(continued from Innovation, Renovation, and Practicality--an 2003 autobiography (part 1 of 2 )
Reflecting on my appoximately fifteen years of research career, I was unable to achieve sustained recognition in the academic community. However, it gave me full confidence in continuing my future work. It also dawned on me that our effort in life should not be for the sake of increasing our confidence, by acquiring various certificates, licenses, or obtaining prestigious titles, and being respected by others, despite the fact that these certificates, documents, or titles can increase one’s revenue. Now my belief is that fame and titles would sooner or later fade away. If one could enrich the lives of one’s children and let them live happily full of hope, if one could assist people who are struggling in hardship and help people in hours of need, it could be just as satisfying and would fulfill the goals of our own lives. I believe we are here, not to strive to obtain bigger titles and positions, but to maximize one’s capacities and carry out tasks that would help humankind. Conducting research is not for the purpose of building my reputation but for producing some results that can help others.
After I started my clinical work in earnest, my income gradually improved. My wife Yui-li was not deterred by the difficulties of the total hearing loss and went on to study further at the Engineering School of Northwestern University. She even completed her Masters degree in computer science and has been employed at the Information Service Center of the Veterans’ Administration Hospital . She has maintained a distinguished service there and received awards repeatedly. All these developments relieved the pressure on our livelihood. I even took time out to engage in sports with whole family members. That was one of the happiest times that I could remember. We did not become isolated and live a lonely life. My classmates from medical school have kept in close touch for thirty years. We publish class communications twice a year, in which, we allow anyone to express his/her opinions. In recent years, we have had more than twenty classmates engaging in almost daily e-mail exchanges during which we joked, debated, and offered encouragement. This has become one of the warmest and most pleasant experiences in my life.
My clinical work in the U.S. involved mostly the nursing home patients who are very frequently admitted with chronic diseases and infections. Since the hospital continued to provide me with research funds, I submitted proposals using the infected elderly nursing home patients as my main study subject. I examined and collected clinical data from the elderly patients. Since I had no interest in writing up survey data on elderly patients that others had already known, it was merely for my understanding of infectious problems of the elderly. I also started to strengthen the teaching capabilities. I designed one simple table on how to use antibiotics empirically in various clinical situations. Over the next 25 years this table proves to be a very useful tool for the physicians or medical students who are not familiar with antibiotics. Mainly for these teaching efforts, I received commendation from Northwestern University . I also gained more in-depth understanding on the problem of candiduria and published a paper, “Two-day Bladder Irrigation with Amphotricin B,” which earned attention and many discussions on the subject. During my research on the nursing home patients, a short report on the methicillin-resistant Staphylococcus aureus (MRSA) proved most useful.
At that time, the nursing homes in the US had one regulation, i.e., they would not allow the patients carrying MRSA to become residents. These nursing home patients staying at the hospital often carried MRSA and these bacteria were very difficult to eradicate. As a consequence, after the cure of the acute illness, the patients could only continue to stay in the hospital. They became a money-losing prospect for the hospital, because the hospital received only a fixed payment from insurance companies per diagnosis, DRG, for each patient. Therefore, many hospitals started to shy away from accepting patients from nursing homes.
I then conducted 3 surveys at two community hospitals covering two time spans. The results indicated that the proportion of MRSA among the Staphylococcus aureus isolated from nursing home patients is 3 times that of the elderly patients from the community. It indicated that the MRSA at a hospital was actually brought in by the patients from nursing homes. This article was cited nearly fifty times and was broadcast by the radio station for medicine. The most important result is that nursing homes no longer reject admitting patients who carry MRSA. Many hospitals again began accepting patients from nursing homes. This rapid change in the policy also demonstrated the flexibility of rules and regulations in the United States. If there is evidence, the regulations can be revised accordingly very quickly. I later found that this is in sharp contrast to the slow action in Taiwan .
In 1990, I decided to return to work in Taiwan by myself. The reasons were that, on one hand, my father was getting old and needed a son nearby to provide support; on the other hand, I also felt that what I have learned over the years must be utilized. Rather than enjoying a higher income in the US , I would rather return to Taiwan and contribute what I have learned to Taiwanese society. I am eternally grateful that my dear wife supported this decision. I first worked at Tzu-chi Hospital in Hualien for five years. Then I went to Po-ai Hospital in Lo-dong for two years. Then I worked for Hualien Hospital of the Department of Health for another seven years. All these hospitals are in east coast of Taiwan where there is relative lack of medical facilities. I am currently at Yuan’s General Hospital in Kaohsiung, the largest city in southern Taiwan , as an adviser in infection control. Throughout these years in Taiwan , infection control has been my main endeavor. At one time, I taught classes at the Nursing College and Medical School of Tzu-chi Foundation, and now at the Kaohsiung Medical University. In the mean time, I served as a member of infection control advisory committee at the Department of Health. I have also served as a hospital accreditation committee member and inspected numerous hospitals in Taiwan as to their quality of medical care. Over the 13 years, I saw grave deficiencies in the use of antibiotics in Taiwan. And the medical record writing needed much improvement. I also felt deeply that the classes and lectures actually had very limited impact. The observation on the misuse of the antibiotics was based on the unprecedented detailed review of cases with infections.
Since 1998 I have had the opportunity to study in detail the medical records from more than 20 medium- to small-sized hospitals all over Taiwan on the antibiotic usage. I found that due to inappropriate guidelines, and over-stringent controls that resulted in the fear of using more expensive broad-spectrum antibiotics, the percentage of inappropriate antibiotic usage in patients with infections amounted to 37%. For this mistake, the delay of proper treatment for more than five or six days reached 12.6%. Half of these patients directly or indirectly died due to this delay. Using the most conservative estimation, if we first set aside those critically ill patients, we estimated that two to three thousand patients died unnecessarily per year! It would be one of the ten leading causes of death in Taiwan! Doing detailed examination on clinical courses, understanding the patients’ illnesses, and the antibiotic given is very time-consuming and very difficult to accomplish. It required one year-long pilot study that helped setting up a definition of what constituted misuse. It further required the opportunity to sample the medical records of many hospitals scattered all around Taiwan. However, the chart review is the most effective, direct, and accurate method to understand the propriety of the antibiotic use.
Upon wide coverage by the news media after the publication of the results in the Infection Control Journal, for which I have been serving as the editor-in-chief, the critical issues on the appropriate usage of antibiotics caught the attention of Taiwanese physicians in just a matter of days. It even prompted the National Health Insurance Bureau to issue public assurance that if the indications are clearly stated in medical records, appropriate management “has always been paid”. It appears that major changes in this issue will finally progress. These changes were the most satisfying for me since my return to Taiwan. I found my learning and my effort is bearing fruits. However, it was most regrettable that despite my attempt for almost two years to communicate these findings and issues with critical medical society or institutions involved, I have been unable to get my message across. The problem was totally ignored! It was only after publication in the news media that we started to hear some responses. Although there were still some people trying to dismiss the problem, my reports have started to have apparent impact in Taiwan on how antibiotics should be prescribed. This raises one serious question: does every thorny medical issue require media coverage in order to gain recognition and resolution? Can’t medical professionals face the errors that have committed?
There are many issues in the Taiwan’s medical community that require self-examination and renovation. When I decided to return to Taiwan , I never expected that my medical career in Taiwan would be more complicated and difficult than in the U.S. , even though many friends, colleagues, and senior officials offered assistance of key importance. It gave me a strong feeling of helplessness. The problems that I encountered were mainly due to the age-long culture of academia and society in Taiwan.
First, the scholars in Taiwan do not have the habit of examining an individual’s experience and capability from a resume. When I was invited to make speeches or work in Taiwan , I was never asked for my Curriculum Vitae. Some people even considered it rude or overly demanding in requesting to see an individual’s CV. Even in formal official resume requirements, you only need to fill in the achievements of the past few years. This way, even if a person might have a very accomplished record from ten years ago, he could not clearly reveal all of his accomplishments. In civilized countries, when one is invited to make a speech, he is required to present his CV to the sponsors so that they can carefully study his professional background and accomplishments. It is the rule and the proper manners. If we cannot correctly recognize a person’s talent and capability, we cannot use him well and it is a great loss to the society.
Second, in evaluating the capability and accomplishment of a scholar, the Taiwanese medical community fails to pay attention to the importance of whether a scholar’s publications were cited in other articles. It only pays attention to the number of papers published and the “SCI ranking” of the journal where the articles are published. This high regard for the “SCI ranking” as a criteria for quality and importance seems to be the special habit of Taiwanese medical community. I have never heard about this ranking in the past. It is only in the past year, due to the issuance of the evaluation criteria in the universities that the importance of the number of citations and quality of a paper’s contents has come into focus. Although the paper’s quality and the importance of the research are not solely determined by the number of times it is cited by other articles, it is a fact that a frequently cited paper must have caused certain degrees of impact in academia. It should become one of the most important indicators on the contribution made to the medical field by this individual. What kind of papers could be cited frequently? Naturally, it must have elements of innovation, usefulness, or eye-opening discoveries. Those papers that gained people’s attention would likely to have made some contributions to the medical field. How can research be innovative? It requires the ability to engage in independent thinking and free expression of the ideas. In general, I found that we are relatively poor on this score in Taiwan. I wonder whether it is related to the authoritarian government’s thought control of the past few decades. Regardless of what could be the cause, cultivation in this area is most needed for Taiwanese scholars.
Third, a very unfair treatment of specialists and scholars is the unwise custom resulting from the general belief that “an official with high standing will definitely possess more knowledge.” This is a prevalent attitude in many countries. However, ignoring the opinions of specialists seems to be a more critical issue in Taiwan . It is no wonder that scholars are competing for the top administrative positions as if it is the ultimate goal of their career. If an individual has achieved great accomplishments in academic field but failed to use their experience in more in-depth research, it is a great loss to the development of this specialty. If scholars are not respected, it certainly is not going to promote advanced studies in academia.
Fourth, discussing differences of ideas with objectivity should be the attitude of an academician. We should use evidence and debates in resolving the dispute. If one side has found inadequacies in their own reasoning, they should candidly admit it and try to correct them. After the debate, there should still be mutual respect to each other and remain friendly. One should never avoid discussions, particularly when it is a clinical therapeutic issue that involves human lives. Sending anonymous letters defaming others without reading carefully and understanding the other side’s opinion is the most unthinkable behavior for scholars. Academicians should understand theories or positions from all sides to maintain its scholastic standing.
Fifth, medicine is a sacred profession that manages human lives. Strict adherence to the medical ethics is of vital importance. However, since hospital physicians’ pay scale has been gradually switched to the fee-for-service system in most hospitals, some doctors devote so much to increase their income and lessened their sense of responsibility to the patients. They have lost sight of the basic principle that a physician’s duty is to regard the safety of the patient as their first priority. Many senior physicians in Taiwan have felt this change to be the most serious threat to the medical profession. However there has been no visible attempt to correct this unfortunate trend from any institution.
After having worked in the United States and in Taiwan for 40 years, I have met many people with great accomplishments. I found the more knowledgeable people are, the more humble they become. Those people who have had more experienced are less egotistical and are quick to admit their faults. I hope in ten years, after we have passed on, some will read this autobiography and will say, “I can not believe that there were such unimaginable customs in the medical field.”
From laboratory work to patient care, from research to teaching, and from overseas to Taiwan , 40 years of observation and experience fostered in me many ideas. I am grateful to Professor Tsai Wen-cheng for giving me this opportunity to reveal and share my thoughts.
Main bibliography：[Number of citations in the Science Citation Index as of December, 1996]
1. Hsu CCS, Leevy CM: Inhibition of PHA-stimulated lymphocyte transformation by plasma from patients with advanced alcoholic cirrhosis. Clin Exp Immunol, 1971;8:749-60 [111]
2. Hsu CCS, LoGerfo P: Correlation between serum alpha-globulin and plasma inhibitory effect of PHA-stimulated lymphocytes in colon cancer patients. Proc Soc Exp Biol Med, 1972;139:575-8 [53]
3. Hsu CCS, Waithe W, Hathaway P, Hirschhorn K: The effects of fetuin on lymphocytes: lymphocyte stimulating property. Clin Exp Immunol, 1973;15:427-34 [13]
4. Hsu CCS: Peripheral blood lymphocyte responses to phytohemagglutinin and pokeweed mitogen during pregnancy. Proc Soc Exp Biol Med, 1974;146:771-5 [50]
5. Hsu CCS, Marti GE, Schrek R, Williams RC Jr: Lymphocytes bearing B- and T-cell markers in patient with lymphosarcoma cell leukemia. Clin Immunol Immunopathol, 1975;3:385-95 [75]
6. Hsu CCS, Floyd M: Lymphocyte stimulating and immunochemical properties of fetuin preparations. 24th Annual Colloquium, “Protides of the Biological Fluids”. Ed by Peeters H, Pergammon Press, Oxford , 1976;pp 295-302 [ 7]
7. Hsu CCS, Chen Y, Patterson R: Peripheral blood B-lymphocyte abnormalities associated with hyperthyroidism of Graves’ disease. Clin Exp Immunol, 1976:26:431-40 [27]
8. Hsu CCS, Wu M-Y B, Rivera-Arcilla J: Inhibition of lymphocyte reactivity in vitro by autologous polymorphonuclear cells (PMN). Cell Immunol, 1979;48:288-95 [23]
9. Hsu CCS, Wu S J-Y, George S, Morgan ER: Assessment of shedding and re-expression of surface immunoglobulin (Ig) and Ia-like antigen （Ia) on normal blood lymphocytes. Cell Immunol,1980;52:154-62 [5]
10. Hsu CCS, Morgan ER: Indirect immunofluorescent assays for acute lymphoblastic leukemia (ALL) cell-associated antigen. Elimination of non-specific fluorescent stain on lymphoid cells. Amer J Clin Path, 1980;73:633-8 [8]
11. Hsu CCS, Macaluso CP, Special L, Hubble RH: High rate of methicillin resistance among Staphylococcus aureus isolated from hospitalized nursing home patients. Arch Int Med, 1988;148:569-70 [48]
12. Hsu CCS, Ukleja B: Clearance of Candida colonizing the urinary bladder by a 2-day amphotericin B irrigation. Infection 1990;18:280-2. [22]
13. 許清曉﹕抗微生物藥劑臨床使用的另一種教學法(A different approach in teaching the empiric use of antimicrobials )。院內感染控制雜誌 NICJ 1996﹔6﹕306-14
14. 許清曉：台灣住院病患抗生素使用管制過度所可能引起的嚴重後果及其補救辦法。感染控制雜誌ICJ 2003; 13: 209-2
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