at five in the morning. There would be seven to eight hours of practice a day, four of which were spent in the Wuji Stance. The rest were invested in various forms, meditation, and basic training in the thirty-eight degree weather. I would return home sore and worn out. But by the end of it, I would have a beginner’s grasp of the Wuji Stance, and would be able to hold it, albeit imperfectly, for an hour.

The Tao that Cannot be Said

Every morning I wake up groggy, stumble into my uniform, and walk out as though in a trance. There are two paths leading out from the motel. Going down, I will reach a plaza that tourists pass by on the way to the cable cars that carry them to the top. We sometimes practice here to promote the school. But most mornings I go up. I reach a secluded spot, surrounded by mountain-scape. We train facing a monolith imprinted with large red letters: “Di Yi Shan,” First Mountain.

The sun is barely visible at this hour. But soon a bright, red hole sneaks up from the distant hills. It glows from ember-red to golden-yellow in a matter of minutes. At this point, the faraway peaks and valleys become a sea of green and grey that die into a flat line along the horizon. It is a picture of silence. Except it is not. The air is suffused with the sound of bird and bugs. There is incessant chatter, amongst which a single voice rises: the cry of some species of bird that echoes throughout the land. IMG_1431

The day after I arrived, a fog rolled in and ushered us into a classroom. Here, Master Chen, who held what is equivalent to a graduate degree in Taoism, taught us Taoist philosophy.

“Divorced from religion,” he emphasized.

Taoism in China is like Christianity in the West, in that many vaguely believe in it but most do not know what it is about. While practicing the Wuji Stance at the plaza, I sampled the various opinions about Taoism from tourists:

“What are they doing?” said one.

“I think it’s Falun Gong,” said another, referring to an illegal cult that espoused familial sacrifice.

“That’s why Taoism is fading so fast,” said the first.

Taoism holds three works as canonical: The Tao Te Ching by Laozi, the I Ching, and Zhuangzi. The Tao Te Ching is a dense volume of eighty-one passages, each no more than a paragraph long, but its official commentary contains over forty volumes.

“The Tao that can be said is not the Tao. The Word that can be said is not the Word,” runs chapter one, based on my very unofficial translation. In eighty-one cryptic paragraphs, the Tao Te Ching presents the great Tao, or pattern, of the universe. Its central dogma is that everything begins in a state of Wuji (“no extreme”), then enters into a state of Taiji (“too much extreme”), from which the nature of duality, the concept of Yin and Yang, emerges. IMG_1186

The day is Yang and the night is Yin. Front is Yang and back is Yin. Male is Yang and female is Yin. Yin taken to the extreme becomes Yang, and Yang to the extreme becomes Yin. The purpose of life is to return to a state of Wuji, to return to a state of childlikeness.

“Taichi is an embodiment of these principles. The Tao manifests itself in the movements.”


Side-note: If a deal seems too good to be true in a tourist spot, it probably is.

I made a Canadian friend while on the mountain. One day, while taking a trip at the touristy part of the mountains, we came across an herbal store that sold a particular herb at a killer price of five yuan per “ke.” My friend, who spoke some Chinese and studied Chinese medicine, asked for some. He held out his hand in the symbol of five. The shopkeeper nodded. He began heaping handfuls of the herb into a bag, then crushed it into powder. We looked at each other incredulously. Five yuan for this much?

It turned out that every one of us was thinking of something different.

I had a brain-freeze and confused “ke,” which means gram, with “jing,” equivalent to five hundred grams. I thought my friend was asking for five five-hundred-grams.

My friend thought he was asking for five grams.

The shopkeeper thought my friend’s open hand meant keep the goods coming or I’ll slap you silly.

In the farce that followed, I played linguistic and cultural mediator to two increasingly amused foreigners and an increasingly exasperated shopkeeper. We ended up paying a hundred yuan for a bag that cost several thousand.


Taoism as a religion is mired in political and social influences. Chinese religion, if it can be said to exist, is Neo-Confucianism, a hodgepodge mixture of Confucianism, Buddhism, and Taoism. Its gods serve social purposes: Some, such as Huang Di and Yan Di, are credited as Chinese ancestors. Others are deified by emperors to promote particular social values. Thus Guan Yu, the general from the Warring States period known for his fierce loyalty, became the god Guan Gong, protector of households.

“Do Taoists believe in fate?” I asked.

“Chinese folk religion believes that a person’s palm patterns and facial features can be used to predict their future. This was adapted from Taoism,” said Master Chen. “True Taoists believe that one’s physical features reflect one’s health and how others would treat them, which, in a way, seems fatalistic. But they also believe that a person can change their disposition, so in that sense people have control over their own fates.”

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The three-point stance is a staple of Xingyi

Taoism is a humanistic religion. Its emphasis on the individual, self-enlightenment, and mastery over one’s own body makes me wonder why Chinese culture is so communal. In my unqualified view, this is due to the overwhelming influence of Confucianism. The latter’s emphasis on social responsibility and accountability must have been auspicious for political figures who would use these to solidify power, and despite Mao’s vilification of Confucius during his reign, large pieces of Confucianism have remained and taken hold on the Chinese soul.

The Tao in Medicine

I am a cultural chimera. Growing up in a Chinese household, I am familiar with concepts such as the body having “too much Fire” or “too little Yin” or “not enough Qi.” Yet, as an aspiring scientist, I identify with the empirical frame of mind. My two worlds have never met. But on this trip, my cognitive dissonance manifested itself in a physical presence.

Jake was a fellow Canadian and student in his mid-thirties. He obtained his high school diploma before going into construction. One day, he “looked at the stars and thought they looked like the meridians in the body” (Meridians are energy channels in Chinese medicine) and enrolled in a Chinese medicine school in Canada. On our first meeting, he annoyed me intensely by suggesting that Western medical doctors were worldly, ineffective, timid money-munchers. Upon further probing, I discovered that his complaint was against the healthcare system, which he lumped together with complaints about the science itself.

I tried to remain objective despite my personal distaste. After all, traditional medicine can be divisive. To the enthusiast, it is a panacea, able to cure anything from the hiccups to cancer. To the dissident, it is a fallacy which, along with homeopathy and ancient Greek theory of the humors, ought to be canned into the past.

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We make dumplings and rice pudding for the Dragonboat Festival

Like with most matters, I find myself somewhere in the middle. The theory behind traditional medicine is fundamentally not scientific, by which I mean it is not empirical or mechanistic. As far as I know, no one has measured Qi or observed meridian channels. Nor is there any way to manipulate Qi in a controlled experimental setting and observe its effects. This means there is no objective standard to refute or support parts of the theory. We have in our hands a theory that cannot possibly evolve. Witness this exchange between two fellow students:

“I’ve been trying to open my third and fourth energy gates,” said one.

“I thought there were three energy gates,” said the other.

“No, there are four,” said the first.

“That’s according to Buddhists. Taoists say…”

“Who cares if it’s Buddhists or Taoists? If there are three, there are three,” said the first student flatly.

Furthermore, due to the lack of statistically rigorous study, traditional medical miracles is susceptible to biases. The most obvious is the survivorship bias. Take one doctor with a thousand patients. If half heal just by chance after treatment, they return to the doctor. If half of that half is treated again and heals, again by chance, we are left with a quarter of the original. Five treatment sessions later, we have thirty patients who believe that their doctor has miraculously cured them at a hundred percent success rate. To further complicate matters, many diseases that traditional medicine (and indeed any medicine) purports to cure are self-limiting, meaning that they heal on their own anyway. The doctor would do just as well to tell the patient to eat, rest, and drink plenty of fluids.

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We celebrate a fellow student’s birthday. Pictured are Master Chen and his four-year-old son.

That said, one cannot help but admit the effectiveness of certain traditional remedies. I have met people who have been cured of allergies and hormonal problems within weeks of treatment. In 1892, the Anglo-Canadian-American physician Sir William Osler, Father of Modern Medicine and co-founder of Johns Hopkins Medical School, testified to acupuncture’s “extraordinary and prompt efficacy.” The first edition of his essential textbook, the Principles and Practices of Medicine, recommended “needling” as treatment for nerve injury and lower back pain. We now have studies that suggest that acupuncture has beneficial effects on certain types of pain.

As for herbal medicine, in 2015, Tu Youyou became the first Chinese Nobel laureate in physiology or medicine for effectively isolating artemisinin, an antimalarial compound. She was inspired to isolate the substance in low-temperature conditions after reading a traditional Taoist medical text on preparing it.

I conclude that although the theoretical foundation of traditional medicine is not scientific, its apparent effectiveness in particular clinical cases leads to interesting questions that may be brought into the scientific frame of inquiry.

We now shift from the scientific to the social perspective of medicine in China.

Chinese people are suspicious of Western medical doctors, an opinion that I generalize, admittedly, based on only a handful of independent opinions. The healthcare system in China ties physician remuneration with drug sales. Pediatricians earn considerably less than other specialties, since drug dosages are lower for children. Under this system, is there any wonder why physicians lose patient trust?

At the same time, much of the Chinese populace seem to hold a slightly mystical view of Western medicine. During my stay, I discovered that one of my fellow students took ampicillin from time to time “to get rid of inflammation.” He had no idea what inflammation was and what antibiotics did, especially if taken discontinuously. His doctor had no incentive to inform him, and apparently his educational background failed to do so either.

Given these issues, many turn to traditional therapies. But traditional medicine in China faces its own problems, the main one that I see being the lack of consistency from doctor to doctor. This is perhaps the greatest obstacle to the adoption of Traditional Chinese Medicine in North America. In a legalistic environment like Canada and the United States, what constitutes a standard of care in traditional medicine? Maybe the interim solution is a technological one. If opinions on individual doctors is crowdsourced, we might have a platform for indicating standard in an intrinsically heterogeneous field.

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The horse stance is our favourite (*sarcasm*) basic training exercise

Personally, all this boils down to one question: would I support Traditional Chinese Medicine as a future physician?

It depends. On the patient, on the disease.

For so-called idiopathic functional disorders, such as irritable bowel disease, for which if I believe Western medicine offer no curative potential, traditional therapies might be tested. For peripheral nerve injuries, acupuncture may be helpful. For more serious afflictions like cancer, conventional treatment is probably wise, at least to avert immediate consequences.

As yet, I am ill-equipped to fully justify my answers. Knowledge, experience, and time will teach me what I need to know.

“You know, it’s all false,” said my French roommate, an osteopathic doctor and one of the few Caucasians in the area.

He knew a bit of English. I knew a very little bit of French. Our conversations were usually brief and cavemen-like:

“No frog tonight.”

“Yes. Oui. No frog.”

“Maybe rest day.”

“Yes, maybe. We rest too.”

“Like frog?”

“Like frog.”

But today his face curled into a serious frown.

“It’s all false, Charlie.”

“What’s all false?”

“Allopathic medicine, osteopathic medicine, Chinese medicine. It’s all false.”

I considered this bit of intellectual nihilism.

“I’ve had fifteen thousand patients. I work with each one with my own hands. They tell me their stories, their troubles. I listen. They speak, I listen. When they speak, I feel change under my hands. The body heals itself. I do nothing. Nothing. The body heals itself. It’s amazing.”

“You go medical school. You learn. It’s good. But remember, you learn a point of view. It’s important to have a point of view, to know that it is false. It’s all false.”

A month passes. Before I realize it, I am once again on a train weaving across the landscape. The mountains flatten into farmlands, then rise back up as buildings. Master Chen set aside seven disciples whom he had given martial art names. Besides Wen and Wu, there were Dao (principle), De (character), Long (dragon), Hu (tiger), and Yun (cloud). Each name was prepended with the character Wei, which means “profound.” He also reserved me a name: Feng, meaning “wind.”

Of course I had to hold in a joke about flatulence.

Next stop: Singapore, again!

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In the picture are De, Wen, Dao, Sifu, Wu, Hu, me and my French roommate Long

For information about the Wuji Kungfu School, I’ve made an English website: www.daoistgongfu.com

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Humour

Chinese Grandparents Spoil the Kids

 

Day 1

I arrive early in the morning. My grandparents are all over me.

“My baby”, says Grandma.

“I’m twenty-two”, I say.

“Let me take your bags,” says Grandpa.

“They’re heavy,” I say. “I’ll take them in myself.”

“Let me give you a bath,” says Grandma.

“I’m twenty-two,” I say.

“Let me cut you some apples,” says Grandpa.

“Sure. Thanks.”

 

Day 2

I wake up late. I’m bored.

“Can I help mop the floor?” I ask.

“No,” says Grandma.

“Can I help wash the dishes?” I ask.

“No,” says Grandpa.

“Can I help with anything?” I ask.

“Why don’t you just sit over there on the comfy chair? I’ll bring you some apples.”

I sit all day.

 

Day 3

I wake up at noon. I’m bored.

“I’ll wash my clothes,” I say.

“I’ll do it for you,” says Grandma.

“I’ll go buy some snacks,” I say.

“I’ll do it for you,” says Grandpa.

“I need to use the bathroom.”

 

Day 4

I lie in bed all day. I get up once to sit on the comfy chair. I accidentally raise my arms while stretching. A plate of apples mysteriously materialize in my hands.

 

Day 5

I wave my hand. A plate of apples appear in five minutes. “You’re two minutes late,” I say.

 

Day 6

“I want my apples cut into Mickey Mouse shapes,” I say.

They cut my apples in the shape of rats.

“What’s this supposed to be?” I demand.

“We don’t know what Mickey Mouse is,” they say.

I throw a hissy fit.

 

Day 7

I’m invalid. I am paralyzed from the waist down. I am confined to the comfy chair.

I demand to be called King of the Seven Kingdoms and Lord of the Seven Seas. With one wave of my hand a plate of apples appear in the shape of assorted Disney characters, and with another my Grandparents chant my name while sacrificing a goat. Slouched on my comfy throne, I am the omnipotent waste that sees all and knows none.

I love my grandparents.

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Medical School

Applying to U.S. Medical Schools as a Canadian Student

AMCAS, the American Medical College Application System, is opening in a week. This time last summer, I had just started gathering materials for my application. It was not a simple process. What made my case especially tricky was that I was a Canadian citizen applying for US medical schools, and I had many Canadian-specific questions that I could not find online resources for. For my fellow Northerners, here are some of the issues I struggled with and answers to them.

First off, what are Canadians to American schools? Technically, we are international students, which due to financial, social, and political factors places us at a disadvantage for many schools. That said, we are better off than students from other countries. After all, most schools prefer applicants who have had some education at a Canadian or U.S. post-secondary institution.

In this post, I will offer some practical takeaways from my application cycle. There are two caveats for my readers. First, these are based on my personal analyses as an Ontario applicant, and individual cases may vary. Wherever possible, I try to include how I’ve obtained the information so that you may check for yourself. Second, the U.S. schools I considered are generally pretty good schools, which limits the relevance of my points. I believe a career in medicine requires both a sense of idealism and of realism. This article focuses on the latter.

Phase 1: Pre-med years

Picking courses

The first dichotomy between US and Canadian schools is how they view the GPA. Both of them require pre-requisite courses that vary by school. But, to the best of my knowledge, Ontario schools do not care what courses you pick beyond that. There are certain restrictions, such as Toronto’s requirement of taking at least 3.0 upper year courses in 3rd and 4th years, but besides those, humanities courses are treated the same as science courses, even though the former are notoriously stingy on marks. GPA cutoffs are usually harsh, so a lower-than-cutoff transcript is unlikely to be given a chance (see here).

On the other hand, US schools tend to factor in the estimated difficulty of courses. A student who has a less-than-stellar GPA may still have a very good shot if she made it up with challenging courses or courseloads, strong extracurricular activities, and/or a well-written personal essay (more on these later). Hence, the GPA, while still important, is seen in the context of the entire application package. This is probably why Harvard had an entrance GPA of 3.8 whereas Toronto’s was a whopping 3.96 (2015 stats).

The practical consequence is that if a student is considering only Ontario schools, she might favour getting a high GPA over taking interesting but potentially challenging courses. If the student is also considering US schools (especially top tier schools), she might be better off picking courses she is interested in.

Extracurriculars

The AMCAS only allows you to include 15 activities as opposed to the 40 slots available on OMSAS (the Ontario medical application system). However, you are asked to write a sizeable paragraph describing your role in each of these 15, then pick 3 to write mini-essays on them, so do not include “resume padding” experiences. One cow-sized duck trumps many duck-sized cows. In other word, quality over quantity.

For top-tier American schools, leadership is the key point. Research is also highly valued, perhaps more so than many Canadian schools. But even for research, they look for independent thinking and initiative, in other words academic leadership.

Phase 2: The Application Process

How do schools view Canadian students?

It depends on the school. Yale is citizenship-blind. Columbia accepts Canadian students but not other international students. UCSF sent me this email:

Canadian citizens are considered international students and therefore not eligible for any federal student aid. International students who meet our eligibility criteria may apply but should be aware we very rarely accept international students.

Once again, we Canadians are a bit of a hybrid animal, so the best way to find out is to email the school yourself.

The vast majority of U.S. schools do not allow international students to apply for their MD/PhD programs due to restrictions on federal funding. Keep that in mind if that is your career path.

In terms of school names, most schools claim to treat every undergraduate institution the same way. That said, according to my friend who graduated from Yale Med, school names may carry an unofficial, or “soft,” power as a deciding factor. A majority of students who matriculated at Yale went to relatively well-known institutions, but students entering those schools were probably intelligent and capable in the first place. I went to the University of Western Ontario, which is not considered “top-tier” worldwide, and made use of the opportunities I had. Ultimately, it is the student rather than the school that counts.

When should one submit their AMCAS application?

As early as possible without sacrificing content. Because many U.S. schools use rolling admissions, submitting AMCAS on the official deadline in November would dramatically decrease your chances. This is different from OMSAS and could very well usurp a strong application. Beware!

The Personal Essay

The personal essay is familiar to most American students, as it is an integral component in undergraduate admissions. Canadian schools generally have no such requirement. In Ontario, only Toronto Med requires something similar to this with their Brief Personal Essays.

I cannot overstate the importance of this essay. There are plenty of smart applicants with similar scores applying for the same schools. At the end of the day, there is a qualitative element to the process which is best exemplified in the personal essay.

Letters of Reference

The OMSAS requires 3 letters of reference that are sent to every school. The AMCAS allows up to 10 letters that can be individually assigned. American universities often have premedical committees that writes a committee letter for the applicant, which includes comments about the student from several professors who know him or her. Although it includes multiple authors, a committee letter still counts as 1 letter out of 10.

As Canadian students, we may have to compensate by seeking more individual letters. For example, I sent a total of 6 letters to Yale. Some schools, such as Duke, restrict the number of letters, in which case you would have to contact the school about it. A good rule of thumb is to secure letters from 2 science professors and 1 non-science professor who have taught you, 1 volunteer reference, 1 extracurricular reference, and all your research supervisors.

Lastly, alumnus connections are more important for U.S. schools than Canadian. If one of your reference letters comes from an alumnus of the school (not necessarily school of medicine), it may be helpful to your application. In my case, I assigned 1 of 10 letter to specifically tailor to a particular school.

Phase 3: Interviewing

Work in progress. Check back later.

 

Have a question? Leave it in the comments below! I may not include it in the post if it’s too general, as I would like to focus on issues faced by Canadian students applying to the U.S.

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Personal Stories

An Adventure with Master Zeke

“It’s a really big tree, Charlie,” he said earnestly. “Huge!” He stretched out his enormous arms, eyes wide and brows raised, his mouth shaped into an open ‘O’. This man was Grandmaster Zeke Petkovic, whom the students of the Seikido club affectionately called Master Zeke. Only he, I thought, would be this excited about a tree. Then I realized that I felt it too. Surely, a tree as big as the span of his arms must be a very rare thing.

One can only describe Master Zeke by contradictions. Tall and burly with hands as big as two hands, he would easily be considered competitive for the role of the Mountain from the Game of Thrones. Yet, there was a playfulness in his eyes and demeanour that was almost childlike. It was the latter quality that I was witnessing now as he described the tree. “Huge!” His eyes widened with delight.

Earlier that day, I had gone to Master Zeke’s home for lunch. He lived a ten-minute drive south-west from campus with his wife Linda and youngest son Al. Linda had spread a feast. Fish, rice, and an assortment of Polish pickles arrayed the dining room table. I began taste-testing each item in turn.

“How’s the food, eh?” Master Zeke asked as I scooped a spoonful of beet paste.

“Different, sir.”

He gave a hearty chuckle and began spreading rose hip jam onto a generous slice of toast. “You and Al keep working at it. I’ll keep it coming.”

I muttered thanks in between mouthfuls.

“Back in Serbia, we always fed our guests well. Food was scarce when we were younger, so now I guess we’re making up for it.”

I caught a glance from Linda. He’s about to start on one of his stories again, it said.

“I came to Canada with a few dollars in my pocket. I worked hard on anything I could get my hands on, driving buses, doing gardening work, whatever it took…I eventually invested in real estate and retired comfortably. I keep telling young practitioners to be smart with their money. Start early and start young…”

“Have you told Charlie about the fish oil story?” Linda said suddenly.

“What fish oil story?” I asked.

“I haven’t told you?” said Master Zeke.

“No. Tell me.”

“Well, there was this river back home that we used to swim in. Before I went for a swim in that river, I would rub some sardine oil over my body, because, you know, fish oil is good for the skin.”

I nodded skeptically. Master Zeke was known to provide spontaneous medical wisdom based on ancient, experiential sources. To be fair , many of them did turn out to be true, but the underlying explanations were somewhat fuzzier. One of his formulations to treat the common cold was raw garlic and a shot of brandy. “It kills everything,” he claimed, by which he meant bacteria and the like. It also killed any chances of my finding a date.

 

“After a swim one day, I went on a date with this girl. As I approached her, I saw her face curl into a look of disgust. It turned out that I’d forgotten to wash the sardine oil off. I stank!” We roared with laughter.

“This way, Charlie,” his voice called, drawing me back to our tree hunt.

We walked around the forest, looking for a path to enter. The small patch of woods was located behind Victoria Hospital. It surrounded two small lakes and a cluster of dilapidated structures which surrounded a large central one. These must have been houses, I thought, as I spotted a chimney and pillars amidst the rubble. A more complete hut stood at the centre, the white paint on its elliptical wall bitten off by the years.

“I used to tend the gardens here for the hospital,” said Master Zeke. “It was a rehabilitation unit that housed veterans of the first World War. They lived in these,” he said, pointing to the smaller structures. “And this was a canteen.” He pointed to the large central one.

“Many of them struggled with mental issues. They came here to recover, but some never did. One went missing once, and they couldn’t find him for days. He was found dead under a layer of leaves.” We walked silently on. I tried to imagine the yellowed grass around me as they once were, lush and adorned with care.

We arrived at a trail leading into the thicket. We hiked along it, him leading the way and me trailing behind, brushing aside strands of woody arms as we went. The weather had only recently turned warm, and many of the trees had yet to shake off their winter drowsiness. We soon found ourselves surrounded on both sides by maple and ash. The air grew cool. In the distance, I saw the parking grounds of Victoria Hospital, but I heard no sound except that of birds and our boots gently brushing against the forest floor.

“Oh, look!” said Master Zeke, stopping mid-stride. “A locust flower seed.” He picked a dried pod from a bush, plucked out the beady black seeds, and promptly popped them into his mouth. Someone once told me that Master Zeke had a habit of “eating everything”, which included wild flowers,  mushrooms, and the occasional poison ivy. I now had concrete evidence.

Fifteen minutes later, we arrived at our destination. He was right. The tree’s girth was as wide as three adult arm spans, and its peak towered above that of its neighbours. Master Zeke and I fell silent as we approached it.

“Why are all the other trees so much thinner?” I asked after a while.

“This one is probably hundreds of years old. The others never got a chance to grow this big. This is a survivor.”

Master Zeke walked up and wrapped his gigantic arms around the trunk. “There’s nothing like hugging a tree,” he said with a satisfied sigh. “Give it a try!”

As I awkwardly placed my arms around the rugged bark, I realized that it wasn’t as uncomfortable as I’d thought. I looked over at Master Zeke. His eyes were closed and his face had relaxed into a peaceful smile. There is a poetry in existence, and it’s written in a language that can only be understood by someone who has hugged a tree, eaten poison ivy, and rubbed their body with fish oil. How often, I thought, do we take survival for granted?

“It’s time to go, Charlie.” Master Zeke’s voice seemed to come from very far away.

Just a little while longer, said a little voice inside my head.

“Alright, let’s go,” I said out loud.

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Philosophy

The Path We Share: the last stretch towards graduation and goodbye

There is a path behind London Hall that runs around TD Stadium. When I was in second year and living in London Hall, I would spend hours walking along that path, mentally reviewing for an exam or pondering on a particularly tricky problem. This weekend, I went back to that path after a year-long hiatus. I don’t quite know what drew me back. Maybe it was nostalgia. Maybe it was the smell of leaves. Maybe I just wanted to pick up my thoughts from where I left off a year ago.

The path begins at the foot of a small hill. It heads south along the stadium, turns east and then abruptly ends. One moment, you’re part of the Western campus, Frosh week and the class of bleary eyes at 8 AM in the morning. The next moment, you find yourself plunged into a thicket of green. You enter a world of whisperings and soft speeches, full of hidden promises and covenants.

I’d never noticed how beautiful that little patch of forest was. One summer morning, I woke up early after struggling with a research problem all night and decided to take a walk to clear my head. As I rounded the bend on that path, I stopped and stood transfixed at the scene before me. The sun had poured itself through an opening in the trees, diffused through the morning mist and gently fell on the ground. Its glow was gentle yet powerful, like a wave and like a star, like that of music. The rays fell on me and through me, and I could feel the trees rustle to a song that was without sound.

I never saw the sun like that again. I rued the fact that didn’t have my camera on me. If only I’d captured it! Then I could relive that moment forever. But this weekend, as I walked along that path again, the sun ordinary and unimpressive as it always was, I decided that it was better that I did not have my camera that summer morning. After all, that moment was precious precisely because it could not be relived.

Then I remembered why I wanted to walk: Goodbyes. There were many of them this weekend. I met up with friends I’d known over the past four years, some of whom I knew I would never see again, and others whom I knew that, try as I might, I had little chance of seeing. Goodbyes are a tiresome business. It hurt to say goodbye to my classmates when I left Singapore 7 years ago. It wasn’t great leaving Vancouver and saying goodbye to my friends there. Moving through four high schools was another string of goodbyes.

Somewhere along the way, I became pretty good at anticipating what would happen. First, you’re all awkward and fidgety. Then you tell each other of the various odds of meeting again, at which point both of you become crummy statisticians. At last, after a hug, a handshake or a nod, you part ways.

Of course, most of what you say don’t happen. The odds of meeting someone you know are high, but the odds of meeting a particular someone are not. Maybe you’re just casting your net wide, hoping that you’d catch something? “Hey, it’s you! Told you we’d meet again!” (But I told that to everyone else too.) Either way, it seemed pointless to get close to anyone if I knew that goodbye was inevitable.

Once, I made a few new friends who came to Western from Vancouver for a conference. That night, I led them down the path, telling them that it was a shortcut back to campus. We were joking around and laughing until we reached the end of the path and the beginning of the forest. With the bluish tinge of streetlights behind and the deep abyss of the midnight forest before us, they stopped and looked at me apprehensively. “You’re not a psycho-killer, are you?” one of them asked me. He was only half-joking.

I began walking.

“What’s that I’m hearing?” he asked.

“…The river,” I said.

They backed off a few steps.

In the end, I convinced them to follow me into the darkness with the promise of a once-in-a-lifetime-at-Western experience. A few steps in, one of the girls began to scream.

“You know,” I shouted over her screaming. “They say experiencing terrifying events together can make people closer! You guys are leaving tomorrow, so treat this as a speed bonding session!”

She kept screaming the entire way.

“If you ever meet someone, you should bring her here,” the guy said after we emerged from the other side. “That really would have worked.”

I smiled as I remembered that memory. Moments like those have changed my opinion about relating to people. In the past, I wanted to mean something to everybody because that meant I was well-liked and admired. As I grew up, I wanted to mean something to a professional group of people because that meant I was smart and valued. Now I simply want to mean something to a few people, to be there when they needed me, to empathize and to heal without a stethoscope.

As I walked, I realized that human connections are worth the time even though they inevitably end with goodbyes. I realized that we strive and stress so that we may be listened to and loved. I realized that as I develop my identity as a healer, my greatest challenge will be to listen to myself and to those who suffer.

I’ve begun counting my life in four-year blocks. Four years of high school, four years of undergrad and then four more years of medical school. I figured that I have about fifteen more of these. That’s not a lot of time left to do something that’s of worth, or to spend my time wallowing in what would have been, could have been, or should have been.

I tried to recall all my four-year blocks. High school was a blur, new school every year, science fairs, biology class, exams. Undergrad was hazy, frosh week seemed like yesterday, first day of class was intimidating, biology was hard. The more I walked, the more details I remembered, and the more I began to realize that the sun that had seemed so ordinary a moment ago was in fact quite special. It was not the same sun that I saw that summer morning, but it was precious by its own right.

I walked, lost in thought. Look! I’m back where I began.

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